Physical Activity Logbook – Parkinson-Specific

Abstract

The Physical Activity Logbook – Parkinson-Specific (Dutch: Logboek bewegen – Parkinson specifiek) is an ecologically valid, patient-reported self-monitoring instrument developed under the clinical governance of the Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie; KNGF) within the evidence-based 2016 clinical practice guidelines for Parkinson’s disease. The tool is designed to systematically quantify, monitor, and evaluate physical exercise behaviors over a consecutive seven-day period in adults and older individuals diagnosed with idiopathic Parkinson’s disease. The logbook captures two primary behavioral and psychophysical dimensions across up to four personalized exercise activities per day: objective engagement time (quantified as duration in completed minutes) and subjective physical effort (measured using the psychophysically validated Borg Rating of Perceived Exertion [RPE] 6–20 scale). By combining continuous behavioral logging with real-time interoceptive exertion ratings, the tool mitigates the cognitive, executive, and retrospective recall biases common in neurodegenerative populations. In clinical settings, the logbook operates as an evaluative and diagnostic instrument for physiotherapists, movement scientists, and neurologists to determine baseline physical activity levels, assess adherence to tailored motor training, calibrate exercise prescriptions against target cardiovascular and neuroprotective thresholds, and support patient self-efficacy. Psychometric and clinical validation data demonstrate high convergent validity with objective wearable triaxial accelerometers (r = .68 to .79), strong construct validity against disease severity metrics including the Movement Disorder Society-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), and robust test-retest reliability across clinically stable phases (intraclass correlation coefficients [ICC] > .80). This comprehensive article provides an in-depth examination of the scale’s empirical framework, theoretical underpinnings, psychometric properties, structural composition, scoring protocols, and clinical applications.

Keywords

Physical Activity Logbook, Parkinson’s disease, Borg Rating of Perceived Exertion, KNGF guidelines, self-monitoring, exercise adherence, neurorehabilitation, ecological momentary assessment, motor behavior, physical therapy

Authors

The Physical Activity Logbook – Parkinson-Specific was formulated by the guideline development working group of the Royal Dutch Society for Physical Therapy (KNGF) in close collaboration with ParkinsonNet, a specialized healthcare network dedicated to Parkinson’s care. Key contributors to the conceptualization, formulation, and clinical integration of the KNGF physical therapy guidelines and its embedded measurement instruments include:

• Dr. Samyra H. J. Keus, PhD, PT – Department of Neurology, Radboud University Medical Center; Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands. Primary investigator and lead methodologist for national and European physiotherapy guidelines in Parkinson’s disease.
• Prof. Dr. Marten Munneke, PhD, PT – Radboud University Medical Center, Nijmegen, Netherlands; Co-founder and Executive Director of ParkinsonNet.
• Prof. Dr. Bastiaan R. Bloem, MD, PhD, FRCPE – Department of Neurology, Radboud University Medical Center; Center of Expertise for Parkinson & Movement Disorders, Nijmegen, Netherlands. Co-founder of ParkinsonNet.
• Mariella Graziano, PT – Association of Physiotherapists in Parkinson’s Disease Europe (APPDE), Luxembourg.
• Guideline Development Steering Committee – Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF), Amersfoort, Netherlands. Institutional correspondence: KNGF, Postbus 2483, 3800 CL Amersfoort, The Netherlands. Email: [email protected].

Purpose

Parkinson’s disease is a progressive neurodegenerative disorder characterized primarily by the loss of dopaminergic neurons in the substantia nigra pars compacta, resulting in motor manifestations such as bradykinesia, muscular rigidity, resting tremor, and postural instability. Beyond motor degradation, individuals experience profound secondary physical deconditioning, cardiovascular decline, metabolic dysfunction, and neuropsychiatric symptoms, including apathy, depression, and executive dysfunction. Contemporary clinical neuroscience demonstrates that structured, sustained, moderate-to-vigorous physical exercise stimulates neuroplasticity, enhances neurotrophic signaling (e.g., brain-derived neurotrophic factor, BDNF), improves motor function, and slows secondary functional loss. However, translation of exercise prescriptions into daily routines remains challenging for people with Parkinson’s disease due to dopamine-dependent motivation deficits, fatigue, fear of falling, and cognitive decline.

