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YOGA THERAPY FOR EARLY ONSET PARKINSON'S DISEASE (continued)


Diagnosis and Treatment/Management



Presentation and pathology make clinical diagnosis challenging. An individualized approach is key and age of onset a factor in treatment.

There is no specific test for Parkinson’s or way to track disease progression on a biological level. Diagnosis is based on history and examination and tests including the use of DaTSCAN, MRI and genetic testing.


Delays in diagnoses and treatment have been identified amongst younger patients in part due to the reluctance to seek diagnosis of a disease associated with “older people” (Rana, Siddiqui and Yousuf 2012).


By the time a person shows classic motor symptoms and is diagnosed with Parkinson’s substantial and widespread loss of brain cells and damage to the functions of the brain and autonomic nervous system have already occurred (NINDS). Progression is measured by the Hoehn and Yahr scale (Hoehn and Yahr 1967) with the addition of non-motor symptoms.


The main purposes of treatment are to slow progression, reduce clinical symptoms (motor and non-motor) and improve QoL. EOPD has specific symptoms, genetic correlation and requires individualized treatment strategies when assessing the benefits and harms of medication below. All needs to be managed alongside careers, relationships, social lives, and families.


The most common pharmacological interventions for Parkinson’s are dopamine precursors such as Levodopa which cross the blood brain barrier and convert to dopamine, however the benefits tend to wane with disease progression and several non-motor symptoms may not respond to this. In EOPD, Levodopa is associated with early occurrence of dyskinesia motor symptoms so low doses or alternatives have generally been prescribed but delays for individuals with EOPD risk greater cumulative disability and have been reviewed in recent years. (Ahlskog 2020). The 2019 Levodopa in Early Parkinsons disease study revealed early use Levodopa gave better control over early motor symptoms and improved quality of life (Vershuur et al 2019). NICE 2017 guidelines recommend Levodopa as first line treatment where motor symptoms affect quality of life.


Alternative treatments include anticholinergic drugs interrupting the production of acetylcholine which may reduce tremors but increase later cognitive decline (Mehanna et al 2014); and dopamine agonists but these are associated with an increase in sleep attacks and impulse control behaviours in those diagnosed younger (Vela et al 2016).


Subthalamic Deep Brian Stimulation (STN-DBS) is a useful intervention for those with EOPD levodopa-initiated dyskinesia, in reducing motor symptoms and additional neuropsychiatric features (Krause et al 2022). DBS does not stop disease progression, requires frequent medical appointments for monitoring and has limited impact on non-motor symptoms which may be relevant in maintaining employment and social activities.


The biomedical approach to treatments for Parkinson’s focuses on pharmacology and targeting motor symptoms but as quality of life in patients with EOPD is affected by mental health co morbidities arising (Mehanna et al 2014) there is a need for psychotherapeutic treatment to improve psychological wellbeing.


The pathogenic mechanisms of mental health disorders in PD are unclear and may be related to dopaminergic dysfunction (Marsh 2013) (Frisina, Haroutunian and Libow 2009). As depression is reported to correlate with other clinical features, a younger onset of Parkinson’s and longer duration of illness (Hwang et al 2023) psychotherapeutic interventions ranging from medication to CBT are recommended. Studies have revealed those developing PD are also more likely to have suffered depression, anxiety before a diagnosis highlighting the complex causal relationship between these (Isihara et al 2008 as cited in Alamri 2015).


The side effects and limitations of medication and surgery have seen an increased use of alternative and complementary therapies to alleviate symptoms (Deuel and Seeberger 2020).


Occupational therapy, exercise and diet are recommended lifestyle changes (Parkinsons UK). As a safe treatment, physical activity especially moderate to vigorous can have a positive effect on PD through a variety of molecular mechanisms including reducing the accumulation of a-syn protein, alleviating inflammation and oxidative stress, whist enhancing nerve regeneration, mitochondrial function and BDNF activity (Fan et al 2020).

Exercise has been shown to have neurogenerative benefits on the Pink 1 gene linked to EOPD (Edbanks et al 2021).


Animal studies have revealed BDNF to be a promising therapeutic agent in treating PD, enhancing the survival of dopaminergic neurons, improving neurotransmission and motor performance (Palasz et al 2020) (Hacioglu et al 2023).

