4th World Parkinson Congress Partland Oregan USA

PARKINSONCONGRESSPartland J Oregan J U S A

Yoga in Parkinson Disease- Whatis the Evidence Telling Us? By Indu Subramanian MD Associate Clinical Professor, UCLA Dept of Neurology South West PADRECC Director West Los Angeles VA Medical Center

Complementary/Alternative Medicine

What is Yoga?

What is Yoga? Started being practiced 5000 years ago, part of the ayurvedichealing science 2016 yoga journal 36.7million Americans practicing yoga ( 16.8billion /year spent in this industry) Many studies on cancer, blood pressure, cholesterol reduction,mood, osteoporosis, pulmonary vital capacity Some evidence to support use in epilepsy, stroke prevention,cognitive state, multiple sclerosis Improvement in fatigue, seizure control, stress, mood, sleep,pain, mobility, problem solving,

Can it be a lifelong practice?YESS Study at UCLA GeriatricsGeorge Salem PhD and Gail Greendale MD

Why Does Yoga Make Sense asRx?

Why Yoga in Parkinson Disease? Breathing, meditative aspects sets it apart from otherexercises and standard Physical Therapy Can use visual cues to help coordinate movement Can use props to get the experience of the fullmovement safely- can then take these supports away aswe progress; really can modify Yoga teacher can give hands-on adjustment to helpwith proper alignment Focus on one aspect of a pose at a time to bringattention to the body in the present moment

Stage IStage IIStage IIIStage IVPD-Hoehn & Yahr StagesStage V

Non- motor symptoms Mood- anxiety, depression Cognition-memory, Apathy-lack of motivation Sleep Autonomic Nervous System Dysfunction – bloodpressure regulation, dizziness when standing up Constipation

Review of Yoga PD Studies 2014Roland 2014 review on evidence of yoga and PD 7 articles; 1 was a Randomized Control Trial(yoga vs waitlist control); 3 were grouppretest/post-test; 3 were case studies

Table I Literature search study characteristicsColgrove et al2113 (7)68.1PD dur,years3.56Boulgarides et al2410 (3)65Lee2517 (7)Scott et al269 (2)Hall et al27Taylor23Moriello et al22N (F)Age,yearsYoga styleDesignDuration,minFreq/weekLength,weeksAll outcomes measuredSignificant improvementsfollowing yogaUPDRS, BBS, ROM,maximum isometric forceIyengarRCT60212UPDRS, BBS, ROM,maximum isometric force,posture, gaitn/aAnanda,restorative hathaPrepost60110UPDRS, HADS, DGI, BBS,FRT, chair standHADS, FRT, chair Gait speed, SPPB, BBS, FESBBS, FRT, tandem stance,single-leg stance, gait, chairstand, GDS, FOF, PDQ-39Gait speed SPPB, BBS, FES67.81 (1)698HathaCase60181 (1)1 (0)5957102HathaHathaCaseCasen/v9021324FRT, chair stand, GDSDB/2016.51312.59.5ROM, BBS, TUG, PDQ-39TUGBBS9Breath, vocal, face, gait, restPDQ-39, HiMAT, flexibility,strength, posture, LOSBreath, vocal, face, gait, restPDQ-39, HiMAT, flexibility,strength88Abbreviations: BBS, Berg Balance Scale; DB, Downs and Black Checklist; DGI, Dynamic Gait Index; dur, duration; F, females; FES, Falls Efficacy Scale; FOF, fear of falling; freq, frequency; FRT, Functional Reach Test; GDS, GeriatricDepression Scale; HADS, Hospital Anxiety and Depression Scale; HiMAT, High Level Mobility Assessment Tool; LOS, limits of stability; min, minutes; n/a, not available; PD, Parkinson’s disease; PD dur; duration since PD diagnosis;PDQ-39, Parkinson’s Disease Questionnaire-39; RCT, randomized controlled trial; pre—post, pretest—post-test study design; ROM, range of motion; SPPB, Short Physical Performance Battery; TUG, Timed Up and Go; UPDRS, UnitedParkinson’s Disease Rating Scale.Review By Roland 2014

