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

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

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

2. Parkinson Disease 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 Kowal SL, Dall TM, Chakrabarti R, Storm MV, Jain A. The current and projected economic burden of Parkinson’s disease in the United States. Mov Disord . 2013;28(3):311-318. doi:10.1002/mds.25292 2. Kwok JYY, Auyeung M, Chan HYL Kwok JYY, Auyeung M, Chan HYL. Examining factors related to health-related quality of life in people with Parkinson’s disease.  Rehabil Nurs . 2018.  D’Iorio A, Vitale C, Piscopo F, et al. Impact of anxiety, apathy and reduced functional autonomy on perceived quality of life in Parkinson’s disease. Parkinsonism Relat Disord . 2017;43:114-117. doi:10. 1016/j.parkreldis.2017.08.003 Blakemore RL, MacAskill’ MR, Shoorangiz R, Anderson TJ. Stress-evoking emotional stimuli exaggerate deficits in motor function in Parkinson’s disease. Neuropsychologia . 2018;112:66-76. doi:10. 1016/j.neuropsychologia.2018.03.006 Landau S, Harris V, Burn DJ, et al. Anxiety and anxious-depression in Parkinson’s disease over a 4-year period: a latent transition analysis. Psychol Med. 2016;46(3):657-667. doi:10.1017/ S0033291715002196 Auyeung M, Tsoi TH, Mok V, et al. Ten year survival and outcomes in a prospective cohort of new onset Chinese Parkinson’s disease patients. J Neurol Neurosurg Psychiatry. 2012;83(6):607-611

3. Insight for Pathophysiology: The neuropathologic hallmarks of PD are the degeneration of dopaminergic neurons in the SN and intraneuronal protein aggregates called Lewy bodies and Lewy neurites. 1 It was long considered that 50% to 70% of SN dopaminergic neurons have died by the time that clinical motor symptoms become evident. The clinical diagnosis of PD is based primarily on motor features, such as a slowly progressive asymmetric resting tremor, cogwheel rigidity, and bradykinesia, although nonmotor features, which include anosmia, constipation, depression, and rapid eye movement sleep behavior disorder, can develop years before motor deficits.  During later stages of the disease, additional nonmotor features, such as autonomic dysfunction, pain and cognitive decline, can appear. 2 . Poewe W, Seppi K, Tanner CM, et al. Parkinson disease. Nat Rev Dis Primers 2017;3:17013. Parkinson Disease Epidemiology, Pathology, Genetics, and Pathophysiology David K. Simon, MD, PhDa , *, Caroline M. Tanner, MD, PhDb,c , Patrik Brundin , MD, PhDd

4. Methods STUDY DESIGN: Assessor-masked, multicentered, randomized clinical trial of PD that compared MY-PD with SRTE. Patient Population: Participants with idiopathic PD were enrolled using convenience sampling from December 1, 2016- 30 May 2017. Recruitment centres: 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.

5. Inclusion and Exclusion Criteria Inclusion Criteria 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) older than 18 years. Could stand unaided and walk with or without an assistive device. Could stand unaided and walk with or without an assistive device. Exclusion criteria Receiving pharmacologic (eg, antidepressants) or surgical treatments (eg, deep brain stimulation) for psychiatric disorders (eg, schizophrenia, psychosis, or major depressive disorder) Currently participating in another behavioral or pharmacologic trial or instructorled exercise program. Had significant cognitive impairment (Abbreviated Mental Test Score)

6. Screening, Baseline and Randomization

7. Primary and Secondary objectives

8. Interventions Mindfullness Yoga for PD Stretching and Resistance Training Exercises A weekly 90-minute session of MY-PD For  8 WEEKS  A weekly 60-minute session of SRTE participants were encouraged to perform 20-minute home-based practice twice a week.  a weekly 60-minute session of SRTE Module:12 basic Hatha yoga poses: sun salutations (60 minutes) with controlled breathing (15 minutes) and mindfulness meditation (15 minutes. progressive set of warm-up, resistance training and stretching, and cool-down exercises 1 . Kwok JY, Choi KC, Chan HY. Effects of mind-body exercises on the physiological and psychosocial well-being of individuals with Parkinson's disease: A systematic review and meta-analysis. Complement Ther Med. 2016;29:121-31 ACC to a systematic review and meta analysis, mind–body exercises such as yoga, Tai Chi and dance therapy demonstrated immediate moderate-to-large beneficial effects on physical outcomes such as motor symptoms, postural instability and functional mobility amongst individuals with mild-to-moderate PD. In particular, yoga was the most effective one in improving motor symptoms and was thus adopted as the fundamental component of the programme .

9. YOGA MODULE SRTE MODULE

10. CONT.. The interventions were comparable in format (group), frequency (weekly), duration (8 weeks, although the mindfulness yoga had an additional 30 minutes per session). Each intervention was delivered according to a manualized protocol in which all instructors were trained.  INTERVENTION DELIVERED BY INTERVENTIONAL KIT 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).

11. Development of yoga module  o

12.                          Outcome measures                                   All outcome measures were administered at each time point: baseline (T0), 8weeks (immediately after the intervention) (T1), and 20weeks (3 months after the intervention) (T2). 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) 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. 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. 

13. Secondary Outcomes severity of motor symptoms as measured by the validated Movement Disorders Society Unified Parkinson’s Disease Rating Scale (MDSUPDRS), Part III (Chinese version), which covers domains related to tremor, rigidity, bradykinesia, gait, and postural instability. Mobility as measured by the validated Timed Up and Go (TUG)Test . Spiritual well-being as measured by the validated Holistic Well-being Scale (Chinese version), which covers 2 major concepts of spiritual health ( perceived hardship and   [enduring happiness]) HRQOL as measured by the validated disease-specific 8-item Parkinson’s Disease  Questionnaire (Chinese version), 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.

14. Sample Size

15. FLOW DIAGRAM

16. Statistical Analysis 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 non-completers 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.

17. Results: Baseline Characteristics of Participants

18. Results

19. 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. Mindfulness-based interventions may provide patients with long-lasting skills effective for stress and symptom management.

20. CONCLUSION