Effect of Yoga on Motor Function in People with Parkinson’s Disease: A Randomized, Controlled Pilot Study

Abstract

Yoga is a form of exercise that may be beneficial to those with Parkinson’s disease (PD). There have been no randomized control research studies investigating the effect of yoga on those with PD. The objective was to determine if yoga can improve motor function in people with PD using a randomized controlled small group design. The PD participants were randomized into a yoga intervention group or a control group of no intervention. Assessment of physical function included motor examination scores from the Unified Parkinson’s Disease Rating Scale, posture, measures of extremity ROM, flexibility and strength, and biomechanical measures of balance and gait that occurred at 3 time points: prior to starting the intervention, at 6 weeks of intervention, and immediately following 12 weeks of intervention. Thirteen adults with PD met the inclusion and exclusion criteria. All participants were unfamiliar with yoga. An Iyengar Hatha yoga program was tailored to fit participants with PD and designed to improve strength, flexibility, body alignment, and overall well-being. A 60-minute session, including physical postures, breathing, and meditation was implemented twice a week for 12 weeks. A significant improvement was found in motor UPDRS scores (p=0.004) and Berg Balance Scale scores (p=0.04) in the yoga group. A general trend of positive outcomes in the yoga group for strength, ROM and flexibility were noted with significant differences at p=0.05 in selected hip and ankle measurements. Qualitative improvements in posture were observed and there were significant improvements in the onset time of foot unloading and onset time of foot lift off. Findings suggest that yoga practice improves motor function which may be partially explained by improvements in balance, strength, posture and gait. Due to the progressive nature of PD yoga programs may offer a way to maintain wellness and perhaps quality of life

Full text

Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
Research Article Open Access
Colgrove et al., J Yoga Phys Ther 2012, 2:2
http://dx.doi.org/10.4172/2157-7595.1000112
Research Article
Open Access
Yoga & Physical Therapy
Effect of Yoga on Motor Function in People with Parkinson’s Disease: A
Randomized, Controlled Pilot Study
Yvonne Searls Colgrove*, Neena Sharma, Patricia Kluding, Debra Potter, Kayce Imming, Jessica VandeHoef, Jill Stanhope, Kathleen
Hoffman, and Kristen White
Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, USA
*Corresponding author: Yvonne Searls Colgrove, Department of Physical
Therapy and Rehabilitation Science, University of Kansas Medical Center, USA,
Tel: 913-588-0249; Fax: 913-588-4568; E-mail: ycolgrove@kumc.edu
Received March 23, 2012; Accepted April 30, 2012; Published May 02, 2012
Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect
of Yoga on Motor Function in People with Parkinson’s Disease: A Randomized,
Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Copyright: © 2012 Colgrove YS, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Keywords: Yoga; Parkinson’s disease; Physical function; Strength;
Flexibility; Balance; Posture; Gait; Exercise; Motor UPDRS
Abbreviations: PD: Parkinson’s disease; ROM: Range of
motion; H&Y: Hoehn & Yahr; UPDRS: Unied Parkinson’s Disease
Rating Scale; COP: Center of Pressure; APA: Anticipatory Postural
Adjustment; BBS: Berg Balance Scale
Introduction
Parkinson’s disease (PD) is a progressive neurological pathology
aecting over one million Americans that causes signicant functional
limitations, such as impaired gait and balance eventually leading to
profound disability. Specically, impaired balance is a major problem
for people with PD. It has been reported that 46% of ambulatory PD
participants without dementia experience a fall annually, with 33%
reporting multiple falls annually [1]. Fall frequency increases with the
severity of the disease, which could be related to the progressive loss
of postural reexes and increased postural instability. Remediable risk
factors for falls include decreased balance, reduced muscle strength
and freezing gait [2].
Akinesia or bradykinesia, a failure or slowness of voluntary
movement is frequently observed in people with PD. Bradykinesia
can lead to problems with gait initiation, which is the period between
standing motionless and the completion of the rst stride [3,4]. Gait
initiation typically involves a shi of the body weight laterally and
posteriorly towards the swing leg, laterally towards the stance leg,
and nally forward momentum, which results in a step [5,6]. People
with PD have delayed onset time and decreased amplitude of these
anticipatory postural adjustments, which can be reversed by deep brain
stimulation [3]. A shuing gait pattern is the most prominent feature
of gait seen in persons with PD with reduced stride length, decreased
walking speed, and longer double-stance time [4,7].
Decreased overall muscle strength and loss of exibility particularly
in the spine is oen noted in people with PD. Studies have found
that people with PD have reduced lower extremity muscle strength,
which make it dicult to perform everyday tasks such as rising from
a chair [8,9]. e forward exed posture seen in PD is attributed to
the contractile elements of the exors becoming shortened and the
extensors becoming lengthened and weakened [10]. It is thought that
bradykinesia and musculoskeletal limitations of the vertebral spine
in turn create pulmonary dysfunction, which is one of the leading
causes of mortality and morbidity in persons with PD [11]. Although
pharmacological interventions can slow the progression of this disease,
medications tend to become ineective over a period of time, and non-
pharmacological interventions may be important to address fall risk
and secondary complications of immobility [12].
Current management of PD involves both pharmacological
treatment and physical activity, but research demonstrates the
benets of physical activity in PD are widely varied in type and
dosage of exercise intervention and application to disease severity.
