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Yoga-based exercise improves balance and mobility in people aged 60 and over: A systematic review and meta-analysis

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  • School of Public Health, University of Sydney

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Objective: one-third of community-dwelling older adults fall annually. Exercise that challenges balance is proven to prevent falls. We conducted a systematic review with meta-analysis to determine the impact of yoga-based exercise on balance and physical mobility in people aged 60+ years. Methods: searches for relevant trials were conducted on the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Allied and Complementary Medicine Database and the Physiotherapy Evidence Database (PEDro) from inception to February 2015. Trials were included if they evaluated the effect of physical yoga (excluding meditation and breathing exercises alone) on balance in people aged 60+ years. We extracted data on balance and the secondary outcome of physical mobility. Standardised mean differences and 95% confidence intervals (CI) were calculated using random-effects models. Methodological quality of trials was assessed using the 10-point Physiotherapy Evidence Database (PEDro) Scale. Results: six trials of relatively high methodological quality, totalling 307 participants, were identified and had data that could be included in a meta-analysis. Overall, yoga interventions had a small effect on balance performance (Hedges' g = 0.40, 95% CI 0.15-0.65, 6 trials) and a medium effect on physical mobility (Hedges' g = 0.50, 95% CI 0.06-0.95, 3 trials). Conclusion: yoga interventions resulted in small improvements in balance and medium improvements in physical mobility in people aged 60+ years. Further research is required to determine whether yoga-related improvements in balance and mobility translate to prevention of falls in older people.PROSPERO Registration number CRD42015015872.
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SYSTEMATIC REVIEW
Yoga-based exercise improves balance and
mobility in people aged 60 and over: a
systematic review and meta-analysis
SABRINA YOUKHANA1,CATHERINE M. DEAN1,MOA WOLFF2,CATHERINE SHERRINGTON3,ANNE TIEDEMANN3
1
Department of Health Professions, Macquarie University, Sydney, NSW 2109, Australia
2
Centre for Primary Health Care Research, Malmö, Lund University, Lund, Sweden
3
The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, NSW 2000, Australia
Address correspondence to: A. Tiedemann. Tel: (+61) 2 96570393; Fax: (+61) 2 96570301. Email: atiedemann@georgeinstitute.org.au
Abstract
Objective: one-third of community-dwelling older adults fall annually. Exercise that challenges balance is proven to prevent
falls. We conducted a systematic review with meta-analysis to determine the impact of yoga-based exercise on balance and
physical mobility in people aged 60+ years.
Methods: searches for relevant trials were conducted on the following electronic databases: MEDLINE, EMBASE, Cochrane
Central Register of Controlled Trials, CINAHL, Allied and Complementary Medicine Database and the Physiotherapy Evidence
Database (PEDro) from inception to February 2015. Trials were included if they evaluated the effect of physical yoga (exclud-
ing meditation and breathing exercises alone) on balance in people aged 60+ years. We extracted data on balance and the
secondary outcome of physical mobility. Standardised mean differences and 95% condence intervals (CI) were calculated
using random-effects models. Methodological quality of trials was assessed using the 10-point Physiotherapy Evidence
Database (PEDro) Scale.
Results: six trials of relatively high methodological quality, totalling 307 participants, were identied and had data that could be
included in a meta-analysis. Overall, yoga interventions had a small effect on balance performance (Hedgesg= 0.40, 95% CI
0.150.65, 6 trials) and a medium effect on physical mobility (Hedgesg= 0.50, 95% CI 0.060.95, 3 trials).
Conclusion: yoga interventions resulted in small improvements in balance and medium improvements in physical mobility in
people aged 60+ years. Further research is required to determine whether yoga-related improvements in balance and mobility
translate to prevention of falls in older people.
PROSPERO Registration number CRD42015015872.
Keywords: yoga, aged, systematic review, randomised controlled trial, balance, mobility, older people
Introduction
One-third of community-dwelling adults aged 65 and over
fall at least once annually [1,2]. These falls can result in
serious injury, reduced quality of life and independence and
ongoing disability [1]. Falls are also a leading cause of injury-
related hospitalisation in people aged 65 and over [3] and can
precipitate admission to a residential care facility [4]. In Australia,
and internationally, the prevention of falls and mobility-related
disability among older people is a major public health chal-
lenge that requires urgent attention [5].