One Meta analysis of 20 studies revealed exercise interventions of 12 weeks or longer significantly improved quality of life (Chen et al 2020). Another recent Meta analysis of exercise interventions effect on Parkinson’s revealed a positive overall effect (Ahmed et al 2023). The Parkinsons Outcome Project established by Parkinsons UK states that those who started exercising earlier and for at least 2.5 hours a week can slow a decline in quality of life.

Several studies have investigated the benefits of dance and dancing with music including a slowing of physical and psychological symptoms (Bearss and De Souza 2021). Also, improvement in functional mobility, symptoms of depression and social support (Carapellotti, Rodger and Doumas 2022).

The benefits of 6 weeks of physical activity on cognition in EOPD were investigated in two interrelated online studies of 132 participants and the results suggested that increased physical activity improved processing speed and attention (Biddiscombe et al 2020). Ideally further research would involve a longer period of activity and larger group.

Rehabilitation therapies and holistic interventions are gaining in popularity plus a growing interest in quality of life making Yoga Therapy a promising intervention. EOPD is characterized by motor, cognitive, autonomic, and psychological issues, giving yoga therapy with its multifaceted whole person focused approach the potential to be a useful tool in conjunction with biomedical treatments.



Yoga Therapy


Yoga, ancient mind body practice includes techniques for mental and physical transformation which may have therapeutic benefits when considered in the context of the biopsychosocial model of modern healthcare.


Yoga Therapy takes this further, via a collaborative exploration between yoga therapist and client, focusing on the therapeutic benefits of yoga backed by science, addressing the unique and specific needs and health conditions of the individual. It encapsulates a multi-dimensional individualized approach to alleviating suffering in non-invasive ways working alongside conventional treatments.


Despite the lack of specific studies on EOPD we can extrapolate relevant findings from the wealth of generic Parkinson’s research what is relevant to the characteristics of EOPD impacting quality of life.


A 2019 randomized clinical trial of 138 patients investigated the effects of Mindfulness Yoga Vs Stretching and Resistance Training (SRT) Exercises on Anxiety and Depression for people with Parkinson’s. Although the mean age of participants was 63.7 the age range was 38-85 and included those with EOPD. Mindfulness Yoga was practised for 8 weeks with the control group practising SRT. The results showed similar physical benefits in relation to motor symptoms, but the mindfulness yoga group had significant improvements in anxiety, depression, health related quality of life and spiritual wellbeing. At follow up these improvements were maintained in contrast with dance and qigong (Kwok et al 2019). Mindfulness and mind/body interventions were superior to conventional physical exercise for stress and symptom management.


Strengths include this being a randomized clinical design with large sample and multiple follow up time but the possibility of expectation and gender bias amongst participants was acknowledged.


A systematic overview of existing mindfulness trials in PD including the one above was conducted in 2021 and highlighted the impact of stress worsening motor symptoms. Mindfulness was seen to encourage individuals to independently self-manage and adapt to the challenges created by their condition. An important factor for those faced with a slower and longer disease progression in EOPD (Van der Heide et al 2021)


A randomized clinical trial by Kwok et al 2023 examined the benefits of mindfulness meditation versus SRT at a time of considerable stress (covid pandemic and social unrest). Of 168 participants with PD, half participated in 8 weekly 90-minute sessions of mindfulness meditation versus SRT. Results revealed the mindfulness meditation group had better outcomes in managing depression and emotional stability during periods of stress. Of interest to those diagnosed with EOPD when navigating demanding careers, young families, and other stressful life events.


Although small the sample was above average, its main limitations were covid reduced face to face examinations and (although the age range of participants was 40-88) the mean age of 64.5 is outside that for a diagnosis of EOPD.


A 2018 Randomized controlled trial examined the functional improvements in Parkinson’s following an 8-week yoga therapy course including asanas, pranayama and relaxation delivered by a certified IAYT Yoga Therapist compared to a non-exercising control group. It reported improvements in balance, fall control and postural stability within the yoga group highlighting the physical benefits of yoga on motor symptoms (Van Puymbroeck et al 2018). Limitations were the small size of 27 individuals and the fact that all were white males with a mean age of 67.75. EOPD does cause early motor symptoms (rigidity and painful cramps) so this study is of interest.


