Using New Research to Adapt Yoga for Parkinson's Disease

Editor's note: The following are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a healthcare professional.

About one million Americans live with Parkinson’s disease (PD), a progressive disorder that affects movement, making it the second-most-common neurological disorder after Alzheimer’s disease.

Though its underlying cause is unknown, Parkinson’s disease may have genetic or, less commonly, environmental, links, such as exposure to pesticides. It occurs more frequently in men than women, and age is the greatest risk factor for developing it, with many studies showing its prevalence rising sharply after age 50.

“Because more and more older adults are involved in yoga, and because this disease is so common among this demographic, it’s likely that some of those diagnosed with Parkinson’s disease will want to try yoga, or want to continue to practice. Those students, and their teachers, might wonder what to do to keep practice safe,” says Bill Reif, a physical therapist and the author of The Back Pain Secret: The Real Cause of Women’s Back Pain and How to Treat It.

In order to understand what would and would not be appropriate for practitioners with Parkinson’s disease, it’s important to understand the symptoms of the disease, and to be aware of recent neuroplasticity research that has important implications for the recommended intensity of yoga practice.

About Parkinson’s Disease

Parkinson’s disease is characterized by the dysfunction or death of the neurons in the brain that produce dopamine, an important neurotransmitter for motor function. Like most neurological disorders, Parkinson’s disease is extremely variable from person to person. Possible symptoms, which range in severity, may include soft or monotonous speech, tremors, slow movement, loss of spontaneous movement, a rigid or unstable posture, trunk flexion (rounding the spine forward), and problems with gait. Falls are common in people with PD.

For some, Parkinson’s disease has cognitive and emotional implications as well. It may be linked not only to declines in motor abilities but also to difficulty remembering, solving problems, thinking abstractly, and organizing ideas. Depression may occur in 30 to 40 percent of those with Parkinson’s disease, and anxiety is not uncommon. This may be because of the difficulty in living with the disease and its symptoms, or from the chemical and other changes that occur in the brain.

Progression is measured in five stages, with the first involving little to no impairment, and the fifth, significant losses in mobility. For some, progression through these stages may take place slowly, over the course of decades during which few or mild symptoms appear; for others, the rate of decline may be more rapid and the symptoms more severe.

Though the disease is not curable, forestalling the progression may now be possible.

The understanding used to be that there was no way to slow the stages of Parkinson’s disease. However, recent discoveries have led to changes in its prognosis: Though the disease is not curable, forestalling the progression may now be possible.

Neuroplasticity, Exercise, and Parkinson’s Disease

“The big change here is that we used to think ‘once you’ve lost it, it’s gone,’” Reif says of the new prognoses for those diagnosed with Parkinson’s disease. “In literature from even a few years ago, you’ll see doctors saying, ‘The brain can’t repair itself.’ Well, now we know that with proper stimulation, the brain can create new pathways.”

It is now known that the neurons in our brains do regenerate: Brains continue to make adaptations, remaining changeable throughout adulthood. There is evidence that even in those with neurological diseases such as PD, the brain continues to repair itself. The brain’s ability to rewire itself is known as neuroplasticity; adaptations may include the regrowth of new neurons (neurogenesis) and alterations in neural networks and in brain chemicals.

What sparks such repair? Hearteningly, for yoga practitioners and teachers, exercise has been shown to lead to neurogenesis and is thus a simple means to maintain brain function and promote brain plasticity. The more intense exercise is, the better for the neuroplasticity and motor performance of those with early-stage Parkinson’s disease: Studies are showing that participants with early-stage PD who undertake high-intensity aerobic exercise experience significant improvements in motor and cognitive functioning.

Though the exact mechanism by which exercise enhances neuroplasticity and improves motor function is unclear, animal models show that exercise seems to increase dopamine’s “synaptic availability”—its release and reception by the neural synapses within the basal ganglia, the part of the brain associated with motor control. Also, in animal studies, vigorous exercise has been associated with the production of a protein called BDNF, which is important to both learning and neuroplasticity.

A 2011 survey in Neurology looked at the overall body of evidence for the neuroprotective benefits of exercise on Parkinson’s disease, concluding that “vigorous exercise should be accorded a central place in our treatment of PD.” Vigorous exercise was defined as: “aerobic physical activity sufficient to increase heart rate and the need for oxygen. For this to be meaningful, it should be sustained (e.g., perhaps for at least 20 to 30 minutes at a time) and repeated/ongoing.”