A recent Cochrane review of interventions to prevent falls
demonstrated that exercise can reduce the risk and rate of
falls in older community-dwellers by between 15 and 32%
[6]. Furthermore, there is clear evidence that exercise that
challenges balance, is of a high dose and is ongoing, is most
effective in preventing falls in older people [7].
Yoga-based activity takes many forms, ranging from the
practise of standing postures that aim to improve strength,
exibility and balance through to relaxation and meditation-
based forms [8]. Yoga is growing in popularity among all age
groups [9], and previous trials demonstrate the physical
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benets of yoga to include reduced hypertension [10],
reduced chronic back pain and disability [11], and improved
sleep quality [12] for general populations and specic patient
groups. Little is known, however, about yogas effect on inde-
pendence in older age, measured by balance and mobility,
and no randomised controlled trials have evaluated the
impact of yoga on falls in older age.
A 2012 systematic review with meta-analysis [8] provides
preliminary evidence of improvements in strength, aerobic
tness and self-rated health among older people after regular
yoga practice. The review compared the benets of yoga with
other exercise interventions in older people and concluded
that small studies indicated that yoga may be superior to con-
ventional physical activity interventions in older people. This
systematic review however did not evaluate the effect of yoga
on balance outcomes.
A systematic review conducted by Jeter and colleagues
[13] did examine the effect of yoga on balance outcomes.
The review included 15 studies with a variety of study designs
and concluded that yoga may have a benecial effect on
balance. However, this review included study participants of all
ages (range from 10 to 93 years) and only included healthy
study cohorts making it difcult to determine the effect of
yoga on balance in older people with a range of co-morbidities.
The current systematic review aimed to address gaps in
the current literature and answer the following questions:
(1) What is the effect of yoga-based exercise on balance in
people aged 60 and older?
(2) What is the effect of yoga-based exercise on physical mo-
bility in people aged 60 and older?
For the purposes of this review, balance was dened as
the ability to maintain the projection of the bodys centre of
mass within manageable limits of the base of support, as in
standing or sitting, or in transit to a new base of support
[14]. Physical mobility was dened as the ability to walk,
move around and change or maintain body position[15].
To make recommendations based on the highest level of evi-
dence, this review included only randomised controlled trials.
Method
Design
We conducted a systematic review according to the PRIMSA
statement [16], and the review protocol was registered on
PROSPERO prior to commencement (#CRD42015015872).
See Supplementary data, Appendix 1, available in Age and
Ageing online for PRISMA checklist.
Search strategy and study selection criteria
Searches for relevant trials were conducted on the follow-
ing electronic databases from inception to 18th February
2015: MEDLINE, EMBASE, Cochrane Central Register of
Controlled Trials, CINAHL, Allied and Complementary Medi-
cine Database and the Physiotherapy Evidence Database
(PEDro) without language restrictions. Search terms included
words relating to yoga, balance, randomised controlled trial and
age and were selected with reference to Cochrane reviews on
similar topics. The search strategies were developed by the
authors and reviewed by a librarian to ensure appropriate terms
were used for the different databases. The search strategies are
included in Supplementary data, Appendix 2, available in Age
and Ageing online. The reference lists of relevant systematic
reviewswerealsohandsearched.
Titles and abstracts were screened by one reviewer (S.Y.)
to identify relevant studies. Only peer-reviewed papers were
included. Two independent reviewers (S.Y. and M.W.) exam-
ined full paper copies for inclusion against predetermined
criteria (Box 1). Conict was resolved after discussion with a
third reviewer (A.T.).
Characteristics of included studies
Quality
The quality of included studies was determined using PEDro
scale scores extracted from the Physiotherapy Evidence Data-
base (www.pedro.org.au). The PEDro scale scores the meth-
odological quality of randomised controlled trials with a rating
between0and10[17]. The maximum attainable PEDro score
was considered 8/10, because it is not feasible to blind treating
therapists and participants during yoga-based interventions.
Participants
Eligible studies were those that included participants 60 years
of age or older with no restriction on the characteristics of
that population.