Some evidence to show improvementin: Mobility ( Sit to Stand test, UPDRS, Timed up and go) Balance (Berg BS, Falls efficacy scale) Strength Flexibility/Range of Motion Fear of falling Quality of Life Depression (GAD, HADS) Sleep

,ngress

PORTLANC1OREGON, USASeptember 20-2312016VariableYOGA(n 15) CON(n 12) PAge(year)Gender (male/female)Height(m)Weight(kg)Disease duration (y)H & Y stageExercise (h/week)Taking sinement as a single medicationTaking sinement with other PD medications71.2(6.5)11/41.73 (0.08)75.1(11.9)6.9 (6.3)2.2 (.7)3.6 (2.8)51074.9 (8.3)6/61.64 (0.10)71.5 67.81.89.74Baseline differences were analyzed using t-test for independent samples.H & Y Hoehn & Yahr.*Significant different from the CON group.PDQ-39. High score reflects poor performance.PretestMobility (10)ADL(6)Emotional well-being (6)Stigma (4)Social support(3)Cognitive impairment (4)Communication (3)Bodily discomfort(3)SumTable 1Participant characteristics. Data was presented as mean (SD).Changes at the post-testTreatment effectsEffect sizespYOGA(n 13)mean (SD)CON (n 10)mean (SD)YOGA(n 13)mean(95% CI)CON (n 10)mean (95% CI)Mean (95% CI)g(95% CI)Adjusted14.5 (10.2)6.8(6.4)5.7(5.5)3.9(4.1).9(2.2)4.5 0(2.8)2.0 (-10.0, -1.2)'-1.4(-3.5, .7)-1.2(-3.2, .9)-1.3(-2.9, .2).1 (-.8, .9)-.5 (-1.3, .4)-1.0(-2.2, .2)-.7(-2.2, .8) -11.5(-22.7, -.4)1.1(-3.0, 5.1)1.2(.3, 2.1).6(-.7, 1.8).5 (-.3, 1.3).1(-.9, .9).1(-.9, 1.0)-.1(-1.2, 1.0).7 (-.7, 2.1)5.2(-1.3, 11.7)-6.7(-12.5, -.9)-2.6(-5.0, -.2)-1.8(-4.3, .8)-1.8(-3.6, .02)-.5 (-1.8, .7)-.5 (-1.7, .7)-.9 (-2.5, .7)-1.4(-3.4, .6)-16.7(-29.1, -4.4)-.82 (-1.65, .01)-.46 (-1.27, .34)-.43 (-1.23, .38)-.57 (-1.38, .24).00 (-.80, .80)-.18 (-.98, .62)-.35 (-1.15, .46)-.46 (-1.27, .34)-.70(-1.52, .013).025 .035.162.052.385.431.257.161.016* P .05, are adjusted for baseline values based on ANCOVA.iss

MDS 2016 Abstract 1950

Goals of future studies Get a better sense of which poses would benefit PD Educate yoga teachers about PD to help them empowerpatients to exercise and stay motivated safely Develop a sense of the disease symptoms/stages and who toinclude in classes- many studies have included H Y stg 1-4too easy for some and often the teacher teaches to the mostdisabled person in the room Identify better ways to blind studies/ what controls shouldbe used? ( social aspects of the class are tremendous) Improve portability of yoga to places easier to reach by PDpatients ( suburban, remote areas); prevent drop out ratesseen in many studies

