Parkinson's disease (PD) is a common neurodegenerative disorder primarily caused by an imbalance of neurotransmitters and a depletion of dopamine in the brain (1). Growing evidence indicates that the incidence of PD has increased in recent years, with reported rates ranging from 3.5 to 42.8% (2). Patients with PD typically present motor symptoms such as progressive motor retardation, myotonia, and abnormal posture and gait. These motor symptoms are often accompanied by non-motor symptoms such as depression, impulse control disorders, anxiety, and insomnia (3). Compared with motor symptoms, non-motor symptoms in patients with PD are more strongly associated with pain severity and hospitalization rates (4). Among these non-motor symptoms, depression and anxiety are common psychiatric conditions that substantially affect the quality of life and contribute to negative psychological states in patients with PD (5). In addition, factors such as self-image, life satisfaction, and social interactions are often negatively affected, which in turn further reduces patients' overall quality of life (6). The World Health Organization (WHO) defines quality of life as “an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns (7).” Quality of life encompasses physical, psychological, cognitive, and environmental factors, as well as autonomy and social relationships (7, 8). The primary goal of PD treatment is to minimize its negative impact on the patient's functional abilities and overall quality of life. Evaluating how the disease affects quality of life serves as a key indicator of treatment effectiveness (9).

At present, the treatment of Parkinson's disease includes drug therapy DBS surgery (deep brain stimulation) (10), while Western medicine mainly focuses on drugs such as levodopa and dopamine receptor agonists. Drug therapy can temporarily improve the physical disability of patients and control some symptoms through the replacement of dopamine in the brain. However, PD patients taking drugs for a long time will lead to side effects such as depression, anxiety, delusion, hallucination, and even mental disorders, and reduce the quality of life of PD patients. Exercise has been identified as a possible adjunctive treatment for Parkinson's disease, and periodic exercise can effectively improve motor function, depressive symptoms, sleep disturbances, and quality of life in patients (11). In one study, Ferreira et al. (12) found that resistance training was effective in improving the quality of life of PD patients. Moratelli et al. (13) found in a study that Brazilian dance can effectively improve the quality of life of PD patients. In a systematic review and meta-analysis, Song et al. (14) found that Tai Chi and Qigong mind-body exercises effectively improved the quality of life in patients with PD. At present, there is still controversy about what kind of exercise can effectively improve the quality of life of PD patients.

Network meta-analysis (NMA) has become increasingly common for evaluating medical interventions because it estimates the relative effectiveness of all interventions and the ranking of interventions, even in the absence of direct dairy comparisons (15).

However, the current NMA on the improvement of exercise in patients with Parkinson's disease mainly focuses on the movement symptoms of PD patients (16, 17), and there is a lack of research on the quality of life of PD patients. Our study took the quality of life of PD patients as the primary outcome indicator, compared the impact of 25 different exercises on the quality of life of PD patients, determined the best exercise mode to improve the quality of life of PD patients, and guided PD patients to choose the best exercise mode.

Parkinson's disease is a chronic and progressive neurodegenerative disease, with a high incidence of non-motor symptoms such as insomnia, impulse control disorders, anxiety and depression (21), which seriously affect the quality of life of Parkinson's patients. Therefore, it is significant to identify exercise methods to improve the quality of life of PD patients. Our study included 52 studies exploring 25 exercise methods to clarify the best exercise to improve the quality of life in people with PD.

Our study found that QG is superior to OE, FAE, VR, TC, CT, RT, CE, GT, FE, SE, CON, TR, VRB, DE, HE, BT, and CST in improving the quality of life of PD patients. In our study, PDQ-39 is the evaluation index of PD patients' quality of life. In this study, PDQ-39 was used to evaluate patients' quality of life. Research has proved that PDQ-39 is a reliable and valid tool for assessing the functional impact of PD (22), demonstrating satisfactory internal consistency and stability (23). It offers clinicians a practical and reliable tool for efficiently assessing and standardizing the quality of life of patients with PD. In our study, QG was characterized as a low- to moderate-intensity aerobic exercise that integrates heart, breath, and body regulation. The exercise routine was carefully structured, with a moderate overall intensity. In practice, its focus on guiding qi, calming the mind, and promoting relaxation helps patients clear their thoughts and achieve a tranquil, relaxed state. The coordinated movements of qi and blood can channel and nourish the meridians, enhance circulation, strengthen muscles, and improve the physiological functions of various tissues and organs in the body (24).

QG can effectively enhance telomerase activity in patients with chronic fatigue by modulating the pituitary–thalamic–adrenal axis, reducing oxidative stress levels, and regulating immune responses. In addition, as a low-impact exercise, QG increases the concentration of serum insulin-like growth factor (IGF), which further promotes telomerase activity and helps delay cellular aging (25). Furthermore, studies have demonstrated that QG can enhance the regulatory mechanisms of the neural circuits connecting the cortex, pons, and cerebellum. This improvement contributes to greater precision in fine motor skills and, in turn, enhances the quality of life of patients with PD (26). Apathetic mood is a common symptom in patients with PD. QG, a low-intensity exercise, is well-suited to the physical and mental attributes of older adults. Communities should provide more accessible exercise spaces and enhance guidance on appropriate exercise methods for patients with PD to help improve their quality of life. Compared with VR, RT, and GT, QG is an effective and low-cost form of exercise. Moreover, long-term RT and VR can lead to increased muscle and visual fatigue in patients with PD. Studies have reported mild dizziness after VR, which ultimately increases discomfort for patients with PD (27). Many factors affect the quality of life of patients with PD. Studies have found that the age (28, 29), gender (29), duration of disease (30) and severity of disease (31, 32) course of PD patients can all affect the quality of life of PD patients. Therefore, the influence of other factors should be comprehensively considered when evaluating the impact of exercise interventions on the quality of life of patients with PD. However, our study observed that only QG was superior to other exercises in improving the quality of life of patients with PD. Notably, only two articles on QG were included in this meta-analysis.

