QIGONG IN PD
Qigong Exercise for the received little scientific interest.1 Physiotherapy and
Symptoms of Parkinson’s Disease:
A Randomized, Controlled
Pilot Study
Tanja Schmitz-Hübsch, MD,1 Derek Pyfer, BS,1
Karin Kielwein, MD,2 Rolf Fimmers, MD,3
Thomas Klockgether, MD,1 and
Ullrich Wüllner, MD, PhD1*
1
Department of Neurology, University of Bonn, Bonn,
Germany; 2Medical Society for Qigong Yangsheng, Bonn,
Germany; 3Institute for Medical Biometrics, Informatics and
Epidemiology, University of Bonn, Bonn, Germany
Abstract: Irrespective of limited evidence, not only tradi-
tional physiotherapy, but also a wide array of complemen-
tary methods are applied by patients with Parkinson’s
disease (PD). We evaluated the immediate and sustained
effects of Qigong on motor and nonmotor symptoms of PD,
using an add-on design. Fifty-six patients with different
levels of disease severity (mean age/standard deviation
[SD], 63.8/7.5 years; disease duration 5.8/4.2 years; 43 men
[76%]) were recruited from the outpatient movement dis-
order clinic of the Department of Neurology, University of
Bonn. We compared the progression of motor symptoms
assessed by Unified Parkinson’s Disease Rating Scale motor
part (UPDRS-III) in the Qigong treatment group (n ⴝ 32)
and a control group receiving no additional intervention
(n ⴝ 24). Qigong exercises were applied as 90-minute
weekly group instructions for 2 months, followed by a 2
months pause and a second 2-month treatment period.
Assessments were carried out at baseline, 3, 6, and 12
months. More patients improved in the Qigong group than
in the control group at 3 and 6 months (P ⴝ 0.0080 at 3
months and P ⴝ 0.0503 at 6 months; Fisher’s exact test). At
12 months, there was a sustained difference between groups
only when changes in UPDRS-III were related to baseline.
Depression scores decreased in both groups, whereas the
incidence of several nonmotor symptoms decreased in the
treatment group only. © 2005 Movement Disorder Society
Key words: Parkinson’s disease; exercise; Qigong; clinical
trial
Despite a long-standing tradition, nonpharmacologic
treatments of degenerative neurological disorders have
This article includes Supplementary Material, available online at
http://www.interscience.wiley.com/jpages/0885-3185/suppmat.
*Correspondence to: U. Wüllner, Department of Neurology, Univer-
sity Hospital of Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Ger-
many. E-mail: wuellner@uni-bonn.de
Received 23 July 2004; Revised 17 January 2005; Accepted 22 June
2005
Published online 14 October 2005 in Wiley InterScience (www.
interscience.wiley.com). DOI: 10.1002/mds.20705
543
other therapies, however, are used frequently by patients
with chronic neurologic diseases.2,3 The evaluation of
such therapies is thus important for adequate counseling
of patients.
We determined the effect of regular Qigong exercise
as a complementary therapeutic measure in Parkinson’s
disease (PD). Qigong is an exercise therapy based on the
principles of traditional Chinese medicine. The exercises
combine the practice of motion and rest, both guided by
mental imagery. The movements or postures are thought
to promote an “energy flow” along meridians that are not
related to anatomic structures. Beneficial effects of
Qigong have been reported on a variety of complaints in
chronically ill patients4,5 and on gait imbalance in the
elderly.6 The Qigong exercises used here,7 although
based on different theories on pathogenesis or salutogen-
esis, can be classified as active physiotherapy using
low-energy exercises with sustained movements of
limbs, trunk, face, and tongue as well as breathing coor-
dination. In contrast to most physiotherapeutic measures,
Qigong exercises can be adopted easily for special needs
(e.g., exercise in sitting position if balance is poor) and
are applicable in groups.8 We chose our main outcome
measure, the Unified Parkinson’s Disease Rating Scale
motor part (UPDRS-III),9 to allow comparison with data
from larger PD trials, thus following the recommenda-
tions of the Cochrane review on this topic.1 In addition,
according to the exploratory approach of this pilot study,
assessments included various other aspects of PD impair-
ment to yield data for the planning of further studies (see
online supplementary material).
