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Abstract Background Over the past few years, the development of telerehabilitation has advanced rapidly. Patients with Parkinson's disease (PwPD) often have difficulty with mobility, making it challenging for them to perform centre-based exercise.This study aims to compare the effectiveness and adherence of home physical therapy (HPT) and telerehabilitation (TR) in mitigating motor symptoms and improving the quality of life in patients with mild to moderate Parkinson’s disease. Methods This randomized controlled trial included a total of 190 patients who underwent in-person eligibility assessment, with 100 allocated to the HPT group and 90 to the TR group. Both interventions consisted of home-based training sessions lasting 40–60 min and were conducted five times a week for 4 weeks. The primary outcome was the Unified Parkinson’s Disease Rating Scale motor section (UPDRS3) score. Secondary outcomes included balance function, assessed using the Berg Balance Scale (BBS); risk of fall, evaluated through the Timed Up-and-Go test (TUG) and the Five Times Sit-to-Stand test (FTSST); gait, measured using the Freezing of Gait Questionnaire (FOGQ) and IDEEA activity monitor; muscle strength, evaluated using the isokinetic dynamometry; motor aspects of experiences of daily living (UPDRS2); and quality of life, assessed by Parkinson's Disease Questionnaire-39 (PDQ-39). Results There was a significant difference in the UPDRS3, BBS, TUG, FTSST, FOGQ,step length, step velocity,preswing angle, UPDRS2 and PDQ-39 between baseline and 4 weeks in both groups. The decrease in the UPDRS3 score was significantly greater in the HPT group (-3.38 points) than in the RE group (-1.45 points) in the older age group (P = 0.021), but there was no significant between-group difference in the younger age group (P = 0.416). Similar changes favouring the HPT group were observed in the BBS, TUG, step velocity, and extension average torque. 7 (7%) patients in the HPT group and 12 (13%) patients in the TR group did not complete their daily exercise plan. Conclusions Both HPT and TR have demonstrated effectiveness, safety, and feasibility in PwPD. However, the HPT program exhibited greater effectiveness among older patients and higher patient compliance compared to TR. Trial registration Chictr.org.cn, ChiCTR2300071648. Registered on 22 May 2023—retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=196313 .