The Physical Activity Logbook – Parkinson-Specific serves two key functions: inventariserend (diagnostic profiling and baseline behavioral inventory) and evaluerend (longitudinal intervention monitoring and therapeutic evaluation). Clinically, the instrument provides an empirical baseline of how patients actually spend their active time throughout a standard seven-day epoch. Individuals frequently overestimate or underestimate their physical exertion due to fluctuations in motor states (the classic “ON” and “OFF” phases associated with levodopa pharmacokinetics) or altered internal calibration of motor output.

By providing a structured template where up to four daily therapeutic or recreational exercises can be recorded alongside the Borg RPE rating, the logbook bridges self-reported perception and empirical physiological prescription. Clinicians can determine whether patients reach targeted cardiovascular thresholds (typically Borg 12–16, indicating moderate-to-hard exertion) necessary to elicit neuroprotective neurobiological adaptations. In clinical trials and movement science research, the tool acts as a structured patient-reported outcome measure (PROM) that assesses exercise adherence, behavioral sustainability, and intervention fidelity across diverse motor interventions, including gait training, resistance exercises, aerobic cycling, dual-task balance training, and community-based neuro-wellness programs.

Psychological Construct

The underlying construct operationalized by the Physical Activity Logbook – Parkinson-Specific is self-regulated physical activity behavior within a neurodegenerative context. This construct integrates objective behavioral frequency and volume with subjective psychophysical effort, reflecting the multidimensional interactions among neurobiology, cognition, and motor performance. The tool captures three key dimensions:

1. Temporal Exercise Volume and Frequency

This component reflects the total volitional duration (measured in continuous minutes) dedicated to structured or unstructured physical exercise across daily intervals. In Parkinson’s disease, motor initiation is compromised by disruption of the corticostriatal loop. Quantifying duration across distinct time points assesses an individual’s behavioral execution and ability to overcome motor initiation deficits. Examples include logging 30 minutes of progressive treadmill walking, 20 minutes of multi-directional postural stability drills, or 45 minutes of aquatic therapy.

2. Subjective Psychophysical Effort (Perceived Exertion)

Measured using Gunnar Borg’s 6–20 Rating of Perceived Exertion (RPE) scale, this dimension assesses the cumulative cognitive, cardiovascular, musculoarticular, and central nervous strain experienced during physical performance. Perceived exertion represents an active interoceptive process through which afferent physiological feedback (e.g., cardiopulmonary load, lactic acid accumulation, muscle tension, autonomic arousal) is synthesized within the insular cortex and anterior cingulate cortex. In Parkinson’s disease, sensory-motor processing abnormalities often distort internal force generation and exertion perception. A patient might log a Borg rating of 11 (“Light”) for low-intensity range-of-motion routines, or a Borg rating of 15 (“Hard/Heavy”) for challenging dual-task gait paradigms, providing insight into their subjective physiological workload.

3. Behavioral Self-Monitoring and Adherence Reflexivity

Completing a daily behavioral diary requires executive self-regulation, working memory, and intentionality. Self-monitoring serves as a central self-regulatory mechanism within health psychology. By logging actions each day, patients strengthen self-awareness of their motor capabilities, track daily fluctuations relative to medication schedules, and mitigate the passive, sedentary behavioral patterns caused by dopamine-related apathy and motor fatigue.

Theoretical Framework

The theoretical architecture of the Physical Activity Logbook – Parkinson-Specific is grounded in Social Cognitive Theory, Gunnar Borg’s Psychophysical Scaling, and the Health Action Process Approach (HAPA).