The National Parkinson's Foundation concurs. Based on the growing body of research, it recommends that people with the disease exercise “as often as possible, as long as possible” to alleviate symptoms and perhaps slow its progression. Moreover, the foundation also notes that “when it comes to exercise and PD, greater intensity equals greater benefits.”

Those who don’t have Parkinson’s disease may benefit from vigorous exercise as well, since greater fitness may prevent some age-related cognitive decline. Some studieseven suggest a slightly decreased risk of developing PD for those who exercise vigorously earlier in life (though the authors of these studies note that some of those who develop Parkinson’s disease might have shown an aversion to exercise earlier in life because of the subtle effects of preclinical Parkinson's disease).

Yoga and Parkinson’s Disease

Preliminary research shows that study participants with mild to moderate Parkinson’s disease show modest improvements in balance, functional mobility, mood, and sleep as a result of practicing yoga.

To enhance yoga’s value as a therapy, and in keeping with the latest research, those with Parkinson’s disease and their teachers could foster neuroplasticity by upping the intensity of practice. “Those with mild or moderate PD should challenge themselves even if they fatigue quickly,” Reif says.

Reif would encourage those with mild Parkinson’s disease (and who’ve received permission from their doctors) to participate in yoga classes for as long as possible, sharing their diagnosis and the advice they’ve received from their doctors with their yoga teachers.

For those with mild PD, classes, in addition to being boons for strength, flexibility, and balance, can offer social connections, which seem to be important for cognitive functionality and even longevity.

A crowded, fast-paced class isn’t usually appropriate for someone with Parkinson’s disease, in Reif’s estimation, but a smaller, slower-paced class that allows for the use of a wall and/or chair may be just the thing.

It is, however, important that those with Parkinson’s disease and their teachers modify practice in the ways suggested below, many of which seek to minimize the risk of falls. “For those with PD, the biggest general rule is, Do not do anything that challenges your balance without some sort of support,” Reif says, adding, “The primary concern for those with even mild symptoms is falling. Once those with PD lose their balance, it seems hard to self-stabilize—to regain their balance. If you’re working one-on-one with a PT or a yoga teacher, that person may be able to safely serve as a ‘spotter’ for you, but if you’re in a group class, chances are, the teacher isn’t going to be right there if there’s a problem.”

For those whose Parkinson’s disease is moderate to advanced, the risks of falling in a class may be too great and the movements too challenging. At these stages it might be best to practice yoga one-on-one with a physical therapist or a knowledgeable yoga teacher who can offer a slower, gentler, and more individualized practice. Practicing chair yoga in a small group might work for this population, especially if the rest of the group has similar needs.

“It would be ideal if the student whose PD is more advanced could participate in classes tailored for those with neurological disorders,” Reif says. He describes the ideal class for those who’ve had strokes or who have advanced multiple sclerosis or Parkinson’s disease: “This class would be small, and move slowly. Practitioners would have the option to be in chairs all or most of the time. Teachers would keep movements slow and cues simple, but gradually offer challenges.” (Here is a chair practice that may be suitable for many of those with mild neurological difficulties and that incorporates many of the suggestions Reif offers below.)

How do Reif’s recommendations for a slower, gentler practice in later stages of Parkinson’s disease square with the recommendations that those with PD exercise vigorously? According to Reif, vigorous is a relative term. “It’s important that those with PD challenge themselves, but as the disease progresses, what is challenging will change. Some formerly simple movements will need to be reclassified as vigorous.”

What to Do

This is the approach to Parkinson’s disease and yoga Reif suggests for those with mild PD and their teachers.

Whether you are teaching or practicing, “avoid frustration,” Reif says. Start simple, then gradually increase challenges to speed and endurance, never going so fast or working so hard that you cause the stress that yoga is meant to ameliorate. Encourage deep diaphragmatic breathing throughout practice to promote calmness.