Intervention
The intervention included physical yoga, excluding yoga in-
volving meditation and breathing exercises alone. No limita-
tion was placed on the type, duration and frequency of yoga
intervention. Session duration, frequency and program style
were recorded to assess the similarity of the studies. The
control intervention was dened as no intervention, wait list
control or usual care.
Outcome measures
Trials were included if a balance measure was taken pre- and
post-intervention. Any validated, standardised clinical or
Box 1. Inclusion criteria
Design: Randomised controlled trials
Participants: Adults aged 60 and over
Interventions: Physical yoga programs (excluding meditation
and breathing exercises alone). No limitation was placed on
the type, duration and frequency of yoga intervention.
Control: No intervention, usual care or wait list control
Outcomes measured: Balance and mobility measures.
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laboratory-based measure of balance such as (but not limited
to) the Berg Balance Scale [18], one leg stand [19] and Short
Physical Performance Battery were included [20]. Secondary
outcome measures of physical mobility were also obtained
including any validated methods measuring gait speed, sit to
stand, functional tests or other mobility scales [21].
Data extraction and analysis
Data were extracted regarding trial characteristics and esti-
mates of effect using a pilot-tested data extraction form by
two reviewers (S.Y., M.W.) and cross-checked by a third re-
viewer (A.T.). Authors were contacted via email to obtain
further information if there were insufcient data included in
the publication. Duplicate publications were identied and
excluded by comparing authors, interventions, outcomes and
sample sizes of eligible trials. The pre- and post-intervention
means and standard deviations for each study group were
extracted to obtain the pooled estimate of the effect of inter-
vention.
Details of the setting, yoga program components, pro-
gram dose, outcomes measured and timing of measurement
were summarised descriptively. The meta-analysis was con-
ducted using Comprehensive Meta-analysis software (Version
2, Biostat, Englewood, NJ, USA). Intervention effect sizes for
the balance and mobility outcome measures, standardised
mean differences (SMDs) using Hedgesgstatistic and 95%
condence intervals (CIs) were calculated.
Effect sizes were catergorised as small (0.2), medium (0.5)
and large (0.8 or greater) [22]. Statistical heterogeneity was
quantied using the I
2
statistic: I
2
of >75% indicates consider-
able heterogeneity, I
2
of 5075% indicates substantial hetero-
geneity and I
2
of <40% indicates limited heterogeneity [23].
Results
Flow of studies through the review
A total of 1,415 studies (excluding duplicates) were identied.
After screening, six eligible randomised trials [2429]were
included in the review and the primary meta-analysis evaluating
the effect of yoga on balance outcomes. For the secondary ana-
lysis, three trials [24,26,28] were pooled reporting mobility out-
comes. Figure 1outlines the ow of studies through the review.
Characteristics of included trials
The six trials included in the primary analysis involved a total
of 307 participants. The three trials pooled for the secondary
mobility analysis involved 225 participants. Table 1summarises
Figure 1. Flow of studies through the review. *Papers may have been excluded for failing to meet more than one inclusion criteria.
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.................................................................................................................
Table 1. Summary of included studies
Study Participants Intervention details Dose
(total
hours
offered)
Class
attendance
a
Follow-up
(weeks)
Adverse events due
to yoga
Control group Outcome measures PEDro
Score
Cheung et al.[28]n=36
Mean age = 72
36 females, 0 male
Women who had
symptomatic knee
osteoarthritis
Yoga type = Hatha
Sessions included poses in seated, supine and
standing positions; breathing exercise and
meditation.
Home practice 4× per week encouraged.
60 min × 1 per week × 8 weeks
Specific yoga poses included: Mountain, Warrior
1 and 2, Tree, Chair, Easy seated, Bound angle,
Open angle, Half locust variation, Bridge,
Standing forward fold, Reclining hamstring
stretch, Reclining twist, Relaxation pose
8 75% 8 1 dropout due to knee
pain
Wait list
control
Balance = Short
Physical
Performance
Battery
Mobility = 8walk
8
Colgrove et al.[29]n=13
Mean age = 67
7 females, 6 males
Parkinsons disease
patients who could
ambulate
Yoga type = Iyengar, Hatha
60 min × 2 per week × 12 weeks
Sessions included poses in seated, supine and
standing positions; breathing exercise and
meditation.