Outcome measures widely vary also [13]. Exercise regimes from more
traditional treadmill training [14-16], balance exercise and progressive
Abstract
Yoga is a form of exercise that may be benecial to those with Parkinson’s disease (PD). There have been no
randomized control research studies investigating the effect of yoga on those with PD. The objective was to determine
if yoga can improve motor function in people with PD using a randomized controlled small group design. The PD
participants were randomized into a yoga intervention group or a control group of no intervention. Assessment of
physical function included motor examination scores from the Unied Parkinson’s Disease Rating Scale, posture,
measures of extremity ROM, exibility and strength, and biomechanical measures of balance and gait that occurred
at 3 time points: prior to starting the intervention, at 6 weeks of intervention, and immediately following 12 weeks of
intervention. Thirteen adults with PD met the inclusion and exclusion criteria. All participants were unfamiliar with
yoga. An Iyengar Hatha yoga program was tailored to t participants with PD and designed to improve strength,
exibility, body alignment, and overall well-being. A 60-minute session, including physical postures, breathing, and
meditation was implemented twice a week for 12 weeks. A signicant improvement was found in motor UPDRS
scores (p=0.004) and Berg Balance Scale scores (p=0.04) in the yoga group. A general trend of positive outcomes in
the yoga group for strength, ROM and exibility were noted with signicant differences at p=0.05 in selected hip and
ankle measurements. Qualitative improvements in posture were observed and there were signicant improvements
in the onset time of foot unloading and onset time of foot lift off. Findings suggest that yoga practice improves
motor function which may be partially explained by improvements in balance, strength, posture and gait. Due to the
progressive nature of PD yoga programs may offer a way to maintain wellness and perhaps quality of life.

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 2 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
resistive strengthening [17-19] to alternative types of physical activity
like Nordic walking [20], tango [21] and Tai Chi [22] have been
investigated. Systematic reviews of exercise in PD [13,23,24] stress need
for comparing specic types of exercise that may be prescribed as a
part of physical therapy in rehabilitation. Although PD is a progressive
disorder, several studies have found that increasing physical activity
can improve aerobic capacity [25], strength and exibility [26], balance
[27,28], increase movement time [29,30] and gait parameters including
speed [31,32] which in turn may contribute to independence in activities
of daily living [33], improved physical function and mobility [34-
36] and increased longevity [33]. Regular physical activity may delay
the onset of PD symptoms [37]. Alternative approaches to physical
exercise are important to explore for people who may not be able to
participate in strenuous, intensive or even moderate activity because
of limitations such as impaired balance or pulmonary dysfunction
Iyengar Hatha yoga emphasizes postural alignment and movement
within postures. is form of yoga provides a gentle alternative method
of exercise that can be easily adapted in people with physical disability
and neurological disorders because of the progression from body
awareness to relaxation to exibility to strength activities [38]. Props
such as belts or cushions are incorporated to achieve body alignment
in lying, seated, and standing positions. Yoga has been shown to
produce strength and exibility improvements in healthy adults [39].
Yoga has been shown to signicantly improve measures of gait, fatigue,
quality of life, and physical function in healthy elderly and people with
neurologic disorders [40-43]. However, similar benets of yoga have
not been investigated in people with PD.
To our knowledge, only two case studies have investigated yoga
in conjunction with physical therapy to treat a single patient with PD
[44,45]. Another survey study investigated the use of complementary
and alternative therapies including yoga in those with PD [46].
erefore, the purpose of this project was to assess feasibility for
the use of Iyengar- based Hatha yoga in people with PD, and to gather
preliminary data on the eects of yoga on functional measures of
motor performance on the UPDRS and Berge Balance Scale. Possible
contributing factors such as, strength, joint ROM, muscle exibility
and posture, balance and biomechanical measures were also assessed.
Methods
Design overview
is pilot project followed a randomized clinical trial design with
a small control group and intervention group to assess feasibility of
Iyengar-based Hatha yoga.
Setting and participants
e CONSORT ow diagram (Figure 1) illustrates the recruitment
and retention process for this study. e initial recruitment goal
was 20 participants. irteen adults with PD consisting of 7 women
and 6 men were recruited. Participants were included if they were:
Hoehn & Yahr Classication of Disability [47,48] stage 1-2 who could
ambulate with or without an assistive device for at least 50 feet and
were able to get up and down from the oor with minimal assist or
less and score 24 or above on the Folstein Mini-Mental State Exam
[49]. Participants were excluded if they had any of the following:
stage greater than 3 on the Hoehn & Yahr Classication of Disability,
decline in immune function such as pneumonia or systemic infection,
progressive degenerative disease besides PD, spinal fusion or other
orthopedic surgery in the past six months, mental disease/psychosis
such as dementia, greater than minimal assistance required for gait and
transfers, inability to make regular time commitments to the scheduled
yoga sessions, or experience with regular practice of yoga within the
past year. e number of potential participants assessed for eligibility
was documented to give an indication of the attractiveness of the yoga
program.
Randomization and interventions
Informed written consent was obtained just prior to the initial
assessment. Participants were randomly assigned by a coin toss to a
control group with no intervention (n=5) or an intervention group that
received yoga training (n=8).
Participants assigned to the yoga intervention participated as
a group in a 12-week Iyengar Hatha program. Yoga sessions were
held twice weekly for 60 minutes each session under the design and
direction of certied master yoga instructor with assistants that helped
with positioning for a 2 – 2.5 participant to personnel ratio. Special
therapeutic modications were designed for the group as a whole.
Participants were strongly urged to honor individual limits and notify
the instructor so that poses could be modied to meet individual needs.