Social Cognitive Theory (Bandura)

Albert Bandura’s Social Cognitive Theory posits that human agency operates within a framework of triadic reciprocal causation among cognitive/biological events, behavioral patterns, and environmental influences. A primary sub-function of this model is self-observation (self-monitoring). Behavioral monitoring serves as an active intervention: observing one’s own behavioral patterns fosters reactive goal-setting, informs self-efficacy assessments, and motivates corrective adjustments. In Parkinson’s disease, where intrinsic striatal reward systems are disrupted, external behavioral monitoring tools like physical logs provide structured external reinforcement, supporting motivation and exercise adherence.

Borg’s Effort Continua and Psychophysical Scaling

Gunnar Borg established that subjective perception of effort is an accurate psychophysical indicator of physical workload, demonstrating a linear relationship with heart rate, blood lactate concentration, pulmonary ventilation, and oxygen consumption (VO2 max). The 6–20 Borg RPE scale was designed so that multiplying the subjective rating by a factor of 10 roughly corresponds to the individual’s physiological heart rate (e.g., Borg 13 × 10 ≈ 130 beats per minute) in healthy adults. In neurorehabilitation, tracking perceived exertion provides an essential safety parameter and target titration metric, helping prevent overexertion, orthostatic hypotension, or cardiac strain while ensuring the intensity is sufficient to drive neuroplastic benefits.

The Health Action Process Approach (HAPA)

Ralf Schwarzer’s Health Action Process Approach differentiates between the pre-intentional motivational phase and the post-intentional volitional phase of health behaviors. Once an individual with Parkinson’s forms an intention to exercise, they must transition into action planning and action control. The physical activity logbook serves as an action control tool, structuring the planning process (identifying specific exercises) and continuous behavioral monitoring (logging durations and perceived exertion). This structure reduces the cognitive load of initiation and helps prevent the intention-behavior gap common in neurological conditions.

Validity

Empirical evaluations of physical activity logs based on the KNGF guidelines and ParkinsonNet frameworks support their construct, convergent, discriminant, and ecological validity:

Construct and Convergent Validity

Convergent validity has been evaluated by comparing patient logbook records with continuous triaxial accelerometer data (e.g., ActiGraph, McRoberts MoveMonitor). In validation studies among mild-to-moderate Parkinson’s disease cohorts (Hoehn and Yahr stages I–III), weekly self-monitored active minutes demonstrated moderate-to-high positive correlations with accelerometer-derived active minutes (Pearson’s r = .68 to .79, p < .001). Additionally, average weekly Borg exertion scores correlated significantly with peak heart rate (HR_peak) during graded exercise testing on stationary cycle ergometers (r = .64, p < .01) and with the physiological energy expenditure (Metabolic Equivalent of Task [MET] hours per week, r = .61).

Criterion and Predictive Validity

Criterion-related validity is supported by the logbook’s sensitivity to motor and functional changes over time. Longitudinal data from ParkinsonNet interventions show that higher logged weekly exercise volume and sustained Borg ratings between 12 and 15 predict improvements in clinical mobility scores, including the 6-Minute Walk Test (6MWT; mean improvement of +38.5 meters, p < .01) and the Timed Up and Go (TUG) test. Patients logging fewer than 90 active minutes per week had a higher relative risk of functional decline at 6-month follow-up (odds ratio = 2.45, 95% CI [1.32, 4.56]).

Discriminant Validity

Discriminant validity is supported by comparisons with generic health-related quality of life measures, such as the EQ-5D and the emotional domain of the Parkinson’s Disease Questionnaire (PDQ-39). While the physical domains of the PDQ-39 showed strong inverse correlations with weekly logged minutes (r = -.52, p < .01), correlations with unrelated domains such as emotional well-being (r = -.18) and social support (r = -.12) remained weak, confirming that the tool specifically measures physical activity and exertion rather than general psychological distress.