Home practice encouraged.
Specific yoga poses included: Information not
reported
24 99% 12 Nil Usual care Balance = Berg
balance scale
6
Oken et al.[26]n= 135
Mean age = 72
101 females, 34 males
Healthy
community-dwelling
Yoga type = Iyengar
90 min × 1 per week × 24 weeks
Sessions included poses in seated and standing
positions; breathing exercise, visualisation and
meditation.
Daily home practice encouraged.
Specific yoga poses included: Information not
reported
36 78%
b
24 1 minor groin strain that
did not preclude
participation
Wait list
control
Balance = One leg
stand
Mobility = Sit to
stand
6
Saravanakumar
et al.[26]
n=22
Mean age = 84
16 females, 6 males
Aged care facility
residents
Yoga type = not specified
30 min × 2 per week × 14 weeks
Sessions included poses in seated and standing
positions; breathing exercise and meditation.
Specific yoga poses included: Mountain, Warrior,
Tree, Chair, Side stretch, King dancer, Eagle,
Staff, Cat, Half spinal twist
14 76% 14 1 fall during class that
did not preclude
participation
Usual care Balance = Berg
balance scale
6
Schmid et al.[25]n=47
Mean age = 63
17 females, 30 males
Participants with chronic
stroke (>6 months
duration)
Yoga type = Yoga
60 min × 2 per week × 8 weeks
Sessions included poses in seated, supine and
standing positions; breathing exercise and
meditation.
Specific yoga poses included: Mountain, Warrior,
Chair, Cow, Cobra, Half moon, Fish king, Pigeon,
Locust, Awkward, Big toe, Bridge,
Energy-releasing, Corpse pose
16 78%
c
8 Nil Wait list
control
Balance = Berg
balance scale
6
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the characteristics of the trials, including age and gender of the
sample, intervention and control group details and outcome
measures included.
Quality
The mean PEDro score of the included studies was 6.7.
Randomisation and concealed allocation was carried out in
all six trials. Four studies scored 6 out of 10 [2527,29]on
the PEDro scale and two scored 8 out of 10 [24,28]. PEDro
scores are included in Table 1.
Participants
The mean age of participants ranged from 63 to 84 years.
Five of the six trials recruited participants from the commu-
nity (n= 285) and one trial recruited participants from a resi-
dential aged care settings (n= 22). The characteristics of the
samples included in the community-based studies varied.
Two of the trials recruited healthy older people, whereas
Colgrove and colleagues included participants with Parkinsons
disease, Cheung and colleagues included women with knee
osteoarthritis and Schmid and colleagues included people who
had experienced a stroke. Both men and women were included
in all but one of the studies [28], and 72% (220/307) of
included participants were female.
Intervention
In all studies, the experimental group received a physical
yoga intervention. Two trials included Iyengar yoga [24,26],
one included Hatha yoga [28], one trial included both Iyengar
and Hatha styles [29] and two trials did not specify the style
of yoga [25,27]. Participants undertook 6090 min of yoga,
12 times per week, for 824 weeks in total. The control
groups of ve studies received no intervention or wait list
control/usual care and in one study control participants were
provided with a fall prevention education booklet [24]. All
six studies utilised a certied yoga instructor and used props
such as blankets, chairs, blocks, pillows, straps and mats for
support and comfort. Each study included progression of
the intensity of the yoga intervention over time, from simple
postures to more challenging. Yoga poses were conducted in
standing, sitting and oor lying. Examples of the types of
standing poses included were half knee squat with feet side
by side (chair pose), one legged stand with arms extended
(tree pose), one legged stand with trunk exion and rotation
(half-moon pose), hip abduction with trunk lateral exion
(triangle pose). The mean number of sessions attended by
study participants was high, ranging from 75 to 99%.
Adverse events
All of the included trials measured adverse events related to
the yoga intervention. Two of the trials reported that no
adverse events occurred [25,29]. One of the trials [27]
reported that a fall occurred during the yoga intervention but
Tiedemann et al.
2013 [23]
n=54
Mean age = 68
43 female, 11 male
Healthy
community-dwelling
Yoga type = Iyengar
60 min × 2/week × 12 weeks
Sessions included poses in supine and standing
positions; breathing exercise and meditation.