Each session began with 5-10 minutes of deep breathing
exercises and relaxation techniques. e session then progressed to
approximately 40 minutes of poses designed to begin with stretching
and move into strengthening. Poses in lying, seated or standing
Enrollment
Allocation
Analysis
Follow-Up
Assessed for eligibility
(n=18)
Excluded (n = 5)
Not meeting inclusion criteria
(n = 4)
Declined to participate
(n = 1)
Other reasons
(n = 0)
Allocated to control
(n = 5)
Received allocated control
(n = 5)
Did not receive allocated
control (n = 0)
Analyzed (n = 5)
Excluded from analysis (n = 0)
Randomized (n=13)
Analyzed (n = 8)
Excluded from analysis (n = 0)
Lost to follow-up (n = 0)
Discontinued intervention (n = 0)
Allocated to intervention
(n = 8)
Received allocated intervention
(n = 8)
Did not receive allocated
intervention (n = 0)
Lost to follow-up (n = 0)
Discontinued intervention (n = 0)
Potential participants were contacted through a single educational seminar
at a local Parkinson’s disease (PD) foundation and through flyers posted
at the yoga facility
Recruitment
Figure 1: The CONSORT ow diagram. The recruitment, enrollment,
allocation to groups, retention, follow-up and completeness of data analysis
is illustrated for the pilot research study.

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 3 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
positions were supported using props such as yoga pillows, blocks and
straps as warranted. Each pose was typically held 3-7 minutes for a
total of 5-8 poses per session. Each session ended with 10-15 minutes
of meditation that included breathing and visualization techniques,
and positive armations. e yoga program progressed from
simple to more challenging poses over the 12 weeks as performance
improved. Due to the individualized nature of the group on any given
day, quantication of the complexity of the poses was not measured.
Participants were given a tape promoting relaxation and weights for
home use. Home practice with 1-2 simple poses was encouraged with
handouts demonstrating poses made available. Participation in home
practice was not measured.
Participants in the control group did not receive an intervention
during the study, but they were invited to participate in 12 weeks of
yoga sessions aer the study at no cost to them.
Information on retention and adherence was acquired by tracking
the number of participants who discontinued the intervention during
the study and attendance of participants. Frequency of adverse events
and major changes in medications were also assessed. If the participant
had a major change in medication aer enrollment in the study
(e.g. dopaminergic drugs or melatonin) as indicated on the medical
information form, the participant was allowed to complete the yoga
training but relevant data was not used aer the medication change.
Outcome measures and follow-up
Participants were assessed at 3 time points: baseline within one week
prior to initiation of research study and then 6 weeks, and 12 weeks
aer baseline. Follow up was done on continued yoga participation
of all participants at 6 and 12 months post intervention. e primary
physical function outcome measures utilized the motor exam of the
Unied Parkinson’s Disease Rating Scale (UPDRS). Other physical
function measures included selected extremity ROM, exibility
and strength measurements, and balance and posture assessments.
Biomechanical measures of function included postural sway and gait
initiation. Assessors were student physical therapists who were blinded
to subject group assignment and remained consistent for the duration
of the project.
Student assessors wrote protocols for each outcome measure
assessed including order of and positioning for specic tests and
measures, as well as standard instructions to the participants. Protocols
were reviewed and revised if needed by the supervising investigator.
Student assessors participated in practice sessions to review and
enhance didactic curricular training in conducting each outcome
measure to ensure prociency. Student assessors were supervised by
investigators during participant assessments.
To assess the eects of yoga on physical function, the motor
examination of the UPDRS, clinical measures of ROM, exibility,
strength and posture, and biomechanical measures of balance and gait
initiation were performed.
UPDRS Motor Examination: Speech, facial expression, body
bradykinesia, posture, gait and tremors were observed and rated by
the assessor during the course of other assessment activities while the
remaining items were specically tested by the assessor.
Berg Balance Scale (BBS): e 14 item scale was scored by the
assessor. Scores range from 0-56 [50].
ROM and Flexibility Procedures: All ROM and exibility
measurements were obtained using a universal goniometer and
standard protocol [51]. Each participant performed 2 trials of shoulder
exion; hip internal rotation, external rotation, exion, and extension;
knee exion and extension, and ankle plantarexion and dorsiexion.
Hamstring and hip exor exibility measurements were also taken.
Strength procedures: Strength was measured using the MicroFET
2 hand held dynamometer (Hoggan Health Industries, 8020 South 1300
West, West Jordan, UT 84088). It is more sensitive to small dierences
in muscle strength than manual muscle testing. e participant
was positioned so that the dynamometer could be placed against a
stationary object while the participant exerted a maximal isometric
force midpoint within ROM. Strength measures were taken for hip
exion, extension, abduction; knee extension; ankle plantarexion and
dorsiexion; shoulder exion and extension, elbow extension. ree
separate measurements were recorded with each test trial consisting
of a maximal isometric contraction for about 3 seconds. A rest period
of 5-10 seconds between trials was used to minimize variability due
to fatigue. Standardized instructions were presented to decrease
variability. Pre-established techniques were used to ensure consistent
dynamometer placement, joint angles, stabilization, and limb position
preventing muscle substitution (Appendix 1).
Posture measure procedures: Markers were placed over bilateral
greater trochanters, greater tubercles of the humerus and lateral
malleoli. Participants were asked to stand on oor markings behind a
plumb line using standard protocol for alignment [52]. Pictures were
taken from the side, back and front views with the camera remaining
at a xed distance using the same focus settings. From photographs,
shoulder angles, hip angles or base of support were measured and the
number of changes in alignment was recorded.
Assessment of photographs for qualitative postural changes
was done by two assessors blinded to both group assignment and
photograph time points. Agreements by both assessors on the postural
deviations found between participants’ two photographs were
necessary to be counted. If there was disagreement, the deviation was
not counted.
