Effect of an Eight-Week Adaptive Yoga Program on Mobility, Function, and Outlook in Individuals with Parkinson’s Disease

1. Effect of an Eight-Week Adaptive Yoga Program on Mobility, Function, and Outlook in Individuals with Parkinson’s Disease Bryan Coleman Salgado, PT, DPT, MS, CWS Lois Boulgarides, PT, DPT, MS Edward Barakatt, PT, PhD Janice Freeman-Bell, RYT Danett Choo, SPT Michelline El-Zahr, SPT Kristi Williams, SPT April Morales, SPT SYTAR 2008 § Los Angeles

2. Introduction & BackgroundParkinson’s Disease • Progressive Neurological Disease • Second most common neurological disease (after Alzheimer’s) • Occurs frequently in older persons -7 million in US • 1 in every 1000 for > 65 yrs of age • By 2020, > 40 million worldwide • Gradually progressive movement disorders • Can lead to paralysis and death (PNA is #1 cause of death)

3. Parkinson’s Disease Signs/Symptoms • Bradykinesia • Tremor • Rigidity • Shuffling gait • Impaired balance • Impaired function • Vocal, facial and oral impairments • Decreased activity level due to impairments

4. Parkinson’s Disease and Exercise Balance training, resistance training, gait training, and Tai Chi programs caused improvement in: • Muscle strength • Balance and coordination • Quality of Life (QOL) • Activities of Daily Living (ADL) (Hirsch et al., 2003, Baatile et al., 2000, Caglar et al., 2005, Venglar, 2005)

5. Literature: Yoga’s Effect on Parkinson’s Disease No research was found that specifically addresses the effect of Yoga on the symptomology of Parkinson’s Disease

6. Purposeof the Study Determine improvement in strength, ROM, balance, gait, depression and anxiety after 8 weeks of participation in a Yoga course

7. Methodology Inclusion criteria: • Follow simple instructions • Tolerate 1 hr of gentle activity • Independent sitting balance Exclusion criteria: • Medical history that would place them at risk Approved by the Committee for the Protection of Human Subjects, CSU Sacramento

8. Participants • Recruited from the Parkinson’s Association of Northern California • 10 subjects dx’d with PD • Hoehn and Yahr stage 3 or less

9. Study Design – One-way Repeated Measures Assessment 1 Assessment 2 Assessment 3 8 weeks 8 weeks No change in activity Adaptive Yoga

10. Yoga Class Description • 1 hour class • 1 time/week • RYT led class • Warm up (10 min) • Poses (40 min) • Cool down (10 min)

11. Adaptive Yoga • Ayurvedic Principles • Asanas to calm vata excesses (etiology of Parkinsonism) • Ananda Yoga • Affirmations, relaxation, meditation • Restorative Yoga • Use of props to help people easily achieve and relax into poses • Appropriate for older adults and special population embarking on a yoga program • Adaptive Devices • Chair, blocks, strap, blankets (Jones et al, 2005)

12. Yoga Asanas - Standing • Tadasana • Baddha Hastasana • Hasta Chakrasana • Vrksasana • Trikonasana • Virabadrasana • Ardha Chandrasana • Adho Mukha Svnasana • Prasarita Paddotanasana

13. Yoga Asanas • Sitting • Upavasta Konasana • Paschimotanasana • Marichiyasana • Lying: • Supta Padangusthasana • Apasana • Jathara parivartasana • Setu Bandasana • Savasana

14. OutcomeMeasures • Overall Status of Disease (UPDRS) • Anxiety and Depression(Hospital Based Anxiety and Depression Scale [HADS]) • Walking (Modified Dynamic Gait Index [DGI]) • Balance(Berg Balance Scale [BBS]) • Falls Risk (Functional Reach) • Flexibility(Sit and Reach LB; Apley’s UE) • Functional Strength (30 Second Chair Stand)

15. Results

16. Descriptive Statistics • Sex • 3 Females • 7 Males • Age • mean: 65.7 years • Range 43-77 years • Average # of Yoga sessions attended • 7.2 • Hoehn & Yahr • Stage 2, 2.5, or 3

17. Inferential Statistical Analysis* Change over time: • One-way ANOVA with repeated measures (Normally distributed data) • Follow up T-test with Bonferroni correction • Friedman’s two-way ANOVA by ranks (Non-normally distributed data) • Follow-up Wilcoxin Signed-Ranks test *using SPSS software v. 13.0

20. Discussion & Conclusion Statistically significant changes in lower body flexibility, functional strength and depression outcomes measures indicate a positive effect of adapted yoga for persons with Parkinson’s Disease • No adverse effects • Yoga program was well received overall: • Continued participation by over half of subjects