“Even those with mild PD can frequently misstep,” Reif says. “And it can be hard for them to catch their balance again.” In the early stages of Parkinson’s disease, placing your mat near a wall and bringing your fingers to the wall as you balance or step a foot forward or back for a transition may be enough to ensure your balance. If balance “becomes more challenging, it will be important to have a chair near your mat,” he says. “You can hold on to it for stability, and sit on it when you need a break.”

3. Keep the space clear…and no need to use a yoga mat if you feel more secure without one.

Make sure the space around you is cleared of any obstacles that could cause you to trip. “The benefits of using a mat must be weighed against the potential of tripping, or the fear of tripping over an edge,” Reif says. For some, practicing yoga on a smooth, even surface like a wooden or carpeted floor might be reassuring.

4. Use props and mirrors.

Since those with Parkinson’s disease may have cognitive or perceptual challenges, “the more feedback the better,” Reif says. “Tactile or visual elements can assist perception and movement.” For example, squeeze a block or lift a broomstick overhead. Looking in the mirror to see where your arms are, in contrast to where the teacher’s arms are, can also be helpful.

5. Transition slowly from pose to pose.

“Students with PD should not rush from pose to pose,” Reif says. In general, make sure one foot is well rooted before you move the other, and move into balance poses one step at a time. For instance, first practice a version of tree with your hands on a chair or touching a wall and the toes of your bent leg on the ground. Then slowly remove one hand and then the other, making sure you have your balance at every stage in the process.

6. Repeat accessible movements to create challenges that don’t compromise stability.

Rather than embarking on acrobatic poses or moving rapidly to make your practice vigorous, “repeat accessible movement many times, until fatigue,” urges Reif. For those whose symptoms are very mild, movements like sun salutations A and B may be suitable. If symptoms are more advanced, simply lifting and lowering the arms for a quarter sun salutation many times or practicing moving from a seated position in a chair to a standing position and then back to seated might be vigorous enough. If you can comfortably get down to and up from the floor, performing challenging movements, such as leg lifts while lying on your belly or your side, is a good way to build intensity without risking a fall.

7. Focus on countering the tendency to round the back with neutral spine postures and gentle backbends.

To counter forward-head posture and the rounded upper back associated with Parkinson’s disease, “do anything that can take you in the direction of mountain pose,” Reif advises. Many of the poses in this kyphosis sequence will be appropriate for those with mild Parkinson’s disease, and even those whose symptoms are more advanced might find it helpful to stand with their back against a wall or lie down and practice pressing the back of their head very gently against yoga blocks.

8. Do core work.

Not only is core work a surefire way to add intensity to your practice while much of your body is supported by the floor, but a strong core can also help with balance and stability, as well as improve your posture. Many of those with mild Parkinson’s disease will be able to do core-strengthening movements, like lifting and lowering their legs or lowering bent legs from side to side, while lying down on their backs.

9. Make big gestures.

“One of the earlier signs of Parkinson’s disease is a lack of arm swing during gait on one side of the body,” Reif says. “Later on, all movements of the arms and legs may shrink. When reaching or walking, persons with PD might think their arms are straight, but they’re nowhere near straight.”

Recent therapeutic treatments are designed to recover some of the loss of limb motion by including exaggerated movements. Large movements have been shown to decrease rigidity. One notable program in particular, LSVT BIG, emphasizes increasing the amplitude of gestures, though studies have found other medium- and high-intensity exercise programs to be as effective as LSVT BIG.

According to Reif, many yoga movements are already big enough to help to restore some loss in range of motion. Since many persons with Parkinson’s disease do not perceive their movements as being smaller than normal, teachers should encourage students with PD to expand their movements, and those with PD should keep in mind that just because your movement feels gigantic does not mean it is. “Exaggerate, and you’re probably well within the normal range,” Reif says.

That said, Reif offers the caveat that the need for stability may outweigh the need for big movements. For instance, stepping feet as far apart as is “normal” in poses like warrior I and II might be destabilizing for students with Parkinson’s disease. Since falls are common among this population, consider that a smaller or shorter stance is often more stable than a very broad one.

10. Make movements that require—and foster—coordination.

Exercises that require coordination, or conscious control, like pointing one finger while touching the opposite ear, or making small movements with the fingers and eyes, may help boost cognitive function in older adults with limited mobility. Eagle pose (standing or seated in a chair), alternate nostril breathing, and making a range of mudras (“hand yoga”) are all examples of yoga movements that require the processing and organization of multiple elements.