Biomechanical measures procedures: e biomechanical
assessment of standing postural sway and gait initiation was conducted
utilizing a force plate system. e participants’ dominant leg was
determined by observing the leg that the participants used most oen
to initiate gait. Ground reaction forces were measured with 2 adjacently
positioned AMTI OR6-5AMTI Biomechanics Force Platforms
(Advanced Medical Technology, Inc., 176 Waltham St, Watertown,
MA, 02472) embedded in an extended walkway.
To assess standing postural sway, participants were positioned with
one foot on each force plate. Participants were instructed to stand as
still as possible and focus on a target that was positioned at eye level
approximately 10 feet in front of them. e participants stood for 30
seconds per trial, a total of 5 trials. Participants were allowed to rest
if necessary between trials. A trial was not accepted if the participant
coughed, talked, or made any other obvious dynamic movements.
For the gait initiation task, participants were positioned with one
foot on each force plate. A verbal “ready” cue was given to prepare
the participant for the visual “go” cue, which was a green light. Upon
visual cue, participants started walking forward. One or two practice
trials were allowed to ensure comprehension of the task. A trial was

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 4 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
not accepted if the participant initiated gait with the non-dominant leg.
is was repeated until 5 acceptable trials were recorded. Participants
were allowed to rest if necessary between trials.
Biomechanical measures: Data Processing. Custom-made
computer programs developed in MATLAB® 6.5 (MathWorks, 3 Apple
Hill Drive, Natick, MA 01760) were used to determine change of center
of pressure (COP) sway in the x and y directions, COP area, onset
time of anticipatory postural adjustment (APA) for gait initiation,
amplitude of APA, onset time of foot unloading, onset time of foot
liing, amplitude of swing, and amplitude of stance.
Statistical analysis
Data analysis was done using Sigma Plot11.0 (SyStat Soware,
1735 Technology Drive Suite 430, San Jose, CA 95110) Feasibility
was assessed by a descriptive analysis of participant recruitment and
retention variables. e percent of exclusion of subject enrollment was
used to indicate the generalizability of the study results to the overall
population of people with PD in our community.
Descriptive statistics (mean, standard deviation, median, and range)
were calculated for all three assessment points. Data were assessed for
normal distribution and to identify outliers. An independent t test
was used to analyze baseline dierences between the groups. If the
equal variance test failed, then a Mann-Whitney Rank Sum test was
used. is was the case for several ROM and strength measures. One
Way Repeated Measures ANOVA was the primary analysis used on
data sets to detect changes over time within groups. All Pair wise
Multiple Comparison Procedures (Holm-Sidak method) were used to
determine signicance between time points. A paired t test was used as
a secondary analysis to detect change in variables from baseline to post-
intervention with a 0.05 signicance level for a 2-tailed test for posture
measures. e 95% condence interval for the mean dierence was also
calculated. Due to the high variability in baseline measures, balance
and gait initiation scores were converted to percent change for analysis.
Results
Feasibility and characterization of groups
As illustrated in the COHORT ow diagram (Figure 1), 18 potential
participants were screened for eligibility; 4 participants were excluded
because they did not meet the inclusion/exclusion criteria (22%) and 1
participant declined to participate (6%). All 13 participants who entered
the study completed the study. e participants in the experimental
group attended 99% of the twice weekly scheduled yoga sessions. All
participants in the control group participated in the full 12 weeks of
yoga following their control group assessments; however, compliance
to the twice weekly sessions was not measured in the control group.
Six month follow up shows that 10 of the 13 participants (76.9%)
continued with yoga: 6 of 8 in the experimental group and 4 of 5 in
the control group. One year follow up revealed 8 of the 13 participants
(61.5%) still continued participation in a yoga program: 4 of the 8 in
the experimental group and 4 of the 5 in the control group. No adverse
complications were reported as a result of the intervention.
A description of the participants with selected baseline variables is
presented in Table 1.
ere were more men randomly allocated to the control group and
more women to the yoga group even though the total number enrolled
was fairly equal (6 men, 7 women). Although there was a greater range
of ages (51-88 years) in the yoga group, the mean age was 62.8 years
whereas the mean age in the control group was 73.5 years. Times since
diagnosis and Hoehn & Yahr score were similar between groups.
Clinical measures
Functional motor and balance scales: A signicant improvement
(p=0.004, F=8.303, df=2) was shown in the UPDRS motor examination
scores in the yoga group over time as compared to the control group
(Figure 2). e yoga group started with overall higher scores (indicative
of lower motor function) and ended with lower scores (indicative of
better levels of function). e yoga group signicantly improved from
Group Age (y) Sex Time since diagnosis (mo./yr.) H&Y score
Motor UPDRS at
baseline
Gait Velocity (m/s)
at baseline
Y 88 M 2 years? months 1 19 .73
Y 51 F 6 years 1 month 2 19 .97
Y 63 F 9 years 7 months 1 18 1.19
Y 59 M 4 years? months 1 37 1.03
Y 53 F 4 years 11 months 1 30 .86
Y 76 F 6 months 1 12 .53
Y 62 F 1 month 1 14 1.26
Y 50 F 3 years? months 1 4 .82
Y Group
Mean (SD)
62.8 (13.2)
3 years 2.75
months
1.25 19.12 (10.32) 0.92 (0.24)
C 66 M 2 years 1 month 1 12 1.00
C 67 M 4 years? months 2 30 .94
C 75 F 6 years 2 months 1 17 .98
C 74 M 7 months 1 4 1.03
C 83 M 5 years 8 months 1 18 .80
C Group
Mean (SD)
73.4
(6.5)
3 years 8.4 months 1.2 16.2 (9.5) 0.95 (0.09)
Table 1: Characteristics of Participants
UPDRS = Unied Parkinson’s Disease Rating Motor Subscale, H&Y = Hoehn and Yahr scale score, Y = experimental yoga group, C = control group, M = male, F =
female.

