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Yoga for Parkinson's Disease Part III: Does Yoga Help?


Hey hey readers! Welcome! In this blog series, I am reviewing what the science suggests about yoga’s effect on the symptomology of Parkinson’s Disease (PD). If you have not read part I (click here) and part II (click here), you might want to go back and check out those installments first, as they each give a good, detailed explanation about what PD is and the common symptoms experienced by people with PD (PWPD).


In this current installment, I am going to review what the scientific research has shown about yoga and PD. I am super excited to share this information with you all for three reasons. First, I work extensively with PD patients in my speech therapy practice, so this population is very close to my heart. Second, I am a devout yogi and yoga teacher, and I know personally how incredible yoga has been, and is, for me and my speech therapy patients. Third, my first master’s degree was in biology, where I published first-authored research in the neuroscience field. The field of science itself is hugely important to me because I believe it is the number one thing on this planet that we have to allow us to come close to what is real and true about our world. In this series, I am aiming to provide scientifically-validated information about yoga, exercise, and PD symptoms in the hopes that it could help those who deal, and live, with PD.


PWPD experience a wide array of symptoms, both in motor and nonmotor domains (see parts I and II for more information on this). Finding healthy and effective treatments is essential, and science gives us the best chance to accomplish that task. The research I am presenting in this installment is based on many well-conducted scientific research studies. Overall, the data is pretty clear – yoga helps those with PD in many, many ways. Read on to find out more about the research that is out there, what it has investigated, and what kind of results were seen. Please feel free to share this blog with anyone who might benefit.


WHAT IS YOGA?

Let me give a little background on what yoga is in case you might be new to the world of yoga. Yoga is a mind-body practice, where certain poses/postures, breathing, and meditation are the primary areas of focus. Yoga basically means “union,” where the body and mind become united via the breath. Sometimes referred to as “mindfulness in motion,” yoga encourages the practitioner to focus on what is occurring in the body, mind, and spirit during movement as well as in stillness. The practice of yoga is highly variable, with some types requiring intense physical postures, other types using easier physical postures, and still others involving more meditation/mental work. There is no right or wrong way to do yoga, as long as the practitioner is honoring what is true for him/her and attempting to stay present and connected to his/her body, mind, and spirit.


Yoga in general populations has been shown to increase awareness and attention for the body, mind, and breath. Practitioners of yoga also report improved balance, posture, flexibility, strength, endurance, agility, and overall fitness. Yoga students also report mental and emotional benefits. For example, yoga helps practitioners explore self-boundaries, redefine experiences (e.g. seeing an illness in a different way), accept what is true in a given moment, and foster resilience for dealing with challenging situations in life. So, the question posited in this blog series is, does yoga confer any benefits to PWDP, and if so, in what ways and how?


WHO WAS STUDIED?

In the research studies reviewed in this blog series, participants were identified as having mild-to-moderate PD. This was particularly interesting to me because in my clinical practice for speech therapy, I typically work with individuals with moderate-to-severe PD. I tried to see if there was research that examined late-stage, or more severe presentations of PD with yoga, but I was not successful at finding anything. But, this has given me an idea for a potential dissertation topic for if/when I go back for my PhD…


The age ranges of participants with PD included in the studies varied widely, but basically the research I read examined individuals over the age of 18 years, with most studies investigating PWPD between 45 – 80 years of age.


Other requirements for inclusion in the studies I read were that the participants with PD were able to walk at least 6m with, or without, an assistive device (i.e. walker), did not need assistance with transfers (e.g. moving from one spot to another), and had no history of falls within the last three months; essentially, the studies examined individuals with PD who were physically independent for all practical purposes. Again, this is highly interesting to me because the majority of my speech therapy patients spend most of their time in a wheelchair and/or are not physically independent. Again, I see a dissertation topic in my future. Also, the studies only included PWPD who had typically cognitive functioning.


WHAT KIND OF STUDIES WERE EXAMINED?

In science, there is a continuum of quality of evidence. In general, the “gold standard” of scientific research is the randomized control trial (RCT), where participants are randomly assigned to the various groups being studied. Even more powerful are meta-analyses of RCTs, where a bunch of RCTs are analyzed together. I am super excited to announce that the majority of the studies I am presenting data from were either RCTs or meta-analyses of RCTs. Thus, you can have pretty strong confidence that this data is representative of those with PD.


