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Figure.
Flow Diagram
Flow Diagram
Table 1.  
Baseline Sociodemographic Characteristics of the Participants
Baseline Sociodemographic Characteristics of the Participants
Table 2.  
Generalized Estimating Equation Analysis for the Comparison of Outcomesa
Generalized Estimating Equation Analysis for the Comparison of Outcomesa
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Original Investigation
April 8, 2019

Effects of Mindfulness Yoga vs Stretching and Resistance Training Exercises on Anxiety and Depression for People With Parkinson Disease: A Randomized Clinical Trial

Author Affiliations
  • 1School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
  • 2The Hong Kong Society for Rehabilitation, Hong Kong Special Administrative Region
  • 3Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong Special Administrative Region
  • 4Department of Medicine and Therapeutics, Therese Pei Fong Chow Research Center for Prevention of Dementia, Gerald Choa Neuroscience Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
  • 5Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong Special Administration Region
  • 6The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
JAMA Neurol. 2019;76(7):755-763. doi:10.1001/jamaneurol.2019.0534
Key Points

Question  Is yoga—a mindfulness-based exercise intervention—a safe and favorable coping strategy compared with conventional stretching and resistance training exercise for management of stress and symptoms in people with mild-to-moderate Parkinson disease?

Findings  In this randomized clinical trial that included 138 patients with Parkinson disease, the mindfulness yoga program appeared to be a safe and favorable coping strategy for patients with Parkinson disease to address their physical and emotional needs. Compared with conventional stretching and resistance training exercise, mindfulness yoga showed additional benefits on psychological distress, spiritual well-being, and health-related quality of life, with comparable benefits related to motor symptoms and mobility.

Meaning  Mindfulness yoga appeared to be an effective and safe treatment option for patients with mild-to-moderate Parkinson disease for stress and symptom management; further investigation is warranted to establish its long-term effect and compliance.

Abstract

Importance  Clinical practice guidelines support exercise for patients with Parkinson disease (PD), but to our knowledge, no randomized clinical trials have tested whether yoga is superior to conventional physical exercises for stress and symptom management.

Objective  To compare the effects of a mindfulness yoga program vs stretching and resistance training exercise (SRTE) on psychological distress, physical health, spiritual well-being, and health-related quality of life (HRQOL) in patients with mild-to-moderate PD.

Design, Setting, and Participants  An assessor-masked, randomized clinical trial using the intention-to-treat principle was conducted at 4 community rehabilitation centers in Hong Kong between December 1, 2016, and May 31, 2017. A total of 187 adults (aged ≥18 years) with a clinical diagnosis of idiopathic PD who were able to stand unaided and walk with or without an assistive device were enrolled via convenience sampling. Eligible participants were randomized 1:1 to mindfulness yoga or SRTE.

Interventions  Mindfulness yoga was delivered in 90-minute groups and SRTE were delivered in 60-minute groups for 8 weeks.

Main Outcomes and Measures  Primary outcomes included anxiety and depressive symptoms assessed using the Hospital Anxiety and Depression Scale. Secondary outcomes included severity of motor symptoms (Movement Disorder Society Unified Parkinson’s Disease Rating Scale [MDS-UPDRS], Part III motor score), mobility, spiritual well-being in terms of perceived hardship and equanimity, and HRQOL. Assessments were done at baseline, 8 weeks (T1), and 20 weeks (T2).

Results  The 138 participants included 65 men (47.1%) with a mean (SD) age of 63.7 (8.7) years and a mean (SD) MDS-UPDRS score of 33.3 (15.3). Generalized estimating equation analyses revealed that the yoga group had significantly better improvement in outcomes than the SRTE group, particularly for anxiety (time-by-group interaction, T1: β, −1.79 [95% CI, −2.85 to −0.69; P = .001]; T2: β, −2.05 [95% CI, −3.02 to −1.08; P < .001]), depression (T1: β, −2.75 [95% CI, −3.17 to −1.35; P < .001]); T2: β, −2.75 [95% CI, −3.71 to −1.79; P < .001]), perceived hardship (T1: β, −0.92 [95% CI, −1.25 to −0.61; P < .001]; T2: β, −0.76 [95% CI, −1.12 to −0.40; P < .001]), perceived equanimity (T1: β, 1.11 [95% CI, 0.79-1.42; P < .001]; T2: β, 1.19 [95% CI, 0.82-1.56; P < .001]), and disease-specific HRQOL (T1: β, −7.77 [95% CI, −11.61 to −4.38; P < .001]; T2: β, −7.99 [95% CI, −11.61 to −4.38; P < .001]).