WPC 2016 Abstract #1311Subramanian, Holland, Mischley

WPC 2016 Abstract : Development and Testing of a Yoga InterventionProgram for Patients with Parkinson’s DiseaseAuthors - Justice, Catherine, DPT, E-RYT, Cheung, Corjena, PhD, RN,Samson-Burke, Amy, Objective – To develop and test a biweekly, 12-week yoga program anddetermine its safety and feasibility for people with Parkinson’s Disease(PD). Methods – Yoga for PD literature reviews were performed by the lead yogateacher who designed and developed a draft of a yoga for PD interventionprogram. The program was reviewed by a group of yoga experts (n 6)that was made up of physical therapists, registered/certified yogateachers, a yoga therapist, a yoga researcher, and a PD patient. The yogaexpert panel meeting was held at a community center that lasted for 1.5hours. At the meeting, certain precautions were discussed such as avoidingsequences of poses that would trigger orthostatic hypotension orretropulsion episodes and the importance of teaching careful transitionsto and from the poses. The therapeutic value of balancing and standingpostures, poses to correct slumped forward posture, and posesencouraging thoracic and hip mobility were also emphasized by the panel.The intervention program was implemented to 10 individuals with PD,

WPC 2016 Abstract -Justice Results – Through this comprehensive development process, a series of 24individual hour-long yoga sequences were created. The initial classes focusedon foundational yoga postures, basic breathing techniques, and yogicprinciples of mindfulness, body awareness, and self-compassion. Each classbuilt upon the previous, adding 1-4 new poses each session. The yoga posturesgradually increased in difficulty from week to week, progressing to balancingpostures, advanced breathing techniques, and poses that encourage thoracicextension and rotation, deep relaxation, and fluidity of movement. Thespecific yoga postures were chosen in order to address concerns unique to thePD population, such as thorax/ spine/ hip flexibility, balance, movementinitiation, respiratory capacity, relaxation, etc. The sequence encouraged theuse of yoga props (bolsters, blankets, blocks, chairs, etc.) to help improvestability, safety, and comfort within the poses. To accommodate a wide varietyof physical abilities within the subject pool, modifications to the traditionalyoga postures (such as seated versions of standing poses)were also included inorder to address the specific needs of each individual student. The yoga for PDintervention program began in April, 2016, results on safety and feasibilitywill be analyzed in June, 2016.

PD Yoga TeamVicki Russell Bell- Yoga TeacherRichard Rosen-PD Patient/Yoga Teacher

PD Yoga Team

Focus on Four main aspects ofPD 1. Upper body- bent neck, shoulders, stooping 2. Lower body-stiff upper legs/hips 3. Balance 4. Anxiety/Depression

Focus on 3 stages of disease forthese 4 symptom groups 1. Early/new diagnosis- mild symptoms; mayhave some denial, anxiety around newdiagnosis, but can physically do a lot of poses,Range of motion 2. Mid stage- may start to need somemodifications around increasingstiffness/slowness, decreasing range of motion,starting to get balance issues 3. Advanced stage- increased balance issues tothe point where largely in a chair, need help to

Short- term Goal Build sequences that are very precisely taught, safe,very clear use of props for all 12 categories Make these sequences reproducible across teachers Produce an illustrated yoga manual that can be used totrain teachers in a systematic way who are interested inworking with PD patients Use drawings, photographs of muscles involved, propsand videos of poses and how to teach them using clearinstructions

Dr. Long drawing

Teacher Trainings A weekend session that would use the manual to teach yogateachers about our method of yoga for PD Instruction would include Disease state background,overview of medications, current treatments Yoga from the perspective of PD patient Precise instruction on the 12 categories and how to teachand modify poses for advancing disease safely Recruitment of students for this training would be nearlarger PD medical clinics and may include physical therapistsalso trained in yoga

Brian Grant Foundation

Yoga is highlighted inApril/May

Yoga Videos

Hip/Leg Stiffness

Hip/Leg Stiffness

Hip/leg stiffness

Neck/Shoulder Tightness

Shoulder/neck

Modified Corpse Pose- opensshoulders

Yoga for PD literature reviews were performed by the lead yoga teacher who designed and developed a draft of a yoga for PD intervention program. The program was reviewed by a group of yoga experts (n 6) that was made up of physical therapists, registered/certified yoga teachers, a yoga therapist, a yoga