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Effects of Mindfulness Yoga vs Stretching and Resistance Training Exercises on Anxiety and Depression for People With Parkinson Disease: A Randomized Clinical Trial
Open accessAbstract
Importance: Clinical practice guidelines support exercise for patients with Parkinson disease (PD), but to our knowledge, no randomized clinical trials have tested whether yoga is superior to conventional physical exercises for stress and symptom management. Objective: To compare the effects of a mindfulness yoga program vs stretching and resistance training exercise (SRTE) on psychological distress, physical health, spiritual well-being, and health-related quality of life (HRQOL) in patients with mild-to-moderate PD. Design, Setting, and Participants: An assessor-masked, randomized clinical trial using the intention-to-treat principle was conducted at 4 community rehabilitation centers in Hong Kong between December 1, 2016, and May 31, 2017. A total of 187 adults (aged ≥18 years) with a clinical diagnosis of idiopathic PD who were able to stand unaided and walk with or without an assistive device were enrolled via convenience sampling. Eligible participants were randomized 1:1 to mindfulness yoga or SRTE. Interventions: Mindfulness yoga was delivered in 90-minute groups and SRTE were delivered in 60-minute groups for 8 weeks. Main Outcomes and Measures: Primary outcomes included anxiety and depressive symptoms assessed using the Hospital Anxiety and Depression Scale. Secondary outcomes included severity of motor symptoms (Movement Disorder Society Unified Parkinson's Disease Rating Scale [MDS-UPDRS], Part III motor score), mobility, spiritual well-being in terms of perceived hardship and equanimity, and HRQOL. Assessments were done at baseline, 8 weeks (T1), and 20 weeks (T2). Results: The 138 participants included 65 men (47.1%) with a mean (SD) age of 63.7 (8.7) years and a mean (SD) MDS-UPDRS score of 33.3 (15.3). Generalized estimating equation analyses revealed that the yoga group had significantly better improvement in outcomes than the SRTE group, particularly for anxiety (time-by-group interaction, T1: β, -1.79 [95% CI, -2.85 to -0.69; P = .001]; T2: β, -2.05 [95% CI, -3.02 to -1.08; P < .001]), depression (T1: β, -2.75 [95% CI, -3.17 to -1.35; P < .001]); T2: β, -2.75 [95% CI, -3.71 to -1.79; P < .001]), perceived hardship (T1: β, -0.92 [95% CI, -1.25 to -0.61; P < .001]; T2: β, -0.76 [95% CI, -1.12 to -0.40; P < .001]), perceived equanimity (T1: β, 1.11 [95% CI, 0.79-1.42; P < .001]; T2: β, 1.19 [95% CI, 0.82-1.56; P < .001]), and disease-specific HRQOL (T1: β, -7.77 [95% CI, -11.61 to -4.38; P < .001]; T2: β, -7.99 [95% CI, -11.61 to -4.38; P < .001]). Conclusions and Relevance: Among patients with mild-to-moderate PD, the mindfulness yoga program was found to be as effective as SRTE in improving motor dysfunction and mobility, with the additional benefits of a reduction in anxiety and depressive symptoms and an increase in spiritual well-being and HRQOL. Trial Registration: Centre for Clinical Research and Biostatistics identifier: CUHK_CCRB00522.
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“To attenuate this effect, both yoga and mindfulness meditation have been shown to improve health-related quality of life by reducing anxiety and depressive symptoms in neurodegenerative diseases [216,217].”
From The Impact of Neurotoxin Proteins Trafficked by Primary Cilia and Extracellular Vesicles in Neurodegenerative Diseases (2025) · cites this paper as [216]
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“Nevertheless, the sample size of the current study is above the average of existing MBI clinical trials for PD patients (number of studies = 7; range = 13–138; mean sample size = 50)12,32–37.”
From A randomized clinical trial of mindfulness meditation versus exercise in Parkinson’s disease during social unrest (2023) · cites this paper as [12]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“it could be argued that only one was adequately powered to detect differences in study outcome measurements (Kwok et al., 2019).”
From A Systematic Review of Third-Wave Therapies to Reduce Distress and Improve Wellbeing and Quality of Life in People with Parkinson's Disease. (2025) · cites this paper as Kwok et al., 2019
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“there was evidence, based on data from the trial with the largest sample size, of an effect of Mindfulness Yoga on both its primary outcome (depression and anxiety) and on secondary outcomes (psychological well-being and quality of life), at the end of the 8-week intervention, which was sustained after 3 months (Kwok et al., 2019).”