The pathophysiological hallmark of Parkinsons is loss of nigrostriatal dopaminergic neurons and this it is believed may increase susceptibility to stress, depression, and low mood (Douma and Kloet 2020) impacting QoL in EOPD. A 2002 study demonstrated increased endogenous dopamine release in the ventral striatum during yoga nidra meditation. The participants underwent two PET scans while attending to speech with eyes closed or active meditation and all participants reported a decreased desire for action. It was noted that the increased dopaminergic tone seemed to be associated with the voluntarily induced suppression of the executive function during relaxation practised in a specific way incorporating imagery and decreased attention inwards. Yoga Nidra practised as part of Yoga Therapy may initiate short term increase in dopamine levels and be of benefit to those navigating the motor and non-motor symptoms impacting QoL (Kjaer et al 2002).


Another study of interest for EOPD and neuroplasticity and relevant changes in neural networks with implications for managing mood and memory is a randomized controlled study by Pickut et al 2013. The effects of an 8-week MBI practice on the brain of 27 PD patients were evaluated when compared with non-exercise controls. MRI scans revealed an increase in grey matter density/increased volume in areas including the hippocampus, caudate and amygdala. A small study which highlighted the benefits of mindfulness, changes to relevant brain areas and the potential for neuroplasticity for those diagnosed at a younger age.


Koshas


As research into a cure continues, treatment of EOPD involves a combination of pharmacological, psychotherapeutic, and measures including occupational therapy geared towards alleviating symptoms and improving quality of life. A multidimensional approach aligning well with the Pancha Kosha model first appearing in the Taittirya Upanishad and used in Yoga Therapy as a holistic multifactorial assessment and diagnostic tool- a lens through which to view the whole person and to determine how they are affected by their presenting health condition/medical diagnosis. The five Kosha sheaths like layers of an onion interconnect and interact with each other. There are the gross more tangible and visible outer layers and the subtle innermost layers where our true nature – “atman” lies. Wellbeing is achieved when there is balance between all five sheaths.


Annamaya Kosha – food sheath


Our physical body and densest of the Koshas is influenced by diet, sleep and posture. EOP presents here as muscle spasms, rigidity, painful cramps, and contractions, erratic involuntary movements, increased motor fluctuations (more on/off periods – “on “meaning responding to treatment) and non-motor symptoms especially insomnia, digestive issues, and fatigue. Overtime postural instability and risk of falls increases.


Those with EOPD may be used to being active and yoga therapy as a therapeutic modality offers opportunities to increase flexibility and counterbalance rigidity, improve functional strength, mobility and balance (Van Puymbroek et al 2018) all of which help build confidence, self-efficacy and encourage those diagnosed at a young age to continue with physical activities bringing joy (Anandamaya Kosha) and reducing mood disorders (Manomaya Kosha) and reigniting enjoyment in a body they may have lost faith in.


The impact of stress demonstrates how intrinsically linked the Koshas are. Stress worsens the motor and non-motor symptoms of EOPD. Cortisol released via the HPA Axis can disrupt mitochondrial function, increase oxidative stress and neuroinflammation recognised as key disease mechanisms in Parkinson’s ( Lutha et al 2022) ( Bougea et al 2022) . In a large survey of 5,000 patients with Parkinsons, stress was shown to worsen symptoms including sleep problems, dyskinesia, and tremor (Van der Heide et al 2021). Stress impacts disease progression increasing the risk of rate of death of dopamine neurons (Espinosa-Olivia et al 2014 as cited in Van der Heide et al 2021) and elevated stress levels have an impact upon neuronal functions in brain structures such as the Hypothalamus, Pre-Frontal Cortex and Hippocampus and increases fatigue (Pranamaya Kosha), depression and anxiety (Manomaya Kosha) all of which affect QoL.


Yoga and mindfulness practices as part of a yoga therapy intervention can reduce activation of the HPA Axis and SNS, increase vagal nerve activation and PNS activation. A 2017 Meta analysis of randomized controlled trials revealed yoga reduced cortisol and improved HPA and ANS regulation (Pascoe, Thompson and Ski 2017) and Mindfulness practices can improve emotional regulation and mood disorders in Parkinson’s (Kwok et al 2019).

Practices to build ANS flexibility and enable a patient to downgrade their stress response can be useful for those with EOPD when faced with stressful situations which impact their disease symptoms. Slow breathing and relaxation practices tone the vagus nerve, enhance HRV and alternating between activating and calming practices (dynamic movement and childs pose) may help lift and lower ANS and build resiliency.