PATIENTS AND METHODS
Patients diagnosed with PD according to the UK brain
bank criteria at any stage of disease, with or without
motor complications, were included. Exclusion criteria
were previous practical experience with Qigong, recent
(⬍1 month) or planned change of medication, or signs of
central nervous system (CNS) disease other than PD,
such as aphasia or dementia (defined by Mini-Mental
Status Examination [MMSE] ⬍2410).
Patient flow is shown in Figure 1. All 56 participants
gave informed written consent during the screening visit
explicitly stating the possibility of being sorted randomly
to the control group. Patients were asked not to change
their anti-Parkinson medication throughout the study;
however, if their medical condition required adaptations,
this would not lead to exclusion. Patients were advised to
continue adjunct treatments like physiotherapy or mas-
sage if applied regularly before enrollment, which was
Movement Disorders, Vol. 21, No. 4, 2006
544 T. SCHMITZ-HÜBSCH ET AL.

supplementary material). The exercises were carried out

standing or optionally in a sitting position adjusted to the
patient’s physical abilities; additional individualized in-
structions were avoided on purpose. The teacher repeat-
edly stressed the importance of home self-exercise. The
control group received no additional intervention.
Baseline evaluation was carried out before randomiza-
tion and included: UPDRS-III for motor symptoms9; the
39-item Parkinson’s Disease Questionnaire (PDQ-39), a
disease-specific self-assessment measure of health-re-
lated quality of life11; the Montgomery-Asperg Depres-
sion Rating Scale (MADRS), a structured interview that
has been shown to be a valid instrument for assessment
of depressive symptoms in PD patients12; the presence of
nonmotor symptoms like sleep disturbance, daytime
sleepiness, dizziness, urinary dysfunction, sexual dys-
function, constipation, loss of appetite, or nausea and
pain, assessed in a structured interview developed for
this purpose; and for the treatment group, follow-up
additionally included a self-reporting questionnaire con-
cerning the acceptance of Qigong instruction and the
extent of self-exercise.
Follow-up evaluations were held for all patients at 3
months (after completion of the first 8-week treatment
course) and at 6 months (after completion of the second
8-week course), at which time patients were asked for
consent to be contacted for 12 months follow-up (i.e., 6
months after completion of the second course) by two
FIG. 1. Patient flow. Dropouts are given along with their Unified investigators (D.P. and T.S.H.) who were un-blinded to
Parkinson’s Disease Rating Scale-motor (UPDRS-III) score at baseline
(UPDRS-IIIb). treatment allocation. Patients of treatment and control
group were equally distributed between raters. Rating
was carried out in the on state, i.e., time of optimal
the case for 46% in the treatment group and 50% in the medication effect as defined by the patient. Follow-up
control group at baseline assessment. assessments were done at similar times of the day to
Participants were sorted randomly to treatment (n ⫽ minimize effects of motor fluctuations.