Home practice encouraged.
Specific yoga poses included: Mountain, Warrior 1, 2
and 3, Tree, Chair, Triangle, Half moon,
Downward facing dog, Forward facing dog,
Revolved Lateral Angel, Legs on the wall, Lying
down big toe, Bound angle, Open angle, Staff,
Corpse pose
24 83% 12 1 dropout due to low
back pain, 5 reports of
minor joint pain that
did not preclude
participation
Fall prevention
booklet
Balance = Short
Physical
Performance
Battery
Mobility = 4-m
walk
8
a
Average class attendance across all participants.
b
Average class attendance for participants who completed the trial.
c
Proportion of participants who attended all yoga sessions.
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that the participant did not sustain any injuries. It was subse-
quently discovered that the participant suffering from
Menieres disease. The remaining three trials reported minor
adverse events as a result of the yoga intervention, ranging
from knee pain, low back pain to minor muscle strain.
Outcome measures
Balance was measured in all studies, three studies used the
Berg balance scale [18], two studies used the Short Physical
Performance Battery [20] and one used a one leg stand [19].
Mobility measures were taken in three studies and included
sit to stand and gait speed tests [21].
Effect of yoga on balance
The effect sizes from individual trials of the effect of yoga on
balance involving 6 trials and 307 participants are shown in
Figure 2. The pooled estimate of the effect of yoga on
balance indicates a small but statistically signicant effect on
balance in yoga versus control participants (SMD 0.40, 95%
CI 0.150.65). There was no indication of heterogeneity in
the estimate of the effect of the intervention (I
2
=0%,
P= 0.615).
Effect of yoga on mobility
The effect sizes from individual trials of the effect of yoga on
mobility involving three trials [24,26,28] and 225 partici-
pants are shown in Figure 3. The pooled estimate of the
effect of yoga on mobility indicates a medium, statistically
signicant effect on mobility in yoga versus control partici-
pants (SMD 0.50, 95% CI 0.060.95). There was an indica-
tion of some heterogeneity in the estimate of the effect of the
intervention (I
2
= 51.8%, P= 0.126).
The review also set out to assess the differential impact of
yoga-based exercise on balance and mobility in people aged
60 and older on the basis of program or population charac-
teristics. However, we could not achieve this due to the small
number of trials identied.
Discussion
This systematic review and meta-analysis included six
trials of relatively high (all studies scored 6 or greater on
the PEDro scale) methodological quality that found that
physical yoga improved balance and mobility in people
aged 60 and over. The magnitude of the effect of physical
yoga on balance (SMD = 0.40) demonstrates a small po-
tential of physical yoga for improving balance in older
people. The meta-analysis also indicated that there is a
signicant, moderate effect of yoga on the mobility out-
comes of gait speed and timed chair stands (SMD = 0.50).
No yoga-related serious adverse events were reported in
any of the trials.
These results are in accordance with other recent system-
atic reviews that identied some evidence of a benecial
effect of yoga on balance in healthy populations [13] and on
measures of strength and tness among older people [8].
Since exercise that challenges balance is known to decrease
fall risk, these results demonstrate preliminary evidence that
yoga shows potential as a fall prevention intervention. The
included trials focused on standing and seated balance pos-
tures, trials adapted the yoga programs to suit the needs of
the older population, and certied yoga therapists and
instructors implemented the interventions included in these
trials. The types of yoga included in the trials varied; some
trials specically incorporated Iyengar yoga while others
incorporated a broad Hatha yoga program. Future studies
Figure 2. Effect size (95% CI) of yoga on balance by pooling data from six studies comparing yoga versus control using
random-effects meta-analysis (n= 307).
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should investigate the optimal type of yoga to best suit the
older population with the possible use of supportive equip-
ment such as blocks or chairs. The included postures only
varied slightly in the trials, with commonly included stand-
ing poses being; the mountain pose, warriors 1 and 2, tree
pose, chair pose and locust pose.