Conclusions and Relevance  Among patients with mild-to-moderate PD, the mindfulness yoga program was found to be as effective as SRTE in improving motor dysfunction and mobility, with the additional benefits of a reduction in anxiety and depressive symptoms and an increase in spiritual well-being and HRQOL.

Trial Registration  Centre for Clinical Research and Biostatistics identifier: CUHK_CCRB00522

Introduction

Parkinson disease (PD) is the second most common chronic neurodegenerative disease with heterogeneous symptomatology.1 Although PD is characterized by 4 motor symptoms (resting tremor, rigidity, bradykinesia, and postural instability), patients with PD experience a variety of nonmotor symptoms, including neuropsychiatric problems, cognitive impairment, sleep disturbances, and autonomic dysfunction. Psychological distress, including anxiety and depression (frequently co-occuring), is common in patients with PD, with a prevalence of 40% to 50%,2 and is associated with care dependency, poor work and social function, fast physical and cognitive decline, increased dementia risk, and high mortality.3-6 Recent evidence identifies functional impairment and psychological distress as significant associating factors of impaired health-related quality of life (HRQOL) in patients with PD,7,8 with psychological distress contributing most to the variance in HRQOL (42.4%; P < .01).2 Despite the high prevalence and substantial negative consequences of psychological distress, this problem is poorly recognized and rarely addressed. Because there is a lack of optimal pharmacologic management options, adopting a complementary, nonpharmacologic approach to manage stress and symptoms in patients with PD is indispensable.7

Exercise and physical therapy have been recommended as essential components in PD rehabilitation, complementary to pharmacotherapy and functional surgery.8-10 A recent systematic review of the long-term effects of exercise and physical therapy for patients with PD concluded that most stretching and resistance training programs had clinically significant benefits on mobility, gait, and balance among patients with PD for the duration of exercise implementation.11 For instance, stretching can reduce the shortening of flexor muscles that contribute to the abnormally flexed posture in PD,8 and resistance training can increase muscle strength and enhance gait performance.12,13 Besides physical exercise, mind-body exercises have been reported to be the most common complementary strategies adopted by patients with PD to enhance their physical and holistic well-being.14

Mind-body exercises adopt an integrative body-mind-spirit approach to achieve physical and mental benefits through physical exertion.15 A 2016 meta-analysis16 concluded that mind-body exercises, including yoga, dance, and tai chi, had immediate moderate-to-large beneficial associations with motor symptoms, postural instability, and functional mobility among patients with mild-to-moderate PD. However, besides physical parameters, studies examining such effects on psychosocial outcomes and HRQOL among patients with PD are lacking. Because psychosocial factors play an important role in stress and associated physical and psychosocial disability,2,17 mind-body exercise, which emphasizes mindfulness during physical exertion, may be superior to conventional physical exercise for stress and symptom management in patients with PD. A mindfulness yoga program—Mindfulness Yoga for PD (MY-PD)—that integrates and emphasizes mindfulness training in yoga practice was tailored for patients with mild-to-moderate PD.

This randomized clinical trial examined the comparative effects of MY-PD and stretching and resistance training exercises (SRTE) on psychological distress (primary outcome), as well as physical health, spiritual well-being, and HRQOL (secondary outcomes) in patients with mild-to-moderate PD. Compared with patients receiving SRTE, we hypothesized that patients with PD randomly assigned to receive the mindfulness yoga program would show a greater improvement in psychological distress in terms of anxiety and depressive symptoms, physical health in terms of motor symptoms and mobility, spiritual well-being in terms of perceived equanimity and hardship, and HRQOL.

Methods
Study Design

This study was an assessor-masked, multicentered, randomized clinical trial of PD that compared MY-PD with SRTE. The trial protocol has been published,18 and the original trial protocol is available in Supplement 1. The setting was outpatient clinics and community-based rehabilitation facilities. The institutional review board of each site (Hong Kong East Cluster Research Ethics Committee and Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee) approved the protocol. All participants provided written informed consent, and all data were anonymous. This trial followed the Consolidated Standards of Reporting Trials Extension (CONSORT Extension) reporting guideline.