Possibly more physically able to explore free flowing dynamic movements enhancing mood, fun (increasing serotonin), neuroplasticty (enhancing BDNF) and also the cerebellar/PFC pathway (Orban et al 2010)


Annamaya Kosha can be supported with lifestyle changes including uptake of natural antioxidants and exercise which may reduce deterioration of dopaminergic neurons and slow progression (Aeseth et al). Diet has a key role to play in microbiota and gut/brain axis regulation of neuroinflammation in Parkinson’s (Jackson et al 2019). The western diet (incl dairy consumption) is a major risk factor for Parkinson’s (Chu et al 2021) and its progression (Mischley, Lau and Bennett 2017).


Suggestions for diet for those with EOPD include increasing fibre to alleviate constipation, one of the most prevalent non-motor symptoms before and after diagnosis (Chen et al 2015), eating good mood foods to address fatigue/low mood and reducing processed and sugary foods. A 2021 meta-analysis confirmed type two diabetes to be a risk for Parkinsons (Chohan et al 2021)

Reducing alcohol consumption and managing protein intake to minimise Levodopa side effects (Parkinsons UK)


Pranamaya Kosha – energy sheath


“Prana” means energy and this Kosha representing the life force flowing through us via the nadis is often assessed in its more tangible form, the breath.

An imbalance here in EOPD may present as fatigue and apathy. Referred to as “an unmet need” by the Parkinsons Foundation research into fatigue and Parkinson’s is ongoing, however exercise and yoga are mentioned as ways to improve fatigue and a 2005 observational study on treatments for unexplained chronic fatigue highlighted yoga as an effective intervention (Bentler, Hartz and Kuhn 2005).


Slow breathing techniques combined with gentle movement increase the release of the neurotransmitters GABA (Streeter et al 2010) and Serotonin and reducing stress (Streeter et al 2012), improving low mood and wellbeing in Manomaya Kosha and increasing vagal tone and improving the quality of sleep and alleviating fatigue arising from insomnia (Jerath, Beveridge and Barnes 2019).


Whether a result of insomnia or EOPD itself the use of restorative poses, relaxation, and yoga nidra may help improve fatigue.


Several non-motor symptoms arise from autonomic nervous system dysregulation (affecting Annamaya and Manomaya Kosha). Pranayama, including Coherent breathing improves HRV, reduces sympathetic drive and increase parasympathetic activation (Streeter et al 2017) are useful tools to alleviate the motor and non-motor symptoms of EOPD.


Manomaya Kosha – mind sheath


Depression and mood disorders are a significant issue for those diagnosed with EOPD and impact QoL. An imbalance in Manomaya Kosha may reduce the ability to motivate self to attend therapy, support groups, to eat well, to exercise, comply with treatment schedules and contribute to emotional dysregulation.


Despite some methodological drawbacks a Meta analysis by Cramer et al 2013 revealed yoga to be a treatment option for people with depression.

Mindful yoga practices have been shown to reduce depression (Kwok 2019), help build emotional regulation and improve cognition and sustained attention they have also been associated with improvements in motor symptoms including rigidity (Dissanayaka et al 2016). Provided the motor symptoms are not a contraindication the practice of walking meditation for those with EOPD (maybe walking arm in arm) combines the benefits of exercise with mindfulness and social connection and support.


Cognitive issues in EOPD are more likely to present as issues with concentration, planning, working memory. Although relating to Alzheimer’s a 2018 study on cell tissues examined the effects of neurotransmitters released during yoga on disease progression and revealed the release of dopamine and serotonin had the potential to slow cognitive decline which may be of interest (Hassan et al 2018).


Benefiting sleep and mood the practice of yoga nidra increases dopamine release (kjaer et al 2022) and the practice of Kirtan Kriya has been shown to enhance executive functioning and focus (Eyre et al 2017).


Vijnanamaya Kosha – wisdom sheath


The wisdom body represents intellect, discernment, decision making and the ability to adapt to change.


Imbalance in Anandamaya Kosha in EOPD might manifest in delaying seeking a diagnosis and unwillingness or inability to accept being diagnosed with a chronic progressive neurological disease at a young age.


Treatment compliance and acceptance of diagnosis have been shown to impact PD symptoms and progression (Mahanna and Jankovic 2019).