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 5 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
baseline to 6 weeks (p=0.001) and baseline to 12 weeks (p=0.016) using
a pair wise multiple comparison procedure (Holm-Sidak method).
Two participants in the yoga group and none in the control
group demonstrated a ceiling eect using the BBS. Since, the mean
baseline BBS scores for the yoga group were (52.125) below the
control group (53.8) but the standard deviation was comparatively
rather large (4.454) compared to the control group (1.483), a paired
t-test comparing baseline and nal assessment score changes was used
for statistical analysis. Following the intervention, the yoga group
demonstrated a positive trend (p=0.063) but when the two participants
who demonstrated the ceiling eect were removed, balance from
baseline to 12 weeks was signicantly improved (p=0.047) as assessed
by the BBS (Figure 3).
Joint range of motion: At baseline the yoga group had greater
exibility in hip exion (le: p = 0.025; right p = 0.051), knee extension
(le: p = 0.033), and shoulder exion (right: p = 0.003). Following the
intervention a trend of positive outcomes in active ROM (Table 2) was
noted in selected hip internal rotation (le; p = 0.09, F = 2.867, df = 2;
right: p = 0.058, F = 3.513, df = 2) and ankle dorsiexion (le: p = 0.028
F = 4.680, df = 2; right: p = 0.107, F = 2.631, df = 2) (Figure 4) range
of motions in participants who received yoga training as compared to
Motor Function
Assessment Time Points:
1. Baseline prior to intervention
2. After 6 weeks of intervention (midway)
3. Upon completion of intervention
0 1 2 3 4
Motor UPDRS Scores
0
5
10
15
20
25
30
Control
Yoga
*b
*a
Figure 2: UPDRS Motor Examination Scores showed signicant improvement
(p=0.004, F=8.303, df2) in the yoga group over time as measured by One
Way Repeated ANOVA. There was signicant difference between baseline
measures (1) and both the midway point (2) of 6 weeks of intervention (*a)
(p=0.001) and the nal point (3) of 12 weeks of intervention (*b) (p=0.016)
using the Holm-Sidak method for all pair wise multiple comparison procedures.
Measurements
Initial (+ SD)
Final (+ SD)
Yoga Group:
Right extremity
Yoga Group:
Left extremity
Control Group: Right extremity Control Group: Left extremity
Joint ROM
Hip Internal Rotation
30.896 + 3.425
34.750 + 5.657
29.188 + 5.763
33.938 + 2.182
27.767 + 6.280
30.5 + 4.345
25.3 + 8.082
31.7 + 6.089
Ankle Dorsiexion
5.438 + 6.603
15.0 + 8.164
6.750 + 6.193
13.688 + 7.24
9.667 + 6.06
10.1 + 3.927
4.834 + 7.645
9.1 + 4.159
Muscle Length
Hip Flexor
-4.5 + 5.819
0.438 + 8.756
-5.357 + 7.081
1.375 + 6.186
-1.3 + 12.637
-4.7 + 8.822
-7.2 + 11.552
-6.3 + 11.037
Muscle Strength
Hip Extension
24.5 + 7.04
31.417 + 8.915
23.875 + 8.539
29.396 + 8.516
43.833 + 16.106
36.6 + 15.754
33.8 + 14.072
32.933 + 12.731
Hip Abduction
10.25 + 2.81
11.0 + 2.016
9.875 + 2.532
12.521 + 2.484
13.0 + 4.848
11.867 + 9.529
13.533 + 8.258
12.727 + 7.537
Knee Extension
28.813 + 10.364
32.750 + 6.807
31.837 + 8.713
34.583 + 6.676
35.86 + 12.365
32.933 + 7.738
41.66 + 12.523
36.467 + 15.354
Ankle Plantarexion
26.354 + 6.254
31.75 + 11.364
25. 813 + 5.693
28.875 + 8.828
36.734 + 17.880
37.0 + 11.277
39.333 + 17.203
41.867 + 11.869
Elbow Extension
13.729 + 3.249
14.75 + 5.111
12.188 + 2.986
15.167 + 3.409
20.533 + 7.294
22.333 + 11.39
24.2 + 6.292
22.333 + 9.863
Table 2: Initial and Final Measurements in ROM, Muscle Flexibility and Muscle Strength Selected joints and muscle groups measures with standard deviations. ROM and
muscle exibility measured by degrees. Muscle strength measured by pounds of force.
8
6
4
2
0
-2
-4
0 1 2 3 4
Assessment Time Points
Control
Yoga
Change Scores
Berg Balance Scale
Figure 3: Berg Balance Scale. There was a signicant improvement between
baseline measures and the nal 12 week point (p=0.047) in the yoga group
but not in the control group (p=0.854).

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 6 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
Dorsiflexion ROM
Degrees
0
5
10
15
20
1 2 3 1 2 3 1 2 3 1 2 3
Assessment Time Points
Left
Right
*b
Control
Yoga
Figure 4: ROM
There was signicant difference between baseline (1) ROM measures and the
nal (3) assessment (*b) for left ankle dorsiexion in the yoga group (p=0.028,
F=4.680, df=2). A similar trend was seen on the right side in the yoga group
that was not signicant (p=0.107, F=2.631, df=2).
