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By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
• The goal of this single-blind, randomized study was to compare a mindfulness-based yoga program developed for Parkinson's patients to conventional stretching and resistance training exercises in treatment of specific psychological and motor symptoms in patients with mild to moderate Parkinson's disease.
• Symptoms of anxiety and depression, measures related to mobility, severity of motor symptoms, and health-related quality of life were assessed at baseline, eight weeks, and 20 weeks in 138 patients with mild to moderate Parkinson’s disease.
• Participants in the mindfulness yoga program arm of the study had significant improvement in anxiety and depression measurements at both time points compared to participants in the stretching and resistance training exercises arm.
• Measures of motor functioning and mobility improved for both groups equally.
SOURCE: Kwok JYY, Kwan JCY, Auyeung M, et al. Effects of mindfulness yoga vs stretching and resistance training exercises on anxiety and depression for people with Parkinson disease: A randomized clinical trial. JAMA Neurol 2019;76:755-763.
SYNOPSIS: A mindfulness yoga program was more effective than stretching and resistance training in addressing the symptoms of depression and anxiety in patients with mild to moderate Parkinson’s disease; both interventions showed equal efficacy in improving symptoms related to motor impairment.
“Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forward, and to pass from a walking to a running pace: the senses and intellects being uninjured.” – James Parkinson, 1817
In the early 1800s, surgeon James Parkinson identified a cluster of patients with distinct appearance and motor impairment, but likely did not envision that one day his name would be attached to this neurological condition. It was not until the mid- to late 1800s that neurologist Jean-Martin Charcot, when describing cardinal features of the disorder, separated it from other known neurological conditions, and coined the term “Parkinson’s Disorder” to describe this set of patients typically presenting with bradykinesia, tremor, rigidity, and postural instability.1,2
Early treatment efforts aimed to ameliorate these motor symptoms via both pharmacologic and nonpharmacologic interventions. In the mid-1900s, medical science grew to understand the important role of dopamine in Parkinson’s disease (PD). By 1970, the use of high doses of levodopa (l-dopa) showed dramatic effects in addressing the motoric manifestations of PD. However, the progressive deterioration associated with this disorder continued, albeit at a slower pace.1,2
More recently, attention has shifted to nonmotor psychological symptoms of PD and the role these play in functional impairment and reduced quality of life (QOL). Up to 40% of patients with PD experience symptoms of anxiety disorders (including generalized anxiety disorder and panic disorder), and just under 20% experience a form of depression. Medication use and effectiveness is limited, in part because of side effects of these agents that worsen the motor manifestations of PD. Anxiety is thought to be critical to address since it can directly worsen some of the motor symptoms of PD, such as tremors and gait problems, as well as nonmotor symptoms, such as dysphagia, sleep disturbance, and cognitive impairment.3,4
Kwok et al noted the importance of managing psychological symptoms in patients with PD and theorized that a complementary approach could bypass the negative side effects seen with available pharmacologic agents. Additionally, the team noted that stretching and resistance training exercises (SRTE) are recommended for management of PD motor symptoms and that mind-body exercise, including yoga, tai chi, and dance, has documented evidence of effectiveness in controlling these symptoms. The premise of the Kwok et al study is that a program incorporating mindful movement, breathing exercises, and meditation could address both the motor and psychological symptoms of PD, leading to increased QOL. A mindfulness yoga program for PD (MY-PD) incorporating these elements was developed and compared to SRTE in this Hong Kong-based, assessor-blinded study.
MY-PD is a 90-minute program composed of 15 minutes of breathing exercises, 15 minutes of warm-up, 30 minutes of progressive Hatha yoga poses, 15 minutes of controlled breathing, and 15 minutes of meditation.
Participants with a diagnosis of mild to moderate PD who had the cognitive ability to participate in a full exercise and mindfulness program were recruited from regional neurology clinics. Exclusions included treatment for a psychiatric disorder. The investigators randomized 138 eligible participants to receive either 90 minutes of MY-PD weekly for eight weeks or 60 minutes of SRTE weekly over this same period. All participants were asked to practice at home as well.