From A Systematic Review of Third-Wave Therapies to Reduce Distress and Improve Wellbeing and Quality of Life in People with Parkinson's Disease. (2025) · cites this paper as Kwok et al., 2019
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“A clinical trial of yoga involving 138 PD patients demonstrated its significant superior therapeutic effects on alleviating anxiety and depression compared to active exercise control (stretching and resistance training exercises), with similar physical benefits12.”
From A randomized clinical trial of mindfulness meditation versus exercise in Parkinson’s disease during social unrest (2023) · cites this paper as [12]
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“its safety has been demonstrated in our previous published trial12.”
From A randomized clinical trial of mindfulness meditation versus exercise in Parkinson’s disease during social unrest (2023) · cites this paper as [12]
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“Compared to our previous clinical trial of mindfulness yoga, there was inconsistency in the evidence of its effects on anxiety, motor symptoms, and HRQOL12,20,21.”
From A randomized clinical trial of mindfulness meditation versus exercise in Parkinson’s disease during social unrest (2023) · cites this paper as [12]
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“The largest effectiveness trial found a significant reduction in Hospital Anxiety and Depression Scale (HADS) following Mindfulness Yoga (n = 71) compared to an active control (n = 67) (Kwok et al., 2019)”
From A Systematic Review of Third-Wave Therapies to Reduce Distress and Improve Wellbeing and Quality of Life in People with Parkinson's Disease. (2025) · cites this paper as Kwok et al., 2019
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“One effectiveness trial showed significant improvement in secondary outcomes measures including the Holistic Well-being Scale (HWS) and Health-Related Quality of Life (HRQOL) following Mindfulness Yoga compared to an active control (Kwok et al., 2019).”
From A Systematic Review of Third-Wave Therapies to Reduce Distress and Improve Wellbeing and Quality of Life in People with Parkinson's Disease. (2025) · cites this paper as Kwok et al., 2019
The cited source says what the claim attributes to it.
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“The current evidence on using mindfulness techniques to improve depression in PD consists of four RCTs (Kwok et al., 2019; Pickut et al., 2015; Rodgers et al., 2019; Son & Choi, 2018) and three uncontrolled pretest-posttest studies (Birtwell et al., 2017; Cash et al., 2015; Dissanayaka et al., 2016), and shows mixed results.”
From Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand? (2021) · cites this paper as Kwok et al., 2019
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“Significant improvements were also observed following the adoption of mindfulness-based yoga, which were maintained at 3-month follow-up (Kwok et al., 2019).”
From Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand? (2021) · cites this paper as Kwok et al., 2019
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“The use of mindfulness-based interventions to address anxiety in PD has been evaluated by three RCTs (Kwok et al., 2019; Rodgers et al., 2019; Son & Choi, 2018) and two uncontrolled pretest-posttest studies (Birtwell et al., 2017; Dissanayaka et al., 2016).”
From Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand? (2021) · cites this paper as Kwok et al., 2019
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“A total of 10 intervention studies have adopted approaches based on mindfulness to target psychological difficulties in PD. Of these, five were RCTs (Advocat et al., 2016; Kwok et al., 2019; Pickut et al., 2015; Rodgers et al., 2019; Son & Choi, 2018).”
From Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand? (2021) · cites this paper as Kwok et al., 2019
The cited source says what the claim attributes to it.
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“The second most common psychotherapeutic model was mindfulness, with 10 studies adopting one of its many variations (e.g., MBCT, MBSR, mindfulness yoga), five of which were RCTs (Advocat et al., 2016; Kwok et al., 2019; Pickut et al., 2015; Rodgers et al., 2019; Son & Choi, 2018).”
From Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand? (2021) · cites this paper as Kwok et al., 2019
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“Significant better outcomes for the mindfulness yoga group in anxiety, depression, and QoL at both post- intervention and follow-up.”
From Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand? (2021) · cites this paper as Kwok et al., 2019
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“For individuals with movement disorders such as PD, in-person yoga interventions have also not reported any signi fi cant adverse events (13, 43, 44).”
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“In four community rehabilitation centers in Hong Kong, researchers evaluated the impacts of a mindfulness yoga session with stretching and resistance training exercise (SRTE) on mental trauma, physical health, psychic well-being, and health-related quality of life (HRQOL) in patients with mildto-moderate PD.”
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“To our knowledge, no studies have exam‑ ined the direct effect of stationary cycling on PwPD anxiety; however, other physical activity interventions have proven efficacious in improv‑ ing co‑morbid PD and anxiety [67, 68, 73, 74].”
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“Studies of Kwok et al. (2019) and Jin et al. (2020) have shown that mind-body exercise can improve depressive symptoms in patients with Parkinsonism, and Tai Chi exercises can improve anxiety and depression in patients with cancer, Parkinson’s disease, and others (Cai et al., 2022).”