Study Participants

Participants with idiopathic PD were enrolled using convenience sampling from December 1, 2016, to May 30, 2017. Participants were recruited through 2 regional neurology outpatient clinics and 4 centers of the Hong Kong Society of Rehabilitation, Hong Kong Parkinson’s Disease Association. These sites cover the 3 main regions in Hong Kong, including Hong Kong Island, Kowloon, and the New Territories. Participants were eligible for inclusion in the trial if they had a clinical diagnosis of idiopathic PD with a disease severity rating of stage 1 on the Hoehn and Yahr scale 3 (rated on a scale of 1-5, with higher numbers indicating more severe disease), were older than 18 years, could stand unaided and walk with or without an assistive device, and could give written consent. Participants were excluded if they were currently receiving pharmacologic (eg, antidepressants) or surgical treatments (eg, deep brain stimulation) for psychiatric disorders (eg, schizophrenia, psychosis, or major depressive disorder), were currently participating in another behavioral or pharmacologic trial or instructor-led exercise program, had significant cognitive impairment (Abbreviated Mental Test Score <6 [range, 0-10]),19 or had debilitating conditions other than PD (eg, hearing or vision impairment) that could impede full participation in the study.

Screening, Baseline Testing, and Randomization

Prescreening was done via telephone and in neurology clinics. Participants who met the criteria underwent baseline assessments. Participants were randomly allocated to experimental or control groups at a 1:1 ratio through a computer-based permuted block randomization with a block size of 8. The randomization sequence was generated by an independent research coordinator, and the details of the group allocation were concealed on cards placed inside sequentially numbered, sealed opaque envelopes.

Interventions
Mindfulness Yoga for PD

For 8 weeks, the intervention group received a weekly 90-minute session of MY-PD (eMethods 1 in Supplement 2). In addition, all participants were encouraged to perform 20-minute home-based practice twice a week. The MY-PD protocol includes a progressive and stepwise delivery of the 12 basic Hatha yoga poses: sun salutations (60 minutes) with controlled breathing (15 minutes) and mindfulness meditation (15 minutes). The MY-PD protocol was developed and guided by the theory of self-transcendence (eMethods 2 in Supplement 2)16 and grounded on the findings obtained from a systematic review13 and a mixed-methods study of the illness experience and unmet care needs of local patients with PD.2,17

Stretching and Resistance Training Exercises

For 8 weeks, the control group received a weekly 60-minute session of SRTE (eTable 1 in Supplement 2). All participants were also encouraged to perform 20-minute home-based practice twice a week. The SRTE protocol consisted of a progressive set of warm-up, resistance training and stretching, and cool-down exercises, which were reviewed by 2 physiotherapists to confirm the validity for the patients with PD.

The integration of an active control group was aimed at counteracting the confounding effects of regular social interaction among participants. The interventions were comparable in format (group), frequency (weekly), duration (8 weeks, although the mindfulness yoga had an additional 30 minutes per session), number of participants per group (15-20 participants per session), and venue (activity rooms in community rehabilitation centers). Each intervention was delivered according to a manualized protocol in which all instructors were trained. The MY-PD was delivered by a yoga instructor with mindfulness-based stress reduction teacher qualifications, whereas SRTE was given by 2 qualified fitness instructors. All instructors were experienced in teaching people with chronic illnesses. Participants in each intervention were given an information booklet covering instructions for home practice. An information booklet with instructions for each intervention was given to all participants, whereas audios and videos were given only to the participants in the MY-PD group (eg, body scan, meditation, yoga movements, and controlled breathing). In addition, sessions were audiotaped, and a study investigator (J.Y.Y.K.) monitored instructors’ adherence to the protocol using the audio recording for at least 2 sessions per group.

Outcome Measures

Outcome assessors were trained and masked to group allocation. Each participant was invited to the nearby community rehabilitation center to conduct a face-to-face clinical assessment and interview. All assessments were conducted during the “on state” of levodopa treatment to minimize motor fluctuations among participants, if indicated. All outcome measures were administered at each time point: baseline (T0), 8 weeks (immediately after the intervention) (T1), and 20 weeks (3 months after the intervention) (T2).