Changes in anxiety and depressive symptoms, measured using the Hospital Anxiety and Depression Scale (HADS), a self-report questionnaire, are shown in Table 1. The HADS has subscales for anxiety and depression; on each subscale, higher scores indicate higher severity of symptoms. The minimal clinically significant difference in scores is 1.32 on HADS anxiety and 1.40 on HADS depression subscales; clinically relevant cut-off for diagnosis is a subscore of 8 (out of 28).
Notably, there was equivalent improvement in motor functioning and mobility at week 8 (end of each exercise program) and week 20 with each intervention. However, there were significant differences in improvement in measures of symptoms of anxiety, depression, and overall QOL in the participants undergoing MY-PD at most time points. The only exception was that at week 8, there was a nonsignificant improvement in anxiety symptoms among those in the MY-PD arm. By week 20, the improvement was statistically significant.
Additional measurements included severity of motor movements, mobility, spiritual well-being, and health-related QOL (HRQOL). Some adverse effects were reported. Several participants from each group reported temporary knee pain, but none required further medical intervention.
PD ranks second to Alzheimer’s disease as the most common neurodegenerative disease. In the United States, there are estimates that 60,000 new cases of PD are diagnosed each year, that about 1 million persons are currently diagnosed with PD, and that the direct and indirect economic impact of this disorder is greater than $20 billion annually. Although medication and even surgical interventions are helpful in controlling the motor impairments of PD, reducing the burden of the psychological nonmotor symptoms remains an elusive, under-investigated goal. As control of these nonmotor symptoms can be key to maintaining function and preventing out-of-home placement, addressing this issue with robust and sound medical studies is critical.3,4,5
Kwok et al added an important study to the field with this randomized, controlled trial of MY-PD vs. SRTE. Interestingly, both interventions consist of multiple elements. MY-PD combines mindfulness, yoga, and breathing exercises while SRTE combines stretching and resistance training. Although the combinations make practical sense, unfortunately this makes it more difficult to draw conclusions about efficacy. Future investigations most likely will need to address this issue by isolating and evaluating effectiveness of exercise program components.
A recently published comprehensive review of nonpharmacologic interventions to manage anxiety in PD explored this issue.6 This study reviewed 13 investigations of various quality and noted that a common element was the use of breath in a focused manner. They recommended looking at the “feasibility of using focused breathing, alone, as an intervention for the self-management of anxiety in Parkinson’s disease.”6
This recommendation is useful to keep in mind when reviewing the Kwok et al study, as focused breathing certainly is a major component of MY-PD. However, there is little necessity to wait for future investigations to recommend mindfulness-based yoga to patients with PD, especially since the motor improvements seen with MY-PD and SRTE were equivalent and the MY-PD arm demonstrated the added advantage of significant improvement in psychological symptoms.
One drawback to recommending this approach globally is that the research is not broad-based enough to generalize this approach for all patients with PD. There are several aspects of the research to keep in mind. First, it is important to remember that these authors looked for improvement in anxiety and depression symptoms, and that none of the groups showed a mean HADS score of clinically diagnosable levels for either of these disorders at baseline. This implies that while participants had symptoms of anxiety and depression, full criteria for a diagnosis were absent. It may be that those with more severe disease were not eligible for the study. Regardless, these results do not give information regarding the treatment of full-blown anxiety or depression with either intervention. Second, it is equally useful to note that the authors only looked at participants with mild to moderate PD; there is not enough information to extrapolate recommendations for treatment of patients with more severe PD.
Considering these limitations, the Kwok et al study certainly provides evidence for use of mindfulness-based yoga in patients with mild to moderate PD, especially for patients who have symptoms of anxiety and depression. While availability of such a program may be a limiting factor, the providers still can encourage patients and families to look for mindfulness-based interventions and discuss adoption of mindfulness techniques with physical therapists or others working with patients with PD. Furthermore, this study reminds providers and patients of the critical importance of a holistic approach to treatment of PD and the need to address both motor and nonmotor symptoms in a comprehensive treatment plan.
Financial Disclosure: Integrative Medicine Alert’s Executive Editor David Kiefer, MD; Peer Reviewer Suhani Bora, MD; Relias Media Associate Editor Journey Roberts; Editorial Group Manager Leslie Coplin; and Accreditations Manager Amy M. Johnson, MSN, RN, CPN, report no financial relationships relevant to this field of study.