Shades of grey: The continuum of therapies for Parkinson's disease along the spectrum of credibility
Cánovas, A. A., Dekkers, O. M., & Bloem, B. R. (2025) · Journal of Parkinson s Disease · doi:10.1177/1877718x251361441
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“We speculate that through these techniques, she had the opportunity to think objectively from a state of mindfulness (Kwok et al., 2019) with her focus on the ‘here and now’, letting go of the sense of loss that lingered in her thoughts and that the exercise aspect of yoga asanas may have helped…”
Önder, H., Özşimşek, A., Ülker, A., Yurekli, M., Bildik, I., Tunc, H., Yavuz, Z., Çomoǧlu, S., & Melek, İ. (2025) · Movement Disorders Clinical Practice · doi:10.1002/mdc3.70378
ROLE OF PHYSICAL ACTIVITY IN PARKINSON’S DISEASE PREVENTION AND MANAGEMENT – A LITERATURE REVIEW
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Hei, L., Zhang, Y., Si, Y., & Bai, L. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1695692
“…have reported reductions in anxiety, depressive symptoms, and perceived stress following regular yoga practice in various populations, including individuals with chronic health conditions, the consistency and generalizability of such effects remain subjects of ongoing investigation (61 – 64).”
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“Examples include Parkinson’s disease (mood and quality-of-life gains without motor compromise) 6,7 , chronic pain (mindfulness-based stress reduction comparable to cognitive behavioral therapy at 26 weeks) 8 , migraine (disability improved without reducing attack frequency) 9 , prevention of…”
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“Most interventions were supervised (Hortobágyi et al., 2021; Duarte et al., 2023; Altmann et al., 2016; Dağ et al., 2022; Hashimoto et al., 2015; Kwok et al., 2019; Kwok et al., 2025; Lee et al., 2018; Lee et al., 2015; FIGURE 1 PRISMA flowchart of study selection.”
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“62 This may explain why the MC group demonstrated the greatest improvement in UPDRS-III scores.”
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“A 2019 randomized clinical trial (RCT) demonstrated that mindfulness yoga is safe and effective in reducing anxiety and improving motor symptoms in individuals with PD, supporting its role as a complementary therapeutic strategy [17].”
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Non-pharmacological interventions for anxiety and depression in Parkinson's disease
Li, T., Shi, J., Zheng, Q., Xu, J., Zhang, M., Ren, Y., Zhang, B., & Li, Z. (2026) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd016360
de Souza, L. C., Senna, L. A. S., D’Oliveira, A., Truppel, R., Vilarino, G. T., & Andrade, A. (2026) · Physiotherapy Research International · doi:10.1002/pri.70266
“Although most studies reported training volume, several did not clearly quantify training intensity (F. Li et al. 2014; Morris et al. 2015, 2017; Kwok et al. 2019; Schlenstedt et al. 2015).”
InfluentialZeng, Z., Li, X., Ma, X., Guo, J., & Qin, L. (2026) · Complementary Therapies in Clinical Practice · doi:10.1016/j.ctcp.2026.102077
MARY, L., Adhikari, P., & Udayakumara, K. (2026) · Annals of Neurosciences · doi:10.1177/09727531261461074
Liu, M., Gao, Z., Wang, Y., Yang, H., Liu, C., Wu, J., Liang, S., Shao, S., Zhang, Z., Kang, J., et al. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1876753
“…observable reductions in depressive symptoms over short-to mid-term intervention periods in individuals with stroke or other neurological disorders (54–56), whereas high-intensity protocols do not appear to yield proportionally greater benefits and may be more prone to fatigue accumulation and…”
Özdemir, A., & Budak, F. K. (2026) · Journal of Integrative and Complementary Medicine · doi:10.1177/27683605261469654
Breaking the Freeze: The Role of Cognitive Function in Freezing of Gait in Parkinson’s Disease
Papáček, O., & Růžička, E. (2026) · Parkinson s Disease · doi:10.1155/padi/7199074
“Nevertheless, an RCT by Kwok et al. (2019) demonstrated comparable improvements in motor symptoms and mobility, along with additional benefts for psychological distress and well-being [65].”
Stites, S. D., Lee, K., Kuz, C., Mandell, D. S., Bogner, H. R., & Brown, R. T. (2026) · Current Psychiatry Reports · doi:10.1007/s11920-026-01704-1
Fearon, C., Jost, W. H., Roth, J., Rožanković, P. B., & Schrag, A. E. (2026) · Journal of Neural Transmission · doi:10.1007/s00702-026-03251-8
Chan, L. M. L., Lam, W., Chan, K. H., Pang, S., Auyeung, M., & Kwok, J. Y. Y. (2026) · JMIR Research Protocols · doi:10.2196/105727
“Previous studies of mindfulness-and acceptance-based interventions have reported large effect sizes (0.96 ‐ 1.14) in people with MS [29] and moderate to large effects for anxiety ( d =0.58) and depression ( d =0.74) in PD [30].”