32) or control group (n ⫽ 24) matched for disease
severity, presence or absence of dyskinesia, and type of
TABLE 1. Baseline data
clinical manifestation (Table 1). Random allocation was
carried out using a list of pseudonyms generated by one Qigong group Control group
Parameter (n ⫽ 32) (n ⫽ 24)
investigator (D.P.) and transferred by fax to the second
investigator (T.S.H.). Age (yr)a 64/8 63/8
Gender (men/women) 24/8 19/5
Intervention consisted of weekly 60-minute lessons of Disease duration (yr)a 6.0/5.5 5.6/3.8
Qigong provided by an experienced teacher (K.K.) in Clinical manifestation (%)
two courses of 8 weeks with an 8-week pause in-be- Tremor 6 (19) 5 (21)
Akinesia 7 (22) 6 (25)
tween. The teacher had no involvement in screening, Mixed type 18 (56) 13 (54)
assessment, or randomization procedures. Lessons were UPDRS-III at baselinea 15.45/10.7 16.9/12.7
held in two groups of 16 patients. The selection of Patients with UPDRS-III ⬍15 (%) 19 (59) 13 (54)
Patients with UPDRS-III 15–30 (%) 7 (22) 6 (25)
exercises was based on the teacher’s expertise and com- Patients with UPDRS-III ⬎30 (%) 5 (16) 5 (21)
prised three opening exercises, three exercises from the Presence of motor complications (%) 11 (34) 9 (37)
syllabus “Frolic of the crane,” all eight exercises from a
Values given as mean/standard deviation.
the syllabus “The eight brocades (in sitting position),” UPDRS-III, Unified Parkinson’s Disease Rating Scale, part III (mo-
and closing exercises as described elsewhere7 (see online tor part).

Movement Disorders, Vol. 21, No. 4, 2006

 QIGONG IN PD
Statistics
Allocation of patients to treatment and control groups
was 32:24; numbers were calculated to detect 50% re-
sponders among the therapy group and 10% among the
controls with ⬎80% power. All analyses were carried
out on an intention-to-treat-basis. Main outcome measure
was the between-group difference in the number of pa-
tients with improvement of motor symptoms (i.e., treat-
ment responders) over a 6-month interval compared with
Fisher’s exact test (two-sided), with a similar comparison
at 3 and 12 months as secondary measure. Motor im-
provement was defined as ⬎20% reduction in UPDRS-
III relative to baseline. This definition has been sug-
gested as clinically relevant in other trials.13–15
Exploratory analyses included similar testing for the
frequency of worsening in motor function (i.e., 20%
increase in UPDRS-III scores toward baseline). No cor-
rection was made for the inclusion of the subgroup of
patients without changes in both analyses. In addition,
individual score changes in UPDRS-III relative to base-
line were compared between groups using the Wilcoxon
test (two-tailed, t-approximated) for all follow-up points.
The impact of the stratification criteria (UPDRS-III at
baseline, type of clinical presentation, and presence of
dyskinesia) on the score changes at 6 months was tested
by two-factorial analysis of variance (ANOVA).
For depressive symptoms, the prevalence of mild/
moderate depression was reported, using the published
cut-off for MADRS scores.16 In addition, mean scores
for its 10 items were reported separately for each group.
PDQ-39 was reported as mean scores for subdimensions
and summary index. These data, as well as the categor-
ical variables such as incidence of nonmotor symptoms,
that are reported in numbers per group at given time
points, were not submitted to statistical analysis.
RESULTS
Compliance and Protocol Violations
Compliance at 1-year follow-up was fair with 5 drop-
outs in the control group (mean UPDRS-III, 23.8) and 2
in the Qigong group (mean UPDRS-III, 10.5; Fig. 1).
Three patients stopped Qigong treatment within the first
three sessions, but attended follow-up. Although patients
were informed and had consented to refrain from
changes in antiparkinsonian medication, 26% in the
treatment and 40% in the control group did report in-
creases of dosage at 6-month follow up. Surprisingly,
such increases more often resulted in deterioration of
motor scores (see online supplementary material, Table
A2). Medication changes thus did not seem to contribute
to a possible benefit of Qigong therapy and all patients
545
FIG. 2. Main outcome criterion: between-group comparison of fre-
quency of ⬎20% change in Unified Parkinson’s Disease Rating Scale-
motor (UPDRS-III) score vs. baseline shown as percentage per group
at different time points. Better, ⬎20% reduction in UPDRS-III toward
baseline; worse, refers to ⬎20% increase.
were included in the analysis. The use of additional
nonpharmacological therapies was reported by almost
50% of participants in both the therapy and the control
group at baseline and 1-year follow-up.