Hip Flexor Length
Degrees
-15
-10
-5
0
5
1 2 3 1 2 3 1 2 3 1 2 3
Assessment Time Points
Left
Right
Control
Yoga
Figure 5: Muscle Flexibility34
Measurement of hip exor length shows trends towards increasing exibility in
the yoga group although not signicant.
the control group. Interestingly in the upper extremity, right shoulder
exion was decreased (p = .035, F = 4.314, df = 2) in the yoga group
over time with no change observed in le shoulder exion.
Muscle exibility: Following the intervention, there was
improvement in hip exor length (le: p = 0.083, F = 3.220, df = 2;
right: p = 0.104, F = 3.050. df = 2) in the yoga group as measured by
change from baseline measures (Figure 5, Table 2) although it was not
signicant. ere were no signicant changes in hamstring length of
either group.
Strength: e yoga group was signicantly weaker at baseline for
shoulder exion (le: p=0.021; right: p=0.030), elbow extension (le: p
= 0.002; right: p = 0.127), shoulder extension (le: p = 0.007; right: p
= 0.065) and hip extension (le: p = 0.138; right: p = 0.030). Following
the intervention, there was a signicant increase in strength over time
for hip extension (le p = 0.105, F = 2.654, df = 2; right p = 0.006, F =
7.512, df = 2) (Figure 5) and hip abduction (le: p = 0.022, F = 5.043,
df = 2) in the yoga group as compared to the control group. Some
improvement in other selected strength measures were also noted but
were not signicant (Table 2 and Figure 6).
Posture: Quantitative analysis of number of changes before and
aer yoga intervention was not signicant as analyzed by a paired t-test
(p = 0.14). ere were variable changes in postural alignment that were
not captured by measuring and statistically analyzing shoulder angles,
hip angles or base of support. Qualitative examination of individual
postures revealed that in the yoga group, 3 participants remained the
same, 1 participant’s posture declined in arm position showing an
asymmetrical arm space and 4 participant’s overall postural alignment
improved in 1-2 aspects including increased base of support, increased
supination of feet, improved cervical lordosis, decreased thoracic
kyphosis, improved stance symmetry (weight shied more evenly)
and improved shoulder levels (Figure 7). In the control group, 4
participant’s postures remained the same while 1 participant’s posture
showed a decline in head alignment.
Biomechanical measures of function
Static balance measures: ere was not a signicant dierence in
baseline measures for center of pressure area between groups (p=0.435),
but there was more variability in baseline measures amongst the
control group whereas the yoga group appeared to be more consistent.
Center of pressure sway during standing and the sway during the onset
of anticipatory postural adjustments during gait initiation determined
by force plate measurements were not signicantly changed over time
for either group.
Gait initiation measures: Two gait initiation measures showed
signicant improvements over time in the yoga group; onset time of
foot unloading (p = 0.039, F = 4.135, df = 2) and onset time of foot li o
(p = 0.044, F = 3.940, df = 2) as compared to the control group (Figure
8, Table 3). ere was a signicant dierence in baseline measures of
the onset time of foot loading between the yoga and control group (p =
0.039) and at post intervention this dierence was no longer signicant
(p = 0.72).
Subjective reports of physical function: ere were no reports of
adverse events in either group. e post intervention survey yielded
only positive subjective reports with yoga intervention to the question,
“What positive and/or negative eects did you experience as a result of
doing yoga?” Comments encompassed increased exibility, decreased
muscle tension or stiness, increased steadiness with gait and balance,
and improved level of functional activity such as playing more golf.
One participant reported an improvement in pain with a pre-existing
orthopedic problem. e participants also responded they appreciated
the program was adaptable to each individual that participated.
Discussion
We conclude that the yoga intervention piloted in this project
was feasible for the participants included in the study. Our high
attendance rate for the intervention and large number of participants
that continued the intervention aer the study was over indicates

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 7 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
A.
Hip Extension Strength
Force in pounds
0
10
20
30
40
50
60
Left
Right
1 2 3 1 2 3 1 2 3 1 2 3
Assessment Time Points
*b
B.
Ankle Plantarflexion Strength
Force in pounds
0
10
20
30
40
50
60
Left
Right
1 2 3 1 2 3 1 2 3 1 2 3
Assessment Time Points
C.
Shoulder Extension Strength
Force in pounds
0
10
20
30
40
50
Left
Right
1 2 3 1 2 3 1 2 3 1 2 3
Assessment Time Points
D.
Elbow Extension Strength
Force in pounds
0
10
20
30
Left
Right
Control
Yoga
1 2 3 1 2 3 1 2 3 1 2 3
Assessment Time Points
Figure 6: Strength
Strength measured by a digital dynamometer show trends towards increased strength over time in the yoga group with signicance in hip extension (p=0.006, F=7.512,
df=2 on the right and p=0.105, F= 2.654, df=2 on the left). Pairwise multiple comparison procedures shows signicance between the baseline and last assessment
(*b) (p=0.017). Similar trends were seen in ankle plantarexion, elbow extension and shoulder extension that were not statistically signicant. There were baseline
differences between groups for as notated by brackets ( ).
