Evidence Summary: Systematic reviews confirm multiple modalities of physical activity have been found to improve depression scores [1 – 4].
Physical activities reviewed decreased depression rating scales (HDRS, MADRS, BDI) including general exercise, Virtual Reality (VR), dancing, aerobic treadmill, Qigong and combination of these .
One systematic review of 64 articles  discussed the commonality of neural circuits for balance and anxiety and how postural instability was linked with mood disorders: anxiety, depression and apathy. All methods showed improved balance and 24 showed reduced levels of anxiety and depression with consequent improved quality of life scores (QOL):
·General exercise and physiotherapy: Highest class of evidence in physiotherapy-based studies – improve QOL  motivation to continue activity 
· Treadmill: all improved postural stability
· Tai chi, Qigong and yoga – Yoga in particular associated with enjoyment, relaxation, lowering anxiety and depression. Needs confirmation with larger studies.
· Virtual reality – positive on depression and QOL
· Dance – tango most promising re balance and well-being, 9/13 reported satisfaction, emotional and social benefits, improvement in apathy and depression although there was mixed study quality and size
· Synthesis of multiple methods proven to increase balance and stability in Parkinson’s and potential for psychological benefit. Hypothesis that balance and mental health/wellbeing are interconnected therefore strategies to improve balance and improving factors affecting QOL appear a reasonable choice to make.
Uc et al study showed, following a 6-month aerobic walking plan @ 3 x 45 minute/week in the community was safe, well tolerated and amongst other benefits improved mood .
Agility and aerobic activities can moderately improve depression in People with Parkinson’s .
Some frustration was shown when individuals struggled with the tasks set reinforcing the need to aim interventions to individual capabilities.
Quality of Evidence
B – 2 systematic reviews and 2 small studies contributed to overall consensus that multiple types of physical activity improved wellbeing and mood as confirmed through a variety of depression scores.
Strength of Recommendation
1 -A broad spectrum of activity interventions shows improved depression scores, reduced anxiety and improved confidence and wellbeing. The positive effect of physical activity on confidence, mood, and anxiety is considered significant by an expert Parkinson’s Focus Group.
Physical activity is associated with improvement in psychological symptoms of anxiety and depression in Parkinson’s Disease. Patients with Parkinson’s Disease should be encouraged to participate in physical activity to improve mental wellbeing.
 Wu et al. Effectiveness of physical activity on patients with depression and Parkinson’s disease: A systematic review. PLoS One. 2017 Jul 27;12(7):e0181515.
 Sumec et al. Psychological Benefits of Nonpharmacological Methods Aimed for Improving Balance in Parkinson’s Disease: A Systematic Review. Behavioural Neurology
Volume 2015, Article ID 620674, 16 pages
 Uc E et al. Phase I/II randomized trial of aerobic exercise in Parkinson disease in a community setting, Neurology; Jul 2014; vol. 83 (no. 5); p. 413-25
 Tollar J et al. A High-Intensity Multicomponent Agility Intervention Improves Parkinson Patients’ Clinical and Motor Symptoms. Archives of Physical Medicine and Rehabilitation; 2018; vol. 99 (no. 12); p. 2478