Main Outcome Criterion:
Change in Motor Symptoms
The proportion of patients who improved in UPDRS-
III, defined as ⬎20% reduction toward baseline score,
was significantly greater in the Qigong-treated group at 3
months (P ⫽ 0.0080) reaching almost significance at 6
months (P ⫽ 0.0503) and no significance at 12 months
(P ⫽ 0.635; Fisher’s exact test). The proportion of pa-
tients who worsened in UPDRS-III was greater in the
control group although with a weaker level of signifi-
cance (P ⫽ 0.0606 at 3 months, P ⫽ 0.0898 at 6 months,
and P ⫽ 0.244 at 12 months; Fisher’s exact test; Fig. 2).
(See online supplementary material, Table A3 for 95%
confidence intervals for the frequency of changes at
different time points.) The differences in proportions are
reflected in the changes of UPDRS-III total scores shown
in Figure 3: the changes in UPDRS-III scores toward
baseline were significantly different between groups at
all follow-up assessments (P ⫽ 0.0014 at 3 months, P ⫽
0.0384 at 6 months, and P ⫽ 0.0428 at 12 months;
Wilcoxon test). Exploratory analysis of changes in single
UPDRS-III items (data not shown) revealed a remark-
able between-group difference for postural stability
(Item 30 in UPDRS-III): the proportion of patients with
score reduction in this item at 6 months was significantly
higher in the Qigong group (35%; 95% confidence in-
terval 19 –5%) than it was in the control group (9.5%;
95% confidence interval 1–30%) at 6 months (P ⫽
0.0044; Fisher’s exact test). (See online supplementary
Movement Disorders, Vol. 21, No. 4, 2006
546 T. SCHMITZ-HÜBSCH ET AL.
material, Table A4 for mean scores for single UPDRS-III
items at all time points.) Two-factorial ANOVA showed
no significant impact of the stratification criteria (type of
clinical manifestation, presence of dyskinesia, or UP-
DRS-III score at baseline) on the results.
Depressive Symptoms and Health-Related
Quality of Life
Scores in MADRS for depressive symptoms were
graded with a cut-off of 9 for mild depression and a
cut-off 18 for moderate depression.16 The prevalence of
mild or moderate depression was 48% in the treatment
group and 41% in the control group at baseline compared
with 33% in both groups at 6 months. At the same time,
proportions of patients using antidepressants were simi-
lar with 19% (therapy) and 24% (control) at baseline but
shifted to 16% (therapy) and 32% (control) at 12-month
follow-up, respectively. The changes of mean scores for
each item of MADRS (see online supplementary mate-
rial, Fig. A1) suggest that tension/anxiety and distur-
bance of sleep contributed most to changes in total score.
Although these items showed reduction in both groups,
items 6 and 7 (problems with concentration and loss of
initiative) were transiently reduced during Qigong ther-
apy only. However, due to imbalances between groups at
baseline data on depressive symptoms remain inconclu-
sive in our study. PDQ-39 assessed at 3 and 6 months
follow-up showed no significant between-group differ-
ences (see online supplementary material, Fig. A2) for
mean scores or changes over time despite a tendency for
transient improvement in activities of daily living in the
treatment group.
Nonmotor Symptoms: Autonomic Dysfunction
For the occurrence of several nonmotor symptoms
(see online supplementary material, Table A5), a sus-
tained benefit was reported for constipation by the treat-
ment group, reflected by decreased use of laxatives in the
therapy group. Similarly, complaints of pain, although
equally frequent in both groups at baseline, were reduced
clearly and sustainedly in the treatment group only,
whereas the proportion of patients using drugs for pain
relief showed similar changes in both groups. Concern-
ing sleep disturbances, a reduction was reported during
therapy only, whereas the use of sleep medication de-
creased to a similar extent in both groups. In contrast,
daytime sleepiness was reduced sustainedly in the
Qigong-treated group. Urinary dysfunction, sexual dys-
function, or nausea and the prevalence of drug-induced
hallucinations or motor fluctuations with dyskinesias re-
mained unchanged in both groups over time.