that the yoga program was attractive to these participants and that
the participants were compliant with the program. e translation
of the yoga program into home practice was not measured. It could
be possible that the intervention group participants who practiced at
home showed greater gains in outcome measures than those who did
not because they practiced more. e lack of adverse events indicates
that the program was safe for participants using the inclusion and
exclusion criteria established. However, the sample size for this study
was less than what we had predicted and several participants who
expressed interest in participating in the study but did not meet study
criteria. Our time for recruitment was limited because our intervention
was designed to be implemented with a cohort, but perhaps if we
had permitted ongoing recruitment over a longer period of time we
would have been able to contact a larger pool of potential subjects. We
excluded participants for a variety of reasons to ensure homogeneity
of participants and safety of the intervention, but perhaps these
exclusion criteria should be revisited to allow an expansion of the target
population. Previous studies of yoga in healthy elderly and in people
with multiple sclerosis report that they enrolled approximately 50%
of screened participants, and found a dropout rate of approximately
15% in the yoga intervention groups [40,41]. e intervention in these
studies was 90 minutes one time weekly for 6 months, and the most
common cause of drop-out was inability to attend classes. None of
the participants in our intervention group dropped out of the study,
perhaps because the duration of intervention was much shorter or
the severity of disease in our participants were mild in this study. All
participants in this study were functional community ambulators who
required no assistive devices.
e participants who participated in the yoga intervention had
a signicant improvement in overall motor function as measured
using the motor examination section of the UPDRS and the BBS.
e largest magnitude of change was noted aer the rst 6 weeks of
the intervention and appeared to be maintained for the remaining
6 weeks of intervention. e motor section of the UPDRS targets
multiple areas of function that are typically impaired by PD including
balance, coordination, posture, muscle tone and presence of abnormal
movement including tremors, slowness and amplitude changes of
movement and gait. Previous studies using the motor UPDRS scores
show that both a home exercise program and physical therapist
supervised exercise program signicantly improve motor symptoms
in mild to moderately impaired individuals with PD with 8 weeks
of training [53] or 4 weeks of LSVT BIG training [54]. Other studies
found that as little as 4 weeks of aquatic therapy could improve overall

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 8 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
UPDRS and BBS scores that were not seen in the same amount of time
with land based therapy [55]. e results of our study found that the
yoga intervention group had an improved motor UPDRS scores at 6
weeks of intervention. Yoga may be viewed as a gentle form of exercise
that may be tolerated more easily by elderly or more functionally
impaired participants with PD than other forms of exercise, but with
similar improvements in motor function. Based on this nding, it may
be valid to investigate the eectiveness of a shorter yoga intervention
in future studies. It would also be worth investigating the sustained
eect over a longer period of time. A dened intervention protocol
of increasing complexity of yoga poses would assist in standardizing
the intervention rather than relying on the skills of the individual yoga
instructor which could give varying results.
It is dicult to identify a clinically meaningful change in motor
UPDRS score as many contributing variables exist in motor function
like strength, joint mobility, exibility, balance and coordination to
name a few. However, balance is a likely contributing factor. e BBS
has been validated in patients with PD and shows signicant correlation
with UPDRS motor examination scores [56]. In the use of the BBS,
the smallest meaningful change for a group was found to be 2.4 SEM
(standard error of measurement) in people with stroke [57]. While fall
risk may be associated with ankle strategies in static standing balance
[58], there are other ways to assess functional balance and determine
fall risk. e relationship between measures of static standing balance
and dynamic balance needed for functional activities is debatable [59-
61]. Falls in PD occur during dynamic activities and are obviously
related to disease severity [62]. Freezing gait, lower extremity weakness
and reduced balance have been shown to be independent predictors of
fall in those with PD [63]. Clinical assessments of functional balance
like the BBS, Functional Gait Assessment, Tinetti Mobility Test and
the Balance Evaluation Systems Test are reliable measures and with
gait velocity, UPDRS scores and HY scores are highly correlated with
fall risk in PD [64-67]. Appropriate scales will need to be individually
selected to counter ceiling eects.
In the early stages of PD, it is crucial to prevent muscular changes
that cause decreased exibility and strength. With consideration of age
and independence with ADLs, baseline active ROM measurements
were considered functional. e dierence in gender predominance in
each group may explain the initial baseline dierences found between
the groups for select measures of ROM, exibility and strength. More
dramatic loss of ROM and exibility to begin with as is oen seen in the
progression of the disease may show more dramatic improvements in
ROM with yoga. Decreased muscle strength is oen associated with PD
patients. One study found that subjects with PD had reduced muscle
strength at the hip compared to controls, which may make it dicult
to perform everyday tasks such as rising from a chair [8]. e gains in
strength we observed tended to be more in the extensors of both the
upper and lower extremities. Since many of the yoga poses were postural,
this was an anticipated nding. Gains in lower extremity strength have
been associated with improvements in postural stability and functional
ambulation in a variety of healthy and disease conditions including PD
Figure 7: Posture
This yoga participant shows qualitative improvements in shoulder and head
alignment (right) from the baseline postural analysis (left).
A.
Onset time of Foot Unloading
Assessment #
0 1 2 3 4
Percentage change
0.0
0.2
0.4
0.6
0.8
control
yoga
B.
Onset Time of Foot Lift Off
0 1 2 3 4
Seconds
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
control
yoga
Time
^
*c
*c
Figure 8: Gait
A difference (p=0.039) in baseline measures (^) but not ending measures were
noted in onset time of foot unloading (A) with a signicant difference (p=0.039,
F=4.135, df=2) in repeated measures (*c) in the yoga group. There were no
baseline differences in onset time of foot lift off but a signicant different in
repeated measures (p=0.044, F=3.940, df=2) in the yoga group (B).

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 9 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
[68-72]. Since there were improvements in lower extremity strength
with yoga training, it was anticipated that improvements in balance
and gait might be detectable aer just 12 weeks of intervention.