The primary outcome, psychological distress in terms of anxiety and depressive symptoms, was measured using the validated Hospital Anxiety and Depression Scale (HADS) (Chinese-Cantonese language),20,21 which is a self-report questionnaire that consists of anxiety and depression subscales. Each subscale consists of 7 items, and each item is rated on a 4-point scale. A high score represents a high level of psychological distress. The HADS has been suggested for use in the population with PD because somatic symptoms that may potentially overlap parkinsonian manifestations are not assessed on this scale.22,23 Also, HADS focuses on measuring the negative emotions of anxiety and depression, which have been reported as being the most prominent psychological factors in patients with PD. In the present study, the levels of anxiety and depression were considered to be clinically relevant at a cutoff value of at least 8 on each subscale (anxiety: sensitivity, 0.89; specificity, 0.75; depression: sensitivity, 0.80; specificity, 0.88)24 and at least 15 for the full scale (sensitivity, 0.79; specificity, 0.80).20 The minimal clinical important difference of HADS anxiety scores was 1.32 and of HADS depression scores was 1.40.25

Secondary outcomes included (1) severity of motor symptoms as measured by the validated Movement Disorders Society Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), Part III (Chinese version),26 which covers domains related to tremor, rigidity, bradykinesia, gait, and postural instability; (2) mobility as measured by the validated Timed Up and Go Test27,28; (3) spiritual well-being as measured by the validated Holistic Well-being Scale (Chinese version),29 which covers 2 major concepts of spiritual health (perceived hardship and perceived equanimity [enduring happiness]) (eMethods 3 in Supplement 2); and (4) HRQOL as measured by the validated disease-specific 8-item Parkinson’s Disease Questionnaire (Chinese version),30,31 which yields a summary index score capturing disease-specific HRQOL regarding mobility, activities of daily living, emotional well-being, social support, cognitions, communication, bodily discomfort, and stigma.

Adverse Events

Adverse events were identified during the intervention sessions and by follow-up interview questions about significant discomfort, pain, or harm caused by the intervention. Participants were instructed to inform the research team if they encountered any adverse event related to the study.

Sample Size

According to a meta-analysis of the association of yoga with depression compared with aerobic exercises,32 a moderate effect size of 0.59 was reported for people who presented with depressive symptoms. Assuming an attrition rate of 25%,16 a sample size of 126 participants with 63 participants per arm was required to provide a 2-arm trial with 80% power to detect an effect size of at least 0.59 at a 5% level of significance.

Statistical Analysis

Descriptive statistics were used to summarize the demographics, health conditions, and clinical outcomes of the participants at each time point. The normality of variables was assessed using the skewness statistic and normal probability plot. All participants were examined at T0, T1, and T2 for changes in psychological distress, motor symptoms, mobility, spiritual well-being, and HRQOL. The intention-to-treat principle was applied. Generalized estimating equation models, specifically with a first-order autoregressive structure, were used to assess the differential change in the primary outcome variable (HADS score) and secondary outcome variables (MDS-UPDRS, Timed Up and Go Test, Holistic Well-being Scale, and 8-item Parkinson’s Disease Questionnaire scores) between the 2 groups at T1 and T2 compared with T0 for both outcomes. Completers and noncompleters were compared to check for any differences in demographic characteristics and health conditions. Statistical analysis was performed using SPSS statistical software, version 22.0 (IBM Corporation). All statistical tests were 2-tailed with a 5% level of statistical significance.

Results

Of 187 potential participants screened, 31 did not meet eligibility criteria and 18 declined to participate (enrollment rate: 73.8%) (Figure). Of the 138 participants randomized, 71 were in the experimental group and 67 were in the control group. Participants randomized to the MY-PD group attended at least 1 session, whereas 15 of 67 participants (22.4%) randomized to the SRTE group did not attend any sessions. The mean (SD) attendance rates were 6.1 (1.9) sessions for the MY-PD group and 6.1 (2.4) sessions for the SRTE group; 50 of 71 participants (70.4%) attended at least 6 sessions of MY-PD, and 55 of 71 participants (77.6%) attended at least 6 sessions of SRTE. The overall dropout rates were 21 of 138 (15.2%) at T1 (MY-PD: 13 of 71 [18.3%]; SRTE: 8 of 67 [11.9%]) and 26 of 138 (18.8%) at T2 (MY-PD: 14 of 71 [19.7%]; SRTE: 12 of 67 [17.9%]). The compliance rates of home practice during the intervention period were 70.4% (50 of 71) for the MY-PD and 73.3% (49 of 67) for the SRTE groups.