Impulse control and self-destructive behaviour in EOPD often arising from the pharmacological treatments offered may manifest as an imbalance here (Cao et al 2021).


Yoga therapy provides an opportunity to highlight lack of linearity in EOPD progression and offers tools via, philosophical texts, visualisations,

affirmations to help a recently diagnosed patient (and informal caregivers) towards acceptance and enabling them to focus on what they can do to benefit them now and alleviate their symptoms, bringing balance to this Kosha, inspiring confidence, self-agency and self-compassion.


The Yama’s and Niyama’s, ethical guidelines set out in Patanjali’s Yoga Sutras provide a toolkit to help navigate EOPD. The Yama, Ahimsa encourages compassion to self and seeking and maintaining support needed. The Niyama’s: Tapas encourage determination and perseverance (perhaps with a treatment schedule and yoga therapy practices) and Ishvara Pranidhana encourages the practice of acceptance of what is. Closely linked to the concept of non-attachment to the fruits of our actions and shifting focus away from those to the way action is undertaken, as described in another historical and philosophical text the Baghavad Gita (Hawley 2001)


Anandamaya Kosha- bliss sheath


The innermost Kosha relates to our sense of meaning and purpose and connection with the world.


Those diagnosed with EOPD may feel disconnected from themselves and others, experiencing stigma and frustrated asking “why me?”, why now?”.

A study by Eccles et al 2023 examining the relationship between self-compassion, stigma and psychological distress in Parkinson’s highlighted the need for the development of relevant individualised and societal interventions with the aim of improving the psychological wellbeing of people with Parkinson's. Of relevance here is a study by Leigh, Simpson and Eccles 2021 which identified the correlation between lack of social support, felt and identified stigma and psychological distress in MND. These highlight the importance of connection, community, and support groups in managing diseases such as EOPD.


Emotional support provided by social ties can enhance psychological wellbeing and reduce the risk of unhealthy behaviours including poor diet impacting Annamaya Kosha and reduce stress and benefit mental health as seen through Manomaya Kosha (Umberson & Montez 2010).


Partners and family members as young caregivers may also experience depression and low mood due to worries of the future. Caregivers can also benefit from mindfulness practices in alleviating depression (Cash et al 2016), yoga, connection, community, and support groups and be better placed to help those with PD. Although small, consisting of only six spouses of older age, a study found that a singing group for caregivers of those with PD created a social identity which helped fulfil their basic psychological needs for belonging, meaning and purpose, social support, and agency within the marital relationship (Forbes 2020). Similar to chanting in a yoga therapy context.


The benefits of spiritual care, provided in Yoga Therapy via the yoga texts and practices, as equivalent to emotional or physical care are well recognised in the palliative care field but there is good reason to explore this in neurological conditions. A study of 162 MND patients revealed religious faith and spirituality helped them avoid despair and make sense of their condition (O’Brien and Clarke 2015). A study by Prizer et al 2020 concluded PD patients’ spiritual wellbeing was related to anxiety and depression and another confirmed it may also help with acceptance and moving forward with new life with PD (Boersma et al 2021).


Yoga therapy encourages balance here via interaction with support groups, time spent in nature, and helping others. In a study on stroke patients Macvaddat et all 2021 highlighted the benefits of practising gratitude, journalling, and acceptance on overall wellbeing. All of these can be part of yoga therapy offered.


In conjunction with pharmacological and psychotherapeutic treatments this paper has identified the role of exercise, dance, music, diet, and community in alleviating symptoms and EOPD disease progression. Many similar elements are evident in Yoga Therapy in the use of asanas, chanting, flowing movements but there are additional elements particularly relevant here. The application of the interdependent Koshas highlights the whole person approach which shows how the emotional, social interactiveness and thought processes impact overall health and wellbeing (Jean Danford 2016 pg. 19).


With EOPD it is seems possible that yoga therapy practices which support and balance emotional health and wellbeing with the addition of encouraging acceptance and an ability to live with the condition may have as much, if not more, benefit to overall health at this early stage of both disease progression and people lives.


As Michael J Fox said, “Acceptance doesn't mean resignation”.