In the studies presented here, there was always a yoga intervention group, and this group was compared to one, or more, of the following comparison groups: resistance training, balance training, wait-list control, routine care, dancing, aerobic exercise (walking, cycling), aquatic training, other mind-body exercises (Tai Chi, Qi Gong), and virtual reality training. In part IV of this blog series, I will go into the research for these other forms of physical activity for PD, so stay tuned!


Motor and nonmotor outcomes were studied, where measurements were obtained before the yoga intervention (i.e. baseline), at the conclusion of the intervention, and at some future time point (typically 6 months out). No serious adverse events were reported by any of the participants in the studies, and participants self-reported that they enjoyed the yoga intervention and felt it was easy to adhere to. So, what did the research find out about yoga for PD?? Read on to find out!


STUDY RESULTS - DOES YOGA HELP?

In general, the results of the studies were highly positive, showing that yoga helped ease, reduce, and mitigate nearly all symptoms of PD. Below is a list of all the areas that showed improvement after participants completed the yoga intervention.


Disease severity. Yoga resulted in improvements in ratings of PD severity, where some individuals with moderate PD presented with more mild PD after the yoga intervention.


Cardinal motor symptoms. Yoga resulted in improvements with tremors, rigidity (tightness), bradykinesia (slowness of movement), and posture (the so-called 4 cardinal motor symptoms of PD). Re: posture, PWDP were more stable, upright, and demonstrated less forward rounding of the spine; also, those with PD demonstrated less postural sway and instability during stillness and movement.


Functional mobility. Yoga resulted in improvements with activities of daily living (ADLs), such as dressing, bathing, toileting, and moving around the environment. Also, after yoga, PWPD were better at transitions (shifting from one position/location to another), and they were more able to react quickly and appropriately to external stimuli (e.g. obstacles in the path). Also, there were improvements in reaction time and movement speed. Gait (e.g. walking speed, turning time, cadence, foot clearance height) improved, and instances freezing of gait (FoG) decreased. Fall risk and fear of falling (FoF) both decreased. Thus, after yoga PWPD were better able to safely and efficiently navigate their environment and daily tasks. This is huge because falls are sadly very common in PWPD and can lead to some quite debilitating injuries (e.g. broken hips, broken ribs, etc.).


Muscle kinematics. After yoga, many different muscle parameters improved. Specifically, balance improved, meaning that the muscles were better able to stabilize joints during movement and stillness (this also reduces fall risk). Muscle strength, endurance, and power, in both upper and lower limbs, improved after yoga intervention (for more information about these muscle characteristics click here).


Psychological and psychosocial outcomes. Anxiety and depression significantly decreased after the yoga intervention. Quality of life (QOL) significantly improved in PWPD after yoga. Even more, the research showed that yoga might actually be the most successful intervention for psychological outcomes compared to other forms of physical activity.


Cognitive function. This includes things like memory, problem-solving, planning, organizing, sequencing, and attention. The data here was a little mixed. Some studies found a positive effect on cognitive skills after yoga intervention, while others did not. So, maybe yoga helps with cognition? I am going to actually tackle this very question (not specifically for PD) in my next big blog series all about yoga for dementia (released towards the end of this year), so stay tuned for that!


Sleep. Variables such as sleep onset, nocturnal restlessness and psychosis, as well as daytime dozing were studied. Similar to cognitive skills, the data for yoga’s effect on sleep in PD was also mixed. So it is unclear at this time if yoga has an effect on sleep outcomes.


Pain. Chronic pain is a massive problem for those with PD, and can often lead to PWPD being put into hospice care so that they can receive the palliative care they need to control the pain symptoms. The research suggested that yoga resulted in reduced pain in general, as well as reduced low back pain, and reduced shoulder pain.


Respiratory function. The ability of the lungs to expand and take in a full breath of air improved for PWPD who received the yoga intervention. This makes total sense for two reasons. One, the breath and proper breathing is incredibly important and integral to the practice of yoga. And, two, the improvements in posture and muscle strength would allow for a more opened trunk, which would allow the lungs to expand more with the breath.


Gastrointestinal (GI) functioning. Yoga resulted in reduced constipation and improved GI motility in PWPD.


Blood pressure. Yoga resulted in improved blood pressure measurements in those with PD.