11. Do one-sided movements.

Some people with neurological disorders have difficulty making a voluntary movement on one side of the body at a time. To practice getting each side to move independently, lift one arm while the other stays down, tap one foot at a time, or practice mudras with one hand at a time. Reif recommends looking into a mirror for this type of movement.

12. Include activities that demand—and capture—attention.

Exercise that promotes awareness and learning and even requires some multitasking seems to be valuable for those with Parkinson’s disease, so consider including activities that you might not have thought of as “yoga” in your practice. For instance, while chatting, play catch in a circle with a large beach ball or (soft foam!) yoga block. Practice a pose while solving a problem, or perform a simple sequence while singing or chanting.

13. Set “targets” for your hands and feet.

Identifying precise destinations may increase your chances of placing your hand or your foot where you mean to. Reif gives an example of using a target: “Instead of ‘step your foot forward,’ a teacher working with a student who has Parkinson's disease might say ‘step your foot forward to the front edge of the yoga mat.’” Using pieces of tape to mark a goal might be useful, as might a yoga mat with foot- and hand-placement diagrams. Reif even suggests dusting off an old Twister mat; the colored dots supply many possible destinations (and encourage fast thinking). Smooth it out, tape it down, and experiment with new ways of cueing poses: “Step your right foot to the blue dot, now to the yellow dot.”

14. If you’re comfortable doing so,accept gentle adjustments from your teacher. (Or, if you are a teacher, give them to students who have given permission to be touched!)

For students with Parkinson’s disease who are comfortable with hands-on assistance from a yoga teacher, adjustments can be helpful. Reif does not endorse hands-on assists in all circumstances, noting that a teacher can easily push a student past their end range. “But students with Parkinson’s disease may be further from their physiological boundaries,” he says. “They often will stop a movement when they’re nowhere close to their end range. A touch from a teacher can be of tremendous help to keep you using the range of motion that is available to you.” For instance, if a student’s arms are bent in a pose that calls for straight arms, the teacher could hold that student’s wrists or arms, and gently help the student to straighten their elbows.

15. Find a teacher who doesn’t overcomplicate things. (If you’re a teacher, keep your directions concise and clear!)

For those with Parkinson’s disease, long lists of complicated directions might become harder to process, especially when part of their attention is given to practicing a pose. They should seek out a teacher who gives straightforward, practical cues. If you are a teacher, minimize your cues. “Be as simple and clear as you can be,” says Reif, which is a good maxim for all instructors, no matter whom they’re teaching.

16. Take breaks.

When you get tired, take child’s pose, or sit down on the floor or a chair. “Fatigue can make tremors worse,” Reif says. Since increased tremors can increase the risk of falling, it’s important that you give yourself a break when you need it. While seated, feel free to make mudras, bringing your index fingers and thumbs together, for example, or focus on diaphragmatic breathing, encouraging your belly to expand as you inhale and contract as you exhale.

17. Don’t let self-consciousness or comparisons with others hold you back from a practice you enjoy.

“If you have PD, you might have to slow down or take breaks even when those around you are still going at full speed,” Reif says. “Don’t worry about what the other students are thinking. They’re probably not thinking about you at all; they’re focusing on their own practices.”

While some classes may genuinely be too demanding or stressful for you to enjoy, do not miss out on the benefits of a group practice that you find valuable simply because you move a little more slowly than some of the other students or skip a pose here and there.

18. Include music in your yoga practice.

For reasons still not understood, music seems to have a vitalizing effect on those with neurological disorders. It may help reduce anxiety, and rhythm may have beneficial effects on movement-related symptoms, assisting with gait and coordination. Play music you like while you’re practicing, and if you’re a teacher, use music that resonates with your students.

Conclusion

Experiences vary tremendously among people with Parkinson’s disease, and individual experiences vary from day to day as symptoms change. The approach to yoga practice that works for one practitioner may not work for another; what worked for one practitioner yesterday may not work for that same practitioner today.

So it is vital that those with Parkinson’s disease and their teachers be mindful of the exigencies of the present moment and be open to making changes as needed, cultivating an approach to practice that is as adaptable and responsive as our neural circuitry.