One characteristic of PD is a forward exed posture. is posture
is attributed to the contractile elements of the exors becoming
shortened and the extensors becoming lengthened and weakened [10].
Although we subjectively noted improved posture in some of our yoga
participants, this was not a statistically signicant nding.
We did not detect appreciable changes in static standing balance.
ere have been many studies investigating intersession reliability in
center of pressure (COP) measures. One study suggests that mean
velocity is the most reliable measure in healthy elderly people [73],
while others have concluded that no single measurement of COP is
signicantly more reliable than others if measured over a 120 second
period [74]. e 30 second time period our study used may have
contributed to the variability in measures observed in the control group.
However, the sway area (Table 2) and sway path lengths reported here
are similar to previous reports of PD which is larger with more variable
than healthy age matched subjects [75]. All participants showed higher
sway area values than the healthy age matched population, as well
as those with early stage disease without detectable clinical postural
instability. Our participants were more in line with those PD subjects
displaying postural instability of both fallers and non-fallers [76-79].
We did nd positive improvements in lower extremity strength,
UPDRS motor scores, BBS scores and in selected gait parameters of
onset of foot unloading and liing o with yoga intervention. Intensive
exercise programs for individuals with PD that include aerobic
training, exibility, strength, coordination and balance training and an
adaptive program that includes exibility, strength, coordination and
balance show similar improvements in balance and mobility aer 6
months [80]. Interestingly, a study has suggested that a 12 week sensory
attention focused exercise program that utilizes sensory awareness
during gait and balance exercise may be more advantageous than
aerobic exercise in those with PD in improving motor symptoms and
functional movement control [81]. is is similar to improved motor
symptoms as measured by the UPDRS motor section found with 12
weeks of yoga training.
ere is growing interest in addressing falls in those with PD. A
study currently in progress is being conducted analyzing a 6 month
exercise program that consisted of lower extremity strengthening and
balance in dierent modes in relation to fall prevention [2]. Abnormal
posture, freezing gait, poor balance and lower extremity weakness have
been identied as independent risk factors in falling in those with PD
[63]. e results of this study suggest that yoga may be impacting all of
these risk factors to some degree. Yoga provides an alternative method
for addressing some of reversible factors that impact motor function
like strength, exibility and balance. e core strengthening that is
part of yoga should be investigated for this reason. e individualized
improvements in posture with yoga training we observed may have
contributed to improved motor scores and noted gait parameters.
An 8-week yoga program in healthy elderly subjects showed
increased peak hip extension and stride length [42]. However, this
study did not have a control group, and gait parameters may be more
malleable in healthy elderly than in people with PD. Another study
showed a positive eect of a 12 week yoga program on fear of falling
and balances in older healthy adults [82]. e results of our study also
show the benecial eects of yoga on those with PD which may make it
viable alternative to standard exercise programs.
e primary limitation of this study was the limited number of
participants. e lower end of the condence interval may be used,
along with the median and range scores, to estimate. Demonstration
may decrease potential fear associated with trying a new activity.
Further, yoga may be appropriate to investigate in participants with
more signicant balance, exibility or strength decits, or more
advanced PD.
When designing an exercise program for a patient with PD, the
following goals should be addressed: increasing movement (ROM
and exibility), improving balance, and maintaining or restoring
functional mobility [83]. Yoga appears to be safe and well-tolerated by
individuals with PD, and has demonstrated an improvement in motor
UPDRS scores. Investigation of the factors like the potentially remedial
balance, trunk and leg strength that may contribute to improved
motor function an important area for future investigation. Due to
the progressive nature of PD, we speculate yoga programs tailored
for this population may oer an enjoyable, eective way to maintain
quality of life. Physical therapists can incorporate yoga principles into
developing a preventative exercise program for those with progressively
deteriorating neurological diseases such as PD. Future studies should
investigate persistence of the benecial eects of yoga over time and
comparison to other types of exercise for improvements in motor
function.
Acknowledgements
This work was supported by an internal grant from the University of Kansas
Medical Center’s School of Allied Health Research Committee to Yvonne Searls.
This committee had no role in the study’s design, conduct, or reporting.
This project was made possible by Grant Number M01 RR023940 from the
National Center for Research Resources (NCRR), a component of the National
Institutes of Health (NIH), and its contents are solely the responsibility of the
authors and do not necessarily represent the ofcial view of NCRR or NIH. We
would like to thank Suzette Scholtes for providing expert yoga intervention, Wen
Liu for consultation using the force plate system, Byron Gajewski PhD for statistical
consultation, and Christy Moorman and Richard Condray for their assistance with
biomechanical data processing.
Baseline 6-weeks 12-weeks
Control Yoga Control Yoga Control Yoga
Onset time of foot unloading (sec) 0.57 0.70 0.56 0.68 0.63 0.60
Onset time of foot lifting (sec) 0.87 1.00 0.84 0.99 0.95 0.89
Onset time of APA (sec) 0.16 0.18 0.14 0.18 0.17 0.18
Amplitude of APA (N) 124.93 77.16 151.69 73.07 140.73 66.21
Amplitude of swing (N) 23.59 14.19 26.04 16.78 19.48 13.95
Amplitude of stance (N) 76.17 51.20 81.50 57.01 75.39 60.75
Table 3: Gait Initiation Parameters Means of individual gait initiation parameters APA = anticipatory postural adjustment.

Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 10 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
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Citation: Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People with Parkinson’s Disease:
A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112. doi:10.4172/2157-7595.1000112
Page 11 of 11
Volume 2 • Issue 2 • 1000112
J Yoga Phys Ther
ISSN: 2157-7595 JYPT, an open access journal
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