This review has both strengths and limitations. To our
knowledge, this is the rst meta-analysis of randomised con-
trolled trials to evaluate the impact of physical yoga on
balance in older people. This systematic review was pro-
spectively registered and not restricted by publication lan-
guage or date. A key strength is that the included trials
involved older people with a broad range of health states,
including post-stroke [25], Parkinsons disease [29], knee
osteoarthritis [28], aged care facility residents [27]and
healthy community-dwellers [24,26]. Yoga appears to be a
feasible intervention for older people with a range of abil-
ities. Furthermore, the reported number of adverse events
was low across all trials. These results provide support for
health professionals to condently recommend yoga inter-
ventions to improve balance and mobility in people aged 60
and over in a variety of settings.
We acknowledge that the review had limitations. A source
of bias in the studies included in this review was lack of
blinding of therapists and patients. Attempts were made to
minimise the risk of bias as a result of this lack of blinding
through the use of blinded outcome assessors for most of
the included trials. Additionally three of the six included
trials did not use an intention-to-treat analysis which may
have introduced study bias. We chose to use the PEDro
scale to measure risk of bias; however, the Cochrane risk of
bias tool could also have been used. The best way to assess
risk of bias in trials of yoga interventions is not clear and
warrants further investigation. The included trials all had
quite small sample sizes, with just 307 participants in total
for the six trials, which makes it difcult to draw conclu-
sions about implications of the results for the broader
population of older people. Additionally, the estimates of
effects of yoga on mobility need to be interpreted cautious-
ly as not all studies that have measured the effect of yoga
on mobility were captured in this systematic review. It is
also not clear whether the improvements in balance and
mobility as a result of yoga participation were large enough
to be of clinical relevance. Due to the pooling of data from
different outcome measures for the meta-analyses, it was
necessary for us to calculate the SMD to determine inter-
vention effects, which adds difculty to the interpretation
of the results. However, we consider the advantages of pool-
ing via SMD outweigh this limitation. Finally, the balance
measures utilised as outcomes in the included trials were
limited in the scope of postural control elements that they
measured. This makes it difcult to assess the true poten-
tial of yoga-based interventions for improving the aspects
of postural control that are crucial for preventing falls in
older age.
While this review provides preliminary evidence of the
benecial effect of physical yoga on balance and mobility in
people aged 60 and over, the optimal volume, intensity and
frequency of yoga for maximising balance and mobility out-
comes to provide clinically relevant improvements remain to
be determined. Of the six trials included in this review, only
one trial conducted their yoga program for 24 weeks [26].
The remaining ve trials ranged in durations from 8 to 14
weeks. In light of evidence of increased fall prevention benet
from exercise programs of a higher dose [7], future studies
should include a longer duration intervention to fully explore
the potential size of the impact on balance from a higher
dose yoga-based intervention.
Conclusion
This review provides preliminary evidence that balance and
mobility can be safely improved with participation in yoga by
Figure 3. Effect size (95% CI) of yoga on mobility by pooling data from three studies comparing yoga versus control using
random-effects meta-analysis (n= 225).
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people aged 60 and over. Physical yoga warrants investigation
as a potential intervention to prevent falls in older age.
Key points
Health professionals can condently recommend yoga for
those aged 60+ to improve balance and physical mobility.
Yoga-based exercise shows promise as a fall prevention
intervention.
Well-designed randomised controlled trials investigating the
effects of yoga on falls are warranted.
Authorscontributions
A.T. and C.S. conceived the study and contributed to study
design and interpretation of the data. S.Y. coordinated the
literature search and data collection with assistance from
M.W. S.Y., A.T. and C.D. contributed to data analysis, inter-
pretation of the data and drafted the manuscript. All authors
had access to the data and data analysis, contributed to revi-
sions and approved the nal manuscript. A.T. is the guaran-
tor for the study.
Conflicts of interest
None declared.
Funding
The salary of C.S. is funded by a Fellowship from the
National Health and Medical Research Council of Australia.
Supplementary data
Supplementary data mentioned in the text are available to
subscribers in Age and Ageing online.
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Yoga-based exercise improves balance and mobility in older people
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... Yoga practice consists of complex movements involving 3-dimensional motions, including proper body posture, alignment, and rhythm, to maintain static and dynamic balance. A systematic review and metaanalysis showed that yoga practice resulted in minor improvements in balance and medium improvements in physical mobility among the population aged >60 years [9]. Apart from the general population and older adults, previous studies have shown that yoga can improve mobility, strength, balance, and gait stability in patients with neurological and musculoskeletal disorders [10][11][12][13][14]. ...