Movement Disorders, Vol. 21, No. 4, 2006
DISCUSSION
We found a stabilizing effect of Qigong exercise on
motor performance and on several nonmotor symptoms
in a controlled, randomized, non-blinded study. This
exploratory study aimed to give estimates of the effect
sizes that can serve as a basis for the biometrical design
of future randomized controlled trials. Consequently,
some relevant methodological weaknesses have to be
considered in interpretation of the suggested effects of
Qigong exercise that do not allow a definite statement on
the efficacy of Qigong. Because no control intervention
was available, it is impossible to determine whether the
actual exercise program or the interaction amongst pa-
tients themselves or with the instructor is responsible for
changes observed. Second, the unblinded assessment
could have biased results, which we tried to minimize by
equally distributing patients of both groups between rat-
ers. As patients obviously could not be blinded to their
intervention, it was felt difficult to conceal group allo-
cation in a largely interview-based assessment. In the
add-on design used here, although most closely reflecting
everyday practice where nonpharmacologic measures are
used as an adjunct to pharmacologic treatment, ceiling
effects could have occurred by the number of treatments.
Major imbalances between groups are excluded, how-
ever, given the similar proportion of patients using ad-
ditional nonpharmacologic interventions.
Qigong was applied in a group setting of patients with
Hoehn and Yahr stages I to IV. During the treatment
period, improvement of PD motor symptoms assessed by
UPDRS-III was found in 52% of participants in the
Qigong-treated group at 3 months and 36% at 6 months,
compared with 14% and 10%, respectively, among the
control group (Fig. 2). Comparing the number of treat-
ment responders instead of absolute score changes is
more appropriate when observing small numbers. The
criterion of 20% UPDRS-III score change toward base-
line has been used by other authors;13–15 however, the
clinical relevance of this criterion was not addressed
formally and might be assumed to differ throughout
severity stages. The dimension of functional capacity in
PDQ-39 (see online supplementary material, Fig. A2)
suggests a transient decrease at 3 months in the Qigong-
treated group, although not a statistically significant one.
Using a measure of functional disability is surely advis-
able for further studies, but at present the UPDRS-III
motor score is the most commonly used assessment
allowing wider comparison of results. The comparison of
mean score changes (Fig. 3) shows a sustained benefit for
the Qigong group at 12 months, although group differ-
ences were most obvious at 3 months. Although few
 QIGONG IN PD
FIG. 3. Between-group comparison of Unified Parkinson’s Disease
Rating Scale-motor (UPDRS-III) score changes relative to baseline at
different time points. Qigong therapy was only applied from baseline to
6 months; between 6- and 12-month assessment, neither group received
additional therapy.
previous studies have shown short-term benefits of phys-
iotherapy in PD,1 our study suggests that such effects can
outlast therapy for up to 6 months.
The similar progression rates in both groups through-
out the second half of the study (without add-on therapy
in any group) most likely reflect the natural progression
in our study population of mostly medicated PD patients
at different disease stages. Our estimates are somewhat
higher than the 1.5-point average progression in UPDRS-
III scores per year seen in larger cohorts.17,18 A motor
decline of similar magnitude in UPDRS-III at similar
intervals has been reported for the placebo arms19,20 or
even treatment arms21,22 in PD trials. Placebo groups in
other drug trials, however, showed no such deterioration
or even improvement over a 6-month period. Data on
motor progression in PD thus remain inconclusive and
are likely to differ between patient populations, further
underlining the necessity of a no-intervention control
group when studying complex therapies in a chronically
progressive disease. Although auxiliary analysis did not
reveal an impact of baseline UPDRS-III on score
changes at 6 months, data are insufficient to rule out the
possibility of different progression rates at different dis-
ease stages. Stratification for disease stages therefore
seems mandatory in further studies.