Depression is a common negative emotion experienced by patients with PD (33). Depression is characterized by the loss of positive emotions and manifests as a reduced interest or pleasure in daily activities, inattention, and low mood (34). Repeated and persistent emotional stress can also contribute to the progression of neurodegenerative diseases. In our study, DE was more effective than TR, BT, BDJ, RT, and TC in improving depression in patients with PD. The American Dance Therapy Association (35) defines dance therapy as “a psychosomatic therapeutic exercise that promotes emotional, cognitive, physical, and social integration.” Dance therapy can improve social interaction among patients with PD, increase their enthusiasm for exercise, and effectively alleviate emotional disorders (35). Compared with BT and RT, dance is a highly social activity that offers opportunities for non-verbal communication and self-improvement (36, 37). Participating in group dance classes and dancing with partners provides valuable social interaction (38). Therefore, dance serves as movement therapy and improves social engagement, interpersonal relationships, and social support for patients with PD. According to the American Dance Therapy Association, dance therapy promotes emotional, cognitive, physical, and social integration. It helps patients with PD connect with others, improve interpersonal relationships, and prevent social isolation, which in turn eases depression. In addition, DE can reduce the progressive degeneration of neuronal axons, promote dendrite formation of new synapses, establish new neural connections, and activate or create new neural pathways. These improvements enhance the brain's regulatory control over the limbs, improve joint flexibility, and alleviate movement disorders (39). During dancing, external stimuli promote the release of various neurotransmitters, which help patients with PD train motor memory, improve balance and cognitive function, and alleviate depression (40).

However, considering that PD patients are usually elderly and have a stiff gait, they are particularly prone to fall when starting to run, turning around or avoiding obstacles. Therefore, special attention should be paid to the safety of the venue environment, and exercise should be carried out in open Spaces without obstacles as much as possible (41, 42). In addition, for PD patients, warm-up activities should be carried out before exercise to increase the movement of various body parts, posture coordination and breathing and prevent muscle strains (37). During the training process, family members of the patients should accompany and protect them and try to minimize unnecessary injuries. Considering that female PD patients are suspicious and sensitive, they are more likely to be unable to proceed smoothly due to the fear of falling. Psychological communication should be conducted when necessary to alleviate the patients' concerns.

Balance capacity refers to the ability to maintain the body's center of gravity within its base of support during both static (stationary) and dynamic (moving) tasks (43). Good balance control and quick postural adjustment to external disturbances are key factors for stable and efficient walking (44, 45). Our study found that ROT was superior to TR in improving balance in PD patients. ROT is based on the theory of central nervous system plasticity and functional reorganization, and a large number of repetitive and purposefully weight-loss walking training can also improve balance and contribute to the automation of gait and the improvement of pace (46, 47). The closed-chain movement assisted by the G-EOSystem^® lower limb rehabilitation robot increased the stimulation of the anti-gravity proprioception of the lower limb with decreased sensitivity. The central nervous system, supplemented by the external visual feedback system, mobilizes the body's postural regulation system and finally realizes the body's balance and stability by effectively exporting the coordinated contraction of the peripheral trunk and lower limb muscles (48). Furthermore, some studies have found that ROT can generate external rhythms through proprioceptive cue effects in a fixed pattern to compensate for the internal rhythm defects caused by abnormal basal ganglion circuits in patients with Parkinson's disease, which is helpful for maintaining normal gait (49, 50), thereby increasing the balance ability of PD patients.

Our study found that QG improved the quality of life of people with Parkinson's disease better than other forms of exercise. DE can effectively improve depression in patients with Parkinson's disease, and ROT can effectively improve balance in patients with PD. In summary, exercise substantially affects PD's quality of life and negative emotions, but its internal molecular mechanism and the connection and regulation of neural circuits remain to be further explored. In addition, in the quality evaluation of this study, we found that many studies did not use blind methods and randomization, resulting in generally low evidential certainty of research results. Therefore, it is suggested that the survey quality be strictly controlled and the sample size be increased to verify this study's results further. Exercise has positive significance in the prevention, clinical practice and rehabilitation of PD. A standardized therapeutic effect evaluation system should be established for clinical medical staff to clarify the optimal training plan and parameter Settings for different disease courses and types of PD patients. Furthermore, due to the diversity of exercise methods, the focus of intervention for patients by various exercise methods is not the same, and thus the intervention effects are also different. PD patients should adopt a comprehensive intervention form that organically and scientifically combines multiple exercise methods to achieve the best intervention effect.