21. Discussion & Conclusion • Further study is justified • Outcome measures to be considered: Timed Up & Go; Gait velocity test • Further refinement of postures to address underlying etiology; combined with other Ayurvedic treatments

22. Questions? This research was assisted in part by grants from: The Parkinson’s Association of Northern California The California State University, Sacramento LIFE Center

23. References • Baatile, J. BS. et al.  Effect of exercise on perceived quality of life of individuals with Parkinson’s disease.  Journal of Rehabilitation Research and Development.  2000; 37(5): 529-534. • Berger, Bonnie G. Foundations of exercise psychology / Bonnie G. Berger, David Pargman, Robert S. Weinberg. Morgantown, WV : Fitness Information Technology, c2002. • Bjelland, I., Dahl, A., Haug, T., Neckelmann, D. The validity of the hospital anxiety and depression scale. Journal of Psychosomatic Research. 2002; 52: 69-77. • Caglar, AT.  et al.  Effects of home exercises on motor performance in patients with Parkinson’s disease.  Clinical Rehabilitation 2005; 19: 870-877. • Corbin, David E. Reach for it : a handbook of health, exercise and dance activities for older adults / David E. Corbin and Josie Metal-Corbin ; with selected chapters by Frank Fong ... [et al.] Dubuque, Iowa : E. Bowers Pub. Co., c1997 • DiBenedetto, M., Innes, K. E., Taylor, A. G., Rodeheaver, P. F., Boxer, J. A., Wright, H. J., Kerrigan, D. C. Effect of a gentle Iyengar Yoga program on gait in the elderly: an exploratory study. Archives of Physical Medicine and Rehabilitation. 2005; 86: 1830-7. • Gauchard, G. C., Jeandel, C., Tessier, A., Perrin, P. P. Beneficial effect of proprioceptive physical activities on balance control in elderly human subjects. Neuroscience Letters. 1999; 273: 81-4. • Haas BM et al.  Effects of Respiratory Muscle Weakness on Daily Living Function, Quality of Life, Activity Levels, and Exercise Capacity in Mild to Moderate Parkinson’s Disease.  Am. J. Phys. Med. Rehabil.  August 2004; 83(8): 601-607. • Hirsch, Mark A. et al.  The Effects of Balance Training and High-Intensity Resistance Training on Persons With Idiopathic Parkinson’s Disease.  Arch. Phys.  Med. Rehabil.  August 2003; 84: 1109-1117.

24. References • Lee, S. W., Mancuso, C. A., Charlson, M. E. Prospective study of new participants in a community-based mind-body training program. Journal of General Internal Medicine. 2004; 19: 760-5. • Manjunath, N. K., Telles, S. Influence of Yoga & Ayurveda on self-rated sleep in a geriatric population. Indian Journal of Medical Research. 2005; 121: 683-90. • National Parkinson Foundation. 2006. Available at: http://www.parkinson.org/site/. Accessed on: April 12, 2006 • Physical activity instruction of older adults / C. Jessie Jones, Debra J. Rose, editors. Champaign, IL : Human Kinetics, c2005 • Pure Yoga : a translation from the Sanskrit Gherandasamhita, with a guiding commentary / by Yogi Pranavananda ; edited with introduction by Tony Rodriguez, Kanshi Ram. Delhi : Motilal Banarsidass Publishers, 1992 • Schenkman, M et al.  Spinal Flexibility and Balance Control Among Community-Dwelling Adults With and Without Parkinson’s Disease.  The Journals of Gerontology Series A:  Biological Sciences and Medical Sciences 2000; 55:M441-M445. • Sherman, K. J., Cherkin, D. C., Erro, J., Miglioretti, D. L., Deyo, R. A. Comparing Yoga, exercise, and a self-care book for chronic low back pain. Annals of Internal Medicine. 2005; 143:849-56. • Sherrill, Claudine. Adapted physical activity, recreation, and sport : cross disciplinary and lifespan / Claudine Sherrill. Boston : McGraw-Hill, c2004 • Umphred D. Neurological Rehabilitation. St Louis, Mo: Mosby, Inc.; 2001 • Venglar, M.  Case Report: Tai Chi and Parkinsonism.  Physiotherapy Research International. 2005; 10(2): 116-121.

25. Acknowledgements Janice Freeman-Bell Our Yoga instructor who gave her time, her enthusiasm, and her compassion to help develop and implement the Yoga program The ten participants of the Yoga program Diligently attended classes, gave us their input, and helped to create an experience that was full of humor, courage, and optimism