Surely, a fundamental limitation of our study is the
lack of a trial arm designed to control for unspecific
effects of Qigong treatment. It seems conceivable that
weekly peer-group meetings or staff attention have an
547
impact on outcome in our treatment group. Such effects
have never been studied, however, and other numerous
different assumptions remain possible, which make the
construct of an adequate control intervention question-
able. It might also be assumed, that Qigong as nonphar-
macologic therapy in general constitutes a “complex”
therapy, showing multiple ways of action, that can be
almost impossible to delineate with a “placebo” control.
Further comparative studies (e.g., against conventional
physiotherapy or regular self-exercise of other methods)
can help to clarify this issue, with standardization of the
treatment applied being the major challenge of such
studies.
In general, possible mechanisms of action of nonphar-
macologic therapies have rarely received scientific atten-
tion and no conclusive hypotheses has been generated to
date. The fact that placebo application in PD patients has
been shown to considerably increase striatal dopamine
release23 suggests, that even “unspecific” treatment can
effect specific transmitter changes in this patient group.
Similarly, motor learning as well as exercise itself can
lead to such increases24 and would explain benefits from
regular exercise irrespective of the kind of exercise per-
formed. These effects and their validity in PD patients,
however, are controversial.25,26 Interestingly, exploratory
analysis in our study suggested pronounced benefits of
Qigong on postural stability, a symptom that reportedly
is not very responsive to dopaminergic treatment. Our
results are in line with previous reports on benefits of Tai
Chi on gait imbalance and falls in the elderly,6 and might
be attributed to motor imagery as a means of internal
cueing; however, the nature of this benefit remains to be
established. Similarly, the sustained reduction in daytime
sleepiness reported by our treatment group (as opposed
to increased reports of daytime sleepiness among the
controls) corresponds to previous reports on improve-
ment of chronic fatigue by exercise, thought to be related
to exercise-induced neurohumoral changes.27 The sug-
gested effects on nonmotor symptoms in our study might
add to the ongoing discussion on possible mechanisms of
action and surely deserve consideration in further
studies.
In conclusion, we observed a stabilizing effect of
Qigong exercise on PD motor symptoms, although this
has to be interpreted with caution due to methodological
weaknesses of our study design. Further, our results
suggest positive effects on several frequent and relevant
symptoms of autonomic dysfunction in PD. Given the
high acceptance and compliance with therapy, we con-
sider Qigong a promising treatment in this patient group,
with possible effects on motor as well as nonmotor
symptoms and the advantage of cost-effective applica-
Movement Disorders, Vol. 21, No. 4, 2006
548 T. SCHMITZ-HÜBSCH ET AL.

tion by group instruction and self-exercise. Comparative 16. Muller MJ, Szegedi A, Wetzel H, Benkert O. Moderate and severe
depression. Gradations for the Montgomery-Asberg depression
studies with blinded rating are needed to corroborate rating scale. J Affect Disord 2000;60:137–140.
these findings and establish the specificity of treatment. 17. Louis ED, Tang MX, Cote L, Alfaro B, Mejia H, Marder K.
Progression of parkinsonian signs in Parkinson’s disease. Arch
Acknowledgments: We thank the German Parkinson’s pa- Neurol 1999;56:334 –337.
tients’ organization (dPV) for financial support. The funding 18. Jankovic J, Kapadia AS. Functional decline in Parkinson’s disease.
source (dPV) had no involvement in study design, collection, Arch Neurol 2001;58:1611–1615.
analysis or interpretation of data or writing of the report. 19. Shannon KM, Bennett JP Jr, Friedman JH. Efficacy of
We thank the participating patients, and Prof. Dr. Gisela pramipexole, a novel dopamine agonist, as monotherapy in mild to
moderate Parkinson’s disease. The Pramipexole Study Group.
Hildebrandt (Medical Society for Qigong Yangsheng, Bonn)
Neurology 1997;49:724 –728.
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Movement Disorders, Vol. 21, No. 4, 2006