Baseline Characteristics of Participants

Intervention and control groups were similar in sociodemographic and clinical characteristics at baseline except more participants from the MY-PD group had received less education and lived alone (Table 1). The mean (SD) age of participants was 63.6 (8.7) years, ranging from 38 to 85 years, and 73 of 138 were female (52.9%). Mild PD (Hoehn and Yahr scale, stage 1–2) was seen in 44 of 138 participants (31.9%), and most (94; 68.1%) had moderate PD (Hoehn and Yahr scale, stage 3). The mean (SD) MDS-UPDRS score was 33.3 (15.3) among all participants. For psychological distress, 52 of 138 (37.7%) presented with clinically significant anxiety symptoms and 48 of 138 (34.8%) with clinically significant depressive symptoms, with a mean (SD) HADS score of 12.4 (6.7). No significant heterogeneity of the demographic data and baseline characteristics was found among those who completed the intervention vs those who did not complete the intervention (eTable 2 in Supplement 2).

Coprimary Outcomes

For anxiety and depressive symptoms, the groups differed significantly at the T1 (P = .001) and T2 (P < .001) end points (Table 2). Compared with the SRTE group, the MY-PD group demonstrated significantly better improvement in anxiety (time-by-group interaction, T1: β, −1.79 [95% CI, −2.85 to −0.69; P = .001]; T2: β, −2.05 [95% CI, −3.02 to −1.08; P < .001]) and depressive symptoms (T1: β, −2.75 [95% CI, −3.17 to −1.35; P < .001]; T2: β, −2.75 [95% CI, −3.71 to −1.79; P < .001]). In the SRTE group, no significant improvement was noted in anxiety and depressive symptoms across time points.

Secondary Outcomes

Both groups showed a significant reduction in motor symptoms (mindfulness yoga, T1: β, −13.90 [95% CI, –15.85 to –11.95, P < .001]; T2: β, −11.59 [95% CI, −13.61 to −9.56; P < .001]); SRTE, T1: β, −8.71 [95% CI, −10.94 to −6.48; P < .001]; T2: β, −6.88 [95% CI, −9.08 to −4.68; P < .001]). Compared with the SRTE group, the MY-PD group showed significant improvement in MDS-UPDRS motor scores (T1: β, −5.19 [95% CI, −8.15 to −2.24; P = .001]; T2: β, −4.71 [95% CI, −7.70 to −1.72; P = .002]), spiritual well-being in terms of perceived hardship (time-by-group interaction, T1: β, −0.92 [95% CI, −1.25 to −0.61; P < .001]; T2: β, −0.76 [95% CI, −1.12 to −0.40; P < .001]) and perceived equanimity (T1: β, 1.11 [95% CI, 0.79-1.42; P < .001]; T2: β, 1.19 [95% CI, 0.82-1.56; P < .001]), and disease-specific HRQOL (T1: β, −7.77 [95% CI, −11.61 to −4.38; P < .001]; T2: β, −7.99 [95% CI, −11.61 to −4.38; P < .001]) at T1 and T2, whereas no significant between-group difference was noted in the Timed Up and Go Test scores at either end point.

Adverse Events

Three participants (4.2%) from the MY-PD group reported temporary mild knee pain associated with yoga, which resolved with the use of a prop (placing a thick towel on the knee); no medical attention was needed. Two participants (3.0%) from the SRTE group reported temporary mild knee pain when squatting or after squatting but required no medical attention. No serious adverse events were reported.

Discussion

Results indicate that MY-PD was superior to conventional SRTE for managing anxiety and depressive symptoms at T1 and T2. The improvement of anxiety and depressive symptoms in the MY-PD group was considered to be statistically and clinically significant. Although the participants in the MY-PD group reported significantly greater improvement in MDS-UPDRS scores compared with those in the SRTE group during the study period, the differences in the mean scores between the 2 groups were considered to be clinically insignificant. Thus, MY-PD was as effective as SRTE in improving motor dysfunction and mobility, with additional benefits related to perceived hardship, perceived equanimity, and HRQOL in people with PD.