Yoga Therapy Plan


The heterogeneous nature of EOPD makes it essential to treat each person on an individual basis and to meet them where they are at that moment. Safety precautions include awareness of medication (for motor and non-motor symptoms) and ensuring that they are “on” at the time of the therapy session. Being diagnosed with a progressive incurable disease at a young age may be overwhelming and suppressed emotions may arise. Mette Meditation which encourages self-compassion and could counteract stigma associated with EOPD (Eccles et al 2020) and practicing gratitude and mindfulness which encourage the ability to self-manage and adapt to the challenges of their lifelong condition (Van der Heide et al 2021) are something to work towards ensuring adequate grounding and regulatory skills are established to avoid overwhelm.


A yoga therapy plan for someone with EOPD could include;


1.Joint Releasing Series - Building strength, mobility, balance, the JRS may enable those with EOPD to feel confidence in what their body can do. A useful warm up to encourage loosening/awareness of the body and support other physical activities enjoyed (dancing, swimming)


2.Dynamic Flowing movements -Those more able can explore more demanding flows built around Surya Namaskar improving rigidity and neuroplasticity between the cortico – striatal and cortico-cerebellar systems of the brain (Doyon and Benali 2005) benefiting cognition and confidence. Movement to music has been reported to benefit motor symptoms and lift mood (Lee & Ko 2003).


3.Asana Practice – Focus on asanas which address specific issues such as twists to help alleviate constipation, restorative postures over bolsters including Viparita Kirani to address fatigue and longer strong stretches to bring relief and to release muscles when in spasm and there is rigidity.


4.Yoga Nidra – in addition to association with short term dopamine increase (Kjaer et al 2002), the reduced respiratory rate and deep sense of relaxation experienced makes this useful for insomnia and reducing stress and anxiety.


5.Kirtan Kriya – helps with cognition, memory loss, lifts low mood and cultivates a sense of acceptance for those with EOPD. A randomized control trial of 81 participants revealed only those practicing Kundalini Yoga including Kirtan Kriya saw a significant improvement in executive functions, depression, and resilience (Eyre et al 2017). A systematic review of research on Alzheimer’s Disease, another neurological condition, reported religious and spiritual practices, including Kirtan Kriya, are crucial in the development of enhanced cognition and well-being, helping prevent and, in sometimes, reverse cognitive decline (Khalsa and Newberg 2021).


6.Breathing Practices – Aimed at slowing the breath, improving ANS regulation and reducing stress and anxiety in EOPD include.

. Coherent Breathing – reducing anxiety and stress by improving HRV and activating the PNS. Breathing at a rate of 5 breaths per minute increases production of GABA and reduces depression and low mood (Streeter et al 2020)

. Brahmari – activating the calming parasympathetic nervous system the vibrational effects of this “humming bee” breath are reported to lift mood, self-esteem, and energy (Srivastava et al 2017).

7.Lions Breath/Chanting – a playful technique involving a long exhale through the mouth sticking the tongue out and relieving tension in the facial muscles (and speech difficulties which affect communication and work). Chanting elongates the exhalation, engages the throat muscles, is uplifting and builds connections. It’s worth noting that two small studies on singing groups for those with Parkinsons reported benefits for motor symptoms (Stegmoller et al 2022) and speech problems and community building (Good et al 2023).

8.Relaxation practices – Body Scan/Progressive muscle relaxation. On a small group the use of guided imagery during relaxation was shown to increase the length of “on” time more so than just listening to relaxing music (Schlesinger et al 2009)



Final Thoughts


Regarded as an older person disease associated with males aged 60 plus there is less research on the impact of Parkinson’s on those with EOPD within the 20-50 age bracket and even less research on the impact upon women. This may be because a smaller percentage (10%) are diagnosed with EOPD, however the impact upon younger people when diagnosed and their families/caregivers can be profound due to a combination of a longer and slower disease progression and the sociocultural and economic costs.


Yoga Therapy as a supportive, accessible, empowering, lifelong therapeutic treatment is welcome and perfectly placed as an adjunct to biomedical treatments.


Biomedical treatments and thinking behind them may prioritise longer term and permanent change over short term and transitory ones. However, when presented at a young age with a degenerative lifelong condition those with EOPD may find themselves welcoming accessible short-term changes and a toolbox of practices provided by Yoga Therapy which help in the present moment (relaxation from yoga nidra, joy from lions’ breath) helping them to live a fulfilling life. This works well alongside the growing recognition of the impact of neurological conditions including EOPD and the need to address stigma faced with the adoption of the IGAP (Kalshoej 2022).


















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