Article In Brief
In a randomized trial with Parkinson's disease patients, researchers found a yoga program that focused on mindfulness was more effective in alleviating anxiety than a more standard exercise program of stretching and resistance training.
An average of six sessions of mindfulness yoga (yoga combined with meditation and controlled breathing) significantly reduced depressive and anxiety symptoms in patients with mild-to-moderate Parkinson's disease (PD) compared with stretching and resistance training, according to a paper published in the online April 8 edition of JAMA Neurology.
“Our study concludes that mindfulness yoga alleviates psychological distress, and improves spiritual well-being, quality of life, motor symptoms, and mobility. When it comes to managing stress and symptoms of PD, what is exciting is that yoga has now been proven to be a better strategy than just stretching,” lead investigator Jojo Y.Y. Kwok, PhD, MPH, RN, a research assistant professor in the School of Nursing at the University of Hong Kong, told Neurology Today in an email.
Previous research has shown that participation in mind-body exercises such as yoga and tai-chi improved the physical well-being of people with PD. However, the research on its psychological benefits has been inconclusive, said Dr. Kwok.
Between 40 percent and 50 percent of people with PD will experience psychological distress, including anxiety and depression, which is associated with care dependency, poor work and social function, rapid physical and cognitive decline, increased dementia risk, and high mortality, according to Dr. Kwok.
Dr. Kwok and her colleagues in Hong Kong conducted a multicenter, randomized clinical trial comparing their mindfulness yoga protocol to stretching and resistance training from December 1, 2016 to May 30, 2017. The protocol consists of dynamic Hatha yoga sequences such as sun salutations, that are modified for patients with mild to moderate PD, breathing exercises, and mindfulness meditation such as body scans, loving-kindness meditation, and mindful walking, according to Dr. Kwok.
She described loving-kindness meditation as practicing visualization and meditation phrases of benevolence, compassion, and loving kindness, “which generate feelings of warmth toward oneself and others. This helps cultivate one's capacity for forgiveness, acceptance and appreciation,” said Dr. Kwok.
They enrolled 138 participants who had a diagnosis of idiopathic PD, had a mean age of 63.7, and were 52.9 percent female. The majority had moderate PD (stage 3 on the Hoehn and Yahr scale) and about one-third had clinically significant anxiety (37.7 percent) or depressive (34.8 percent) symptoms.
Participants were excluded if they could not stand unaided, could not walk with assistance, or were receiving any psychiatric treatment including medications.
Yoga instructors trained in mindfulness-based stress reduction taught eight weekly 90-minute sessions (60 minutes yoga, 15 minutes meditation, and 15 minutes of controlled breathing). Qualified fitness instructors taught the eight SRTE 60-minute sessions consisting of a progressive set of warm-ups, resistance training and stretching, and cool-down exercises, according to the paper. All participants were encouraged to perform 20-minute home-based practice twice a week and approximately 70 percent did.
The researchers assessed the participants at baseline, eight and 20 weeks for the primary outcomes of anxiety and depressive symptoms using the Hospital Anxiety and Depression Scale, and secondary outcomes including severity of motor symptoms using the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS), mobility, spiritual well-being in terms of perceived hardship and equanimity (non-attachment to pleasure or pain), and health-related quality of life (HRQOL).
The mindfulness yoga participants were the only group to experience a significant decrease in depressive and anxiety symptoms at eight and 20 weeks. Their level of anxiety decreased significantly from a mean of 6.32 (SD: 3.57) at baseline to 3.97 (SD: 3.57) at eight weeks; while their depressive symptoms decreased significantly from a mean of 6.69 at baseline (SD: 3.36) to 4.10 (SD: 3.18) at eight weeks. The improvement in anxiety and depressive symptoms was sustained at 20 weeks.
Both groups showed a significant improvement in motor symptoms and mobility while only the mindfulness yoga group experienced significant improvements in health-related quality of life and spiritual well-being.
“The effects of mindfulness yoga in improving psychological outcomes were moderate to large, which has been typical of evidence-based treatments recommended for psychiatric conditions of PD. It was remarkable that participants in the yoga intervention received these benefits by attending only a mean of six sessions,” said Dr. Kwok.
The main study limitations were the exclusion of participants with severe motor limitations and the attrition rate of about 15 percent at eight weeks and 19 percent at 20 weeks for the entire sample.
Dr. Kwok and her colleagues will continue to examine how best to disseminate this evidence-based practice as a sustained, complementary treatment option in the community.
“I was struck that an average of just six sessions of mindfulness yoga improved anxiety, depression, and motor function scores. This speaks to the tremendous importance of the mind-body connection. The findings suggest that when one is in a centered, relaxed state, one functions better in general.”
—DR. MARGARET SCHENKMAN
“It's exciting to have a complementary or alternative approach to pharmaceutical drugs for treating non-motor skills in PD patients including depression and anxiety, which affect patients' quality of life,” said Indu Subramanian, MD, clinical professor of neurology at UCLA and director of the VA's Southwest Parkinson's Disease Research, Education and Clinical Center, who was not involved in the study.
She praised the study for being well-designed, including the 20-week follow-up, and having a large enough sample size to “power the data” given the relatively high drop-out rate. She agreed with the researchers' decision to exclude participants with severe motor disabilities.
“We can help patients feel better with mindful yoga, which is well-tolerated and can be sustained with just two 20-minute sessions a week. Focusing on the breath helps calm the autonomic nervous system, which is dysfunctional in PD patients,” said Dr. Subramanian.
Training yoga teachers in PD is important because “it's a complex disease with multiple layers and the last thing you want is to have a program being implemented incorrectly that harms a patient or worsens their mood,” said Dr. Subramanian, who co-developed a yoga program for PD patients and co-wrote a training manual for yoga teachers.
Dr. Subramanian encouraged neurologists to understand why yoga may be helpful for PD patients especially for non-motor issues such as anxiety or apathy that are not well treated and to refer them to trained teachers in their community who know about the disease.
“I was struck that an average of just six sessions of mindfulness yoga improved anxiety, depression, and motor function scores. This speaks to the tremendous importance of the mind-body connection. The findings suggest that when one is in a centered, relaxed state, one functions better in general,” said Margaret Schenkman, PT, PhD, FAPTA, professor and associate dean of physical therapy education at the Colorado University School of Medicine in Denver.
However, the overall ability of patients with PD to carry out daily physical functional activities includes more than these aspects, said Dr. Schenkman. She led a study on exercise in mild-to-moderate PD patients published in 2012 that suggests that flexibility and balance training that incorporated targeted spine flexibility exercises (the Axial Mobility Program) improved overall ability to carry out household activities.
She suggested that Dr. Kwok and her colleagues look next at how the mindfulness yoga program fits into the bigger picture of health, wellness, and function among patients with PD and what additional aspects of training are critical to daily functioning and participation in life activities.
Drs. Kwok and Schenkman had no competing interests. Dr. Subramanian receives honoraria from Acorda Therapeutics and Acadia Pharmaceuticals.