The MY-PD group had greater improvement in psychospiritual outcomes, including anxiety and depressive symptoms, perceived hardship, perceived equanimity, and HRQOL at T1 and T2 compared with the SRTE group. 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.33 These benefits were remarkable because the participants who received the MY-PD intervention attended a mean of only 6 sessions.

Both groups showed significant improvement in physical outcomes related to motor symptoms and mobility, with no statistically and clinically significant superiority noted. These findings were consistent with the conclusion of a 2017 systematic review11 that reported exercise interventions had beneficial effects on the physical health of patients with PD. This study also partially confirmed the findings of another review of exercise interventions in PD34 that found that physical exercise interventions had a positive impact on physical and functional capacities, but there was inconsistent evidence of its effects on nonmotor symptoms and the psychosocial aspects of life. Integrating mindfulness training into evidence-based exercise prescription, such as stretching and progressive resistance exercises,35,36 could be considered in future PD rehabilitation to optimize patients’ well-being.

Our study findings showed that only the MY-PD group demonstrated significant improvement regarding the psychospiritual aspects of life. Mindfulness yoga has been shown to be more effective than conventional physical exercises for psychological distress management. The noticeable success of the mindfulness yoga program in improving psychospiritual well-being confirms the mindfulness component of the interventions.

Mindfulness, a modern Buddhist meditation practice, emphasizes the nonjudgmental acceptance of people and symptoms and the value of being in the here and now.37 From the Buddhist context, hardship is inherent in life processes, whereas nonattachment to pleasures and hardship brings about emotional stability. Although the current study is not intended to emphasize Buddhist philosophy or religion, the patients with PD who engaged in mindfulness practice inevitably exhibited increased spiritual self-care. Thus, they may have cultivated a greater acceptance toward hardship and perceived less hardship and more equanimity while confronting the vulnerable conditions of PD.

These findings are consistent with the conclusions of various recent systematic reviews38,39 that reported that mindfulness-based interventions had beneficial associations with the physical and mental health of patients with chronic conditions. Through the practice of mindfulness, patients learn to relate differently to their physical symptoms with a nonjudgmental attitude, such that when new symptoms emerge, the consequences are less significantly disturbing.40,41 In addition to preserving physical and functional capacities, the mindfulness yoga program appeared to be a favorable strategy for stress and symptom management among patients with PD.

Our findings of the increased effects of mindfulness yoga at T1 to T2 follow-up regarding psychospiritual outcomes contrasted with the findings of other studies of dance therapy42 and Qigong43,44 conducted in the same population. In those studies, the treatment effects decreased at follow-up. This suggests that mindfulness-based interventions may provide patients with long-lasting skills effective for stress and symptom management. Substantial residual gains of mindfulness practices have been reported for psychiatric treatments. Shapiro and Carlson45 highlighted the dynamic and evolving nature of mindfulness skills, which would continue to grow and deepen alongside practice. Morgan46 found that the residual gains of mindfulness skills were significantly associated with reductions in anxiety and worry and with improved HRQOL. The present-focused nature of mindfulness practice may exert a long-lasting beneficial effect as an emotional coping skill to counter the future-oriented nature of anxiety and worry and the past-oriented nature of depression and rumination. Although the residual gains of mindfulness skills were not measured in the present study, the results highlight the importance of continual mindfulness practice in daily living.

To complement the subjective self-reported outcomes regarding psychological distress in the present study, future research should integrate the use of objective psychoneuroimmunologic markers (such as cortisol and cytokines) to elucidate the mediating effects of mindfulness yoga on stress and inflammatory responses in relation to progression of PD. Research to evaluate the long-term benefits and compliance of mindfulness yoga, identify the reasons for noncompliance, determine the minimum dose required, and perform cost-effectiveness analysis is also necessary.

Compared with other relatively well-established mindfulness practices, including 8-week mindfulness-based stress reduction and cognitive behavioral therapy, our mindfulness yoga program adopts a dynamic exercise approach of mindfulness practice that relies on physical exertion to achieve physiopsychospiritual benefits. Further research is needed to compare different approaches of mindfulness practices, for example, exercise-oriented yoga vs meditation-oriented mindfulness. Regarding the cultural popularity of various mindfulness practices, a better understanding of the different mindfulness practices is crucial to enable patients and health care professionals to select the best practice to optimize the benefits, satisfaction, adherence, and sustainability for each patient.