InfluentialSelf-citationTowards the Prevention of Freezing of Gait in Parkinson's Disease
Tosserams, A., Nonnekes, J. H., Bloem, B. R., & Postma, E. M. (2026) · European Journal of Neuroscience · doi:10.1111/ejn.70636
“Especially mindfulness can have beneficial effects on stress (Goldberg et al. 2022) and can have synergetic effects when combined with exercise (Kwok et al. 2019).”
Gwak, J., & Park, J. (2026) · BMC Psychology · doi:10.1186/s40359-026-05436-y · Cited by 1
Understanding Neuropsychiatric Fluctuations in Parkinson's Disease: From Mechanisms to Management
Sousa, M., Amstutz, D., Natera‐Villalba, E., Krack, P., & Martínez‐Fernández, R. (2026) · Movement Disorders Clinical Practice · doi:10.1002/mdc3.70771
Diederich, N. J., & Pauly, C. (2026) · Journal of Neural Transmission · doi:10.1007/s00702-026-03267-0
“Short-term studies over 8 weeks (one large randomized clinical trial as well as several smaller studies) have reported favorable effects on anxiety, motor symptoms, and quality of life (Boulgarides et al 2014; Kwok et al 2019; Trinh et al 2026).”
Lifestyle medicine for neuroprotection: evidence and implementation in Asian contexts
Kim, S., Chung, S. J., Yoon, S., Bloem, B. R., Postma, E., Kim, R., Fujioka, S., Nagaishi, Y., Phokaewvarangkul, O., Park, K. W., et al. (2026) · Journal of Neural Transmission · doi:10.1007/s00702-026-03294-x
Physical Activity and Motor and Cognitive Progression in Parkinson Disease
Ryu, D.-W., Duque, K. R., Marsili, L., Abanto, J. T., Paredes, N. O. C., Deraz, H. A., Gorriti, A. H., Hill, E. J., Mahajan, A., Duker, A. P., et al. (2026) · Neurology · doi:10.1212/wnl.0000000000218682
Yan, Y., Wang, M. P., Lau, K. K., Chen, H., Yang, Y., Yang, Z., Ye, F., & Lee, J. J. (2026) · Nursing Open · doi:10.1002/nop2.70973
“A first-order autoregressive (AR1) working correlation structure will be adopted to account for within-participant correlation across repeated measurements, assuming that correlations diminish over time (Gosho 2014; Kwok et al. 2019).”
Bai, H., Chen, Z., Li, L., 段美强, Fan, T., & Zhang, Y. (2026) · Frontiers in Aging Neuroscience · doi:10.3389/fnagi.2026.1982103
Metadata
- Authors
- Kwok, J. Y. Y., Kwan, J. C. Y., Auyeung, M., Mok, V. C. T., Lau, C. K. Y., Choi, K. C., & Chan, H. Y. L.
- Affiliations
- University of Hong Kong (HK)
- The Hong Kong Society for Rehabilitation, Hong Kong Special Administrative Region
- Pamela Youde Nethersole Eastern Hospital (CN)
- Chinese University of Hong Kong (HK)
- Prince of Wales Hospital (CN)
- Corresponding author
- Kwok, Jojo Y. Y.
- Venue
- JAMA Neurology
- Publisher
- American Medical Association (AMA)
- Published
- 2019-07-01
- Volume
- 76
- Issue
- 7
- Pages
- 755
- ISSN
- 2168-6149 (ISSN-L)
- PMC
- PMC6583059
- OpenAlex
- W2929550160
- Cited by
- 379
- References
- 52
- Citations by year
- 2026: 43 · 2025: 69 · 2024: 79 · 2023: 61 · 2022: 59 · 2021: 38 · 2020: 23 · 2019: 6
- FWCI
- 36.79
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Neurology (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Clinical Neurology › Parkinson's Disease Mechanisms and Treatments
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Keywords
- mindfulness yoga, Parkinson's disease, anxiety, depression, exercise therapy, spiritual well-being, health-related quality of life, motor symptoms, mobility (physical function), psychological distress, non-pharmacological treatment, community rehabilitation centers, MDS-UPDRS, Hospital Anxiety and Depression Scale, equanimity, older adults, community-dwelling
- MeSH terms
- Aged, Anxiety, Depression, Exercise Therapy, Female, Hong Kong, Humans, Male, Middle Aged, Parkinson Disease, Quality of Life, Severity of Illness Index, Yoga, Treatment Outcome, Muscle Stretching Exercises, Resistance Training, Mindfulness
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