Oxidative stress. Oxidative stress is one of the hypothesized reasons for the pathology of PD (see part II of this series for more). One study investigated markers of oxidative stress – specifically, glutathione levels. Glutathione is helpful for reducing oxidative stress, so this study examined if yoga perhaps would improve glutathione levels. Sadly, this study did not find an effect from yoga on glutathione levels. So, maybe more research would show an effect, or maybe yoga just doesn’t help with this. That is yet to be determined at this time.


WHAT KIND OF YOGA WAS STUDIED

In the research studies I read, yoga sessions were held for 30-60 minutes, 1-2x per week for 8-12 weeks. Some studies included a home practice component, where participants had to do a home yoga practice twice per week for approximately 20 minutes. Thus, for the yoga to be effective it seems best to participate in the practice regularly and frequently for an extended period of time.


All of the following were programmed into each yoga intervention – centering with breathwork and meditation, gentle warming movements, sun salutations, more demanding standing poses and flows, cool down and stretching, and resting pose.


HOW MIGHT YOGA CONFER ITS BENEFITS?

The data strongly suggest that yoga is highly effective for improving PD symptoms. So, why might yoga be helpful? Well, gosh, there are many potential reasons, so I will put forth a few of my hypotheses.


Increased flexibility from the yoga postures and flows could theoretically reduce bradykinesia and rigidity. Balance could improve because many yoga postures challenge balance by placing the body in a variety of unstable positions, where different appropriate muscle activation is required to stabilize the joints. Also, the balance challenges imposed in a yoga practice can improve sensitivity of muscle proprioception, which allows the practitioner to have a better sense of where his/her body is in space and how it is moving. The vestibular, or balance system, also gets exercised in yoga, which could also explain the improvements in balance. This could also help explain why functional mobility improved too.


Yoga postures are essentially a body weight workout, so this could explain the improvements in strength and power, and the improved endurance might be because of the flowing-like nature of yoga, where one pose is sequenced after another, moving in/out of poses with the breath.


Regarding the psychological benefits of yoga, this could be due to the fact that yoga helps to improve parasympathetic nervous system activation, which is the body’s rest/digest/repair system (click here to read more about this). This helps the yoga student to feel more relaxed, calmer, and more at ease. Additionally, the through the practice of mindfulness, practitioners learn to relate differently to their physical symptoms with a nonjudgmental attitude, which could explain the improvements in mood and QOL.


SUMMARY

Thank you so much for sticking with me until the end of this very dense post! Several RCTs and meta-analyses of RCTs have evaluated the impact of yoga on motor and nonmotor functions in PWPD. The results seem to suggest that yoga essentially helps improve nearly all symptoms associated with the disease. While it is pretty clear that yoga is an effective and alternative treatment for PWPD, there are still some unanswered questions. First, as mentioned earlier, are these same effects seen in those with more severe forms of PD? Also, while most studies examined yoga interventions 1-2 times per week for 8-12 weeks, it is unclear what the optimal dose and frequency of yoga is. Perhaps more frequent yoga, or a different combination of different styles of yoga (e.g. restorative, power, etc.) would lead to greater results, or perhaps not. Third, what are the long-term gains like, if any? For instance, do PWPD see benefits over time with continued practice? Or, is there a point where the progressive nature of PD takes over and makes the yoga less effective? Overall, my takeaway from this data is that integrating yoga into the life of a PWPD can help optimize his/her wellbeing and QOL. Of course every BODY is different and responds differently to things, but why not at least give it a try and see if it helps. Thank you so much for joining me this month. Come back next month for part IV of this series, where I will go over what the research suggests about other forms of physical activity and PD.


As always, the information presented in this blog post is derived from my own study of human movement, anatomy and physiology, yoga, and neuroscience. If you have questions about Parkinson's disease specific for you, please follow up with your physician, neurologist, or physical therapist. If you are interested in private yoga and/or personal training sessions with me, Jackie, email me at info@lotusyogisbyjackie.com for more information about my services. Also, please subscribe to my website so you can receive my monthly newsletters (scroll to the bottom of the page where you can submit your email address). This will help keep you "in-the-know" about my latest blog releases and other helpful yoga and wellness information. Thanks for reading!

~Namaste, Jackie Allen, M.S., M.Ed., CCC-SLP, RYT-200, RCYT, NASM-CPT, NASM-CES, NASM-CNC, NASM-SFC, NASM-WLS


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