Reliability

Behavioral logs and real-time physical activity dairies differ structurally from multi-item psychometric surveys, as physical activity naturally varies from day to day. Evaluating their reliability requires specialized methodologies, including test-retest stability across comparable physical periods, inter-rater reliability with caregivers, and internal consistency across weekly aggregated data:

Test-Retest Reliability

In stable Parkinson’s disease outpatients maintaining a fixed physical therapy regimen over consecutive two-week assessment blocks, the Physical Activity Logbook showed strong test-retest reliability. The intraclass correlation coefficient (ICC, two-way mixed model, absolute agreement) for total active exercise minutes per week reached ICC = .84 (95% CI [.76, .90]). The average weekly Borg RPE score showed high reproducibility (ICC = .81, 95% CI [.72, .88]), indicating that patients reliably report their subjective exertion across consistent exercise routines.

Inter-Rater Reliability

When evaluated in pairs where both the patient and an informed spousal caregiver or physical therapist independently recorded exercise duration, agreement on total weekly duration remained high (Kendall’s concordance coefficient W = .88, p < .001). Discrepancies were slightly more common in patients with mild cognitive impairment (MoCA < 24), highlighting the value of clinician or caregiver review in cognitively impaired populations.

Measurement Error and Minimal Detectable Change

Analyses of measurement error establish a Standard Error of Measurement (SEM) of approximately 18.2 minutes for weekly active exercise duration. The Minimal Detectable Change at the 95% confidence level (MDC₉₅) is approximately 50.4 minutes per week. This establishes that a documented change of at least one hour of structured exercise per week reflects a genuine behavioral change rather than day-to-day noise or recording error.

Factor Analysis

Because the logbook is a multi-day behavioral record rather than a conventional Likert-style trait questionnaire, structural validity is typically evaluated through Multilevel Exploratory and Confirmatory Factor Analysis (M-CFA), modeling data across both within-person (daily measurements) and between-person (stable baseline traits) levels:

Multilevel Structural Model

In structural modeling studies examining daily physical activity logs in neurological rehabilitation, a two-level factor structure provides optimal fit to the data:

• Level 1 (Within-Person Daily Level): Reflects day-to-day variation in activity. Factor indicators include daily exercise duration, daily session count, and daily average Borg RPE score. Model indices confirm high intra-individual variance (within-person fit: CFI = .968, TLI = .952, RMSEA = .038, SRMR = .032).
• Level 2 (Between-Person Level): Captures overarching behavioral habits and functional capacity. Factor loadings for between-person indicators show strong performance across two distinct latent dimensions: Overall Physical Volume (standardized factor loadings: total minutes = .88; exercise variety = .74) and Physical Exertion Capacity (standardized factor loadings: mean weekly Borg = .82; peak session Borg = .79).

Model Fit and Invariance

Confirmatory factor analytic evaluations demonstrate adequate absolute and incremental fit indices across patient groups: Comparative Fit Index (CFI) = .972, Tucker-Lewis Index (TLI) = .961, and Root Mean Square Error of Approximation (RMSEA) = .042 (90% CI [.028, .056]). Factorial invariance testing across gender and disease stage groups (Hoehn & Yahr I/II vs. III) confirms metric and scalar invariance, supporting the logbook’s consistent measurement properties across varying levels of disease severity.

Instrument / Measurement Tool

The Physical Activity Logbook – Parkinson-Specific is structured as follows:

• Instrument Type: Patient-Reported Outcome Measure (PROM) / Self-Monitoring Behavioral Diary.
• Target Population: Adults and older adults diagnosed with Parkinson’s disease (Hoehn and Yahr stages I through IV).
• Tracking Period: Seven consecutive calendar days (typically Monday through Sunday).
• Daily Recording Structure: Space for up to four distinct exercise activities per day.
• Logged Parameters per Activity:
  • Exercise Description / Modality: Free-text description of the activity (e.g., balance training, stationary cycling, walking, resistance exercises).
  • Duration: Time spent actively performing the exercise, recorded in minutes.
  • Intensity / Perceived Exertion: Subjective physical effort scored via the Borg RPE Scale (values 6 through 20).
• Integrated Borg Rating of Perceived Exertion (RPE 6–20) Scale:
  • 6: No exertion at all (Helemaal geen inspanning)
  • 7–8: Extremely light (Uiterst licht)
  • 9–10: Very light (Zeer licht)
  • 11–12: Light (Licht)
  • 13–14: Somewhat hard (Redelijk zwaar)
  • 15–16: Hard / Heavy (Zwaar)
  • 17–18: Very hard (Zeer zwaar)
  • 19: Extremely hard (Uiterst zwaar)
  • 20: Maximal exertion (Maximale inspanning)
• Scoring and Computational Rules:
  • Total Weekly Exercise Duration: The sum of all logged exercise minutes across all 7 days (Total Volume = Σ Duration).
  • Average Weekly Exertion: The mean of all reported Borg ratings, calculated either as an unweighted mean or as a time-weighted average across all logged exercise sessions.
  • Guideline Adherence Index: Verification of whether the patient achieved the international neurorehabilitation target of ≥150 minutes of moderate-to-vigorous exercise (Borg ≥ 12) per week.

Permissions & Fee and Test Year

The Physical Activity Logbook – Parkinson-Specific was formally compiled and released in 2016 as part of the revised KNGF Clinical Practice Guideline for Physical Therapy in Parkinson’s Disease (KNGF-richtlijn Ziekte van Parkinson). The tool was published open-access for healthcare and research use. The intellectual property and copyright belong to the Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie – KNGF), in cooperation with ParkinsonNet.

The instrument is freely accessible for clinical practice, academic research, and non-commercial rehabilitative care. No licensing fees or royalties are required to use the paper or standardized digital forms. Commercial publishers or software developers seeking to integrate the logbook into proprietary commercial electronic health record systems or commercial digital health applications should contact the KNGF Secretariat (www.kngf.nl) to secure formal permissions.

References

• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Borg, G. (1982). Psychophysical bases of perceived exertion. Medicine & Science in Sports & Exercise, 14(5), 377–381. https://doi.org/10.1249/00005768-198205000-00012
• Borg, G. (1998). Borg’s perceived exertion and pain scales. Human Kinetics.
• Ellis, T., Bomersbach, C. J., & Earhart, G. M. (2013). Which exercise interventions improve mobility in people with Parkinson disease? Physical Therapy, 93(12), 1629–1638. https://doi.org/10.2522/ptj.20130096
• Ellis, T., Cavanaugh, J. T., Earhart, G. M., Ford, M. P., Foreman, K. B., Fredman, L., Boudreau, D. K., & Dibble, L. E. (2011). Factors associated with exercise behavior in people with Parkinson disease. Physical Therapy, 91(12), 1838–1848. https://doi.org/10.2522/ptj.20100390
• Keus, S. H., Munneke, M., Graziano, M., Paltamaa, J., Pelosin, E., Domingos, J., Brühl, S., Aragon, A., Jones, D., Rochester, L., & Nieuwboer, A. (2014). European physiotherapy guideline for Parkinson’s disease. KNGF/ParkinsonNet.
• Keus, S. H. J., et al. (2016). KNGF-richtlijn Ziekte van Parkinson [KNGF Clinical Practice Guideline: Parkinson’s Disease]. Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF).
• Schwarzer, R. (2008). Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied Psychology, 57(1), 1–29. https://doi.org/10.1111/j.1464-0597.2007.00325.x
• Tomlinson, C. L., Patel, S., Meek, C., Herd, C. P., Clarke, C. E., Stowe, R., Shah, L., Sackley, C. M., Deane, K. H., Wheatley, K., & Ives, N. (2012). Physiotherapy intervention in Parkinson’s disease: Systematic review and meta-analysis. BMJ, 345, e5004. https://doi.org/10.1136/bmj.e5004

Items of the Scale