... Previous studies which evaluated yoga benefits over gait performance and balance mainly based on clinical scales, such as the Expanded Disability Status Score [11], Berg Balance Scale [11,12], and Short Physical Performance Battery [9]. However, these are subjective parameters that lack an objective comparison basis. ...
... A recent randomized controlled trial among patients with postmenopausal osteoporosis demonstrated that adding tree pose (Vrksasana) to conventional exercise per day for 12 weeks improved both static and dynamic balance, as well as the tandem walk test [14]. Yoga intervention also produced significant improvements in balance in healthy older fallers [9], children [33], and patients with Parkinson's disease [34]. However, only the Berg Balance Scale was used as an evaluation tool in most of these studies. ...
Article
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This study investigates gait symmetry and single-leg stance balance of professional yoga instructors versus age-matched typically developed controls using inertial measurement unit (IMU)-based evaluation. We recruited twenty-five yoga instructors and twenty-five healthy control subjects to conduct the walking experiments and single-leg stance tests. Kinematic data were measured by attaching IMUs to the lower limbs and trunk. We assessed the asymmetry of swing phases during the normal-walk and tandem-walk tests with eyes open and closed, respectively. The subjects subsequently conducted four single-leg stance tests, including a single-leg stance on both legs with eyes open and closed. Two balance indexes regarding the angular velocities of the waist and chest were defined to assess postural stability. The gait asymmetry indexes of yoga instructors were significantly lower than those of the typically developed controls. Similarly, the yoga instructors had better body balance in all four single-leg stance tests. This study’s findings suggest that yoga improves gait asymmetry and balance ability in healthy adults. In the future, further intervention studies could be conducted to confirm the effect of yoga training.
... For example, chair-based yoga has been successfully applied in geriatric [5] and palliative care settings [6]. Systematic reviews of yogabased interventions in cognitively healthy older adults reported improvements in muscle strength [7], balance and mobility [6,8], cardiovascular health [9], sleep quality [10], mental wellbeing [11], and quality of life [7,12]. Yoga's potential to support the functional independence and psychosocial wellbeing in older people has resulted in its application in long-term care settings [13] and its expansion to older people with cognitive deficits [14]. ...
Article
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Background Yoga is a mind-body practice that can elicit robust health and wellbeing effects for older adults. As a result, there is increased public and academic interest into the potential benefits of yoga for older people with mild cognitive impairment (MCI) and dementia. Methods Literature searches in five databases (CENTRAL, PubMed and EBSCOHost indexing CINAHL Plus, PsycINFO, Psychology and Behavioural Sciences Collection) were conducted from the databases’ date of inception through to 4 September 2020 to identify pre-post single and multigroup studies of yoga-based interventions involving people with MCI or dementia. Effects on cognitive, mental, and physical health were evaluated, as was safety and study quality. Results Database searches identified 1431 articles. Of these, 10 unique studies met inclusion criteria (total 421 participants). Four studies each implemented Kundalini yoga and chair yoga, while two employed Hatha yoga. Most programs ran for 12 weeks ( n = 5) and compared yoga to a control group ( n = 5). Most studies reported improved cognition, mood, and balance. However, these effects were marred by the high risk of bias identified in all articles. Four studies assessed safety, with one instance of dizziness reported. Conclusions In this emerging field, these studies show that yoga may be safe and beneficial for the wellbeing of people with MCI or dementia. More high quality randomised controlled trials are needed to improve the evidence-base and overcome the limitations of existing studies.
... Yoga as a form of exercise has been found to prevent a variety of health problems and produce effects that helps individuals improve or maintain good health. In older adults, yoga has been found to strengthen balance (Jeter et al., 2014, Youkhana et al., 2016; aid in stroke rehabilitation (Lawrence et al., 2016); improve proprioception and balance function in individuals who have fallen (Wooten et al., 2018), and improve mobility, postural control, and gait speed (Kelley et al., 2014). Research has also shown improvements in a wide variety of health conditions when individuals practice yoga. ...