Strengths and Limitations

Study strengths include an assessor-masked, randomized clinical design with large sample and adequate statistical power to detect a clinically meaningful effect, multiple follow-up time points to elucidate the residual effects of interventions, involvement of an active control group, and comprehensive measurement of physiopsychospiritual outcomes.

The limitations of this study must be acknowledged. Expectation bias may exist because participants were aware of the treatment allocation. Selection bias may arise because study participants were enrolled through convenience sampling. The volunteer sample might be more active in reaching out to community resources and more willing to exercise compared with those who refused to participate or withdrew from the study. There might be potential bias based on female predominance and early dropout (n = 15) in the SRTE group. Females were more interested in receiving mindfulness yoga intervention. Because SRTE was more commonly prescribed for PD rehabilitation, future control may incorporate more innovative designs, such as performing resistance training on an unstable device,12 to enhance participants’ interest, uptake, and adherence of the control intervention. We purposely excluded people with severe PD who had severe motor limitations, and the attrition rates of 15.2% at T1 and 18.8% at T2 should be acknowledged. The results were based on a unique population of people with mild-to-moderate PD who attended the follow–up sessions. All these factors may limit the generalizability of the study findings to the entire PD population.

Conclusions

Among people with mild-to-moderate PD, mindfulness yoga compared with conventional SRTE resulted in greater improvement in psychospiritual and HRQOL outcomes and had similar benefits on physical outcomes, including motor symptoms and mobility. These findings suggest that mindfulness yoga is an effective treatment option for patients with PD to manage stress and symptoms. Considering that PD is not only a physically limiting condition but also a psychologically distressing life event, health care professionals should adopt a holistic approach in PD rehabilitation. Future rehabilitation programs could consider integrating mindfulness skills into physical therapy to enhance the holistic well-being of people with neurodegenerative conditions.

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Article Information

Accepted for Publication: January 11, 2019.

Corresponding Author: Jojo Y. Y. Kwok, PhD, MPH, BN, RN, School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 4/F, William MW Mong Block, 21 Sassoon Rd, Pokfulam, Hong Kong Special Administrative Region (jojo.yykwok@gmail.com).

Published Online: April 8, 2019. doi:10.1001/jamaneurol.2019.0534

Author Contributions: Dr Kwok had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kwok, Kwan, Mok, Chan.

Acquisition, analysis, or interpretation of data: Kwok, Auyeung, Lau, Choi, Chan.

Drafting of the manuscript: Kwok, Kwan, Mok, Chan.

Critical revision of the manuscript for important intellectual content: Kwok, Auyeung, Lau, Choi, Chan.

Statistical analysis: Kwok, Choi.

Obtained funding: Kwok.

Administrative, technical, or material support: Kwok, Kwan, Auyeung, Mok, Lau.

Supervision: Kwok, Mok, Chan.

Conflict of Interest Disclosures: None reported.

Funding/Support: This trial was supported by the Professional Development Fund, Association of Hong Kong Nursing Staff.

Role of the Funder/Sponsor: The Association of Hong Kong Nursing Staff had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This paper was presented at the 22nd International Congress of Parkinson’s Disease and Movement Disorders; October 6, 2018; Hong Kong; and the 15th International Congress of Behavioral Medicine; November 17, 2018; Santiago, Chile.

Data Sharing Statement: See Supplement 3.

Additional Contributions: Kenneth Y. K. Wong, MSSc, City Oasis Mindful Yoga Center; Quentin K. C. Yau, MSc, BSc, MYO Sports Clinic; Lily M. L. Chan, BN, RN, North Lantau Hospital, Hospital Authority; and K. H. Liu, BA, RSW; Carrie S. W. Ha, MSSc, BSS, RSW; Wing W .Y. Ho, RSW; Eva Q. W. Yip, MSSc, RSW; and Patsy K. Y. Chan, BSSC, MSW, RSW, Community Rehabilitation Network, the Hong Kong Society for Rehabilitation provided expertise and assistance. The Hong Kong Parkinson’s Disease Foundation, Hong Kong Parkinson’s Disease Association, the Association of Hong Kong Nursing Staff, and the Y. K. Pao Foundation Centre for Nursing Excellence in Chronic Illness Care provided support to promote the mindfulness yoga program for chronic illness management in the community. We thank the study participants.

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