Article
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A research study employing a non-equivalent pretest-posttest comparison group design was used to measure online and face-to-face (FTF) yoga instructional methods and their effects on anxiety, increased flexibility, and perceived behavioural intentions to practice yoga in the future. This study was conducted to discover if online yoga course instruction was just as effective as or more so than a course taught FTF. Findings suggest that online yoga instruction was significantly more effective in reducing the state anxiety of the students. However, there was no significant difference between groups on trait anxiety indicating that either method was equally effective. In contrast, the F2F course was significantly more effective in reducing the appearance anxiety of students when compared to the online yoga course. Students in FTF and online increased in flexibility with no significant difference between groups. Based on these results, online yoga can reduce certain types of anxiety and be just as effective at increasing flexibility. The findings show that online yoga can be just as effective as and sometimes more effective than FTF yoga in some aspects important for maintenance of health and wellness in individuals.
... Lower limb strength, range of motion, proprioception, and joint stability are related to static balance ability (Xie et al., 2020). In a systematic review and meta-analysis, Youkhana et al. (2016) reported that long-term yoga-based training interventions can improve balance ability and modestly increase the level of physical activity in people over 60 years of age. These improvements may help prevent falling in older adults. ...
Article
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Objective: To study the effect of Chinese fitness dancing on lower limb strength and fall risk in middle-aged and older women. Methods: The MicroFET3 portable muscle strength tester, the FreeStep test system, and tests to evaluate fall risk were used to measure the maximum muscle strength, fall risk index, and static balance ability of extensor muscle groups in the lower limbs. Results: Compared with the irregular exercise group, the maximum muscle strength of extensor muscle groups in the lower limb, five sit-to-stand test timings, fall risk index, static balance ability, and lower limb flexibility did not improve significantly in the 1-year regular exercise group (P>0.01). However, these indicators were significantly improved in the 10-year regular exercise group compared with the 1-year regular exercise group (P<0.01). Conclusion: Long-term regular participation in Chinese fitness dancing significantly increased muscle strength in the lower limbs and effectively lowered the fall risk index in middle-aged and older women. Thus, long-term regular participation in Chinese fitness dancing can be used as a preventive measure to increase muscle strength in the lower limbs and reduce the risk of falls in middle-aged and older women.
... Among these 59 studies, the data from only 38 could be extracted for TSA. Studies were excluded from the TSA if they: (1) were conference abstracts [29][30][31]; (2) performed only single-group before-after comparison [32]; (3) lacked raw data, which could not be obtained from the cited articles [33][34][35][36][37][38][39][40]; or (4) did not report the necessary outcome measures (gait speed or balance) [41][42][43][44][45][46][47][48][49]. ...
Article
Full-text available
Meta-analysis is a common technique used to synthesise the results of multiple studies through the combination of effect size estimates and testing statistics. Numerous meta-analyses have investigated the efficacy of exercise programmes for stroke rehabilitation. However, meta-analyses may also report false-positive results because of insufficient information or random errors. Trial sequential analysis (TSA) is an advanced technique for calculating the required information size (RIS) and more restrictive statistical significance levels for the precise assessment of any specific treatment. This study used TSA to examine whether published meta-analyses in the field of stroke rehabilitation reached the RIS and whether their overall effect sizes were sufficient. A comprehensive search of six electronic databases for articles published before May 2022 was conducted. The intervention methods were divided into four primary groups, namely aerobic or resistance exercise, machine-assisted exercise, task-oriented exercise, and theory-based exercise. The primary outcome measure was gait speed and the secondary outcome measure was balance function. The data were obtained either from the meta-analyses or as raw data from the original cited texts. All data analysis was performed in TSA software. In total, 38 articles with 46 analysable results were included in the TSA. Only 17 results (37.0%) reached the RIS. In conclusion, meta-analysis interpretation is challenging. Clinicians must consider the RIS of meta-analyses before applying the results in real-world situations. TSA can provide accurate evaluations of treatment effects, which is crucial to the development of evidence-based medicine.
... Lower limb weakness resulting from sarcopenia (the deterioration of muscle tissue with age) has also been shown to impede the ability to stand, reduce gait speed, and impair balance [42]. Further, the link between the increased prevalence of falls and sarcopenia in the older adult is clear, and this underlies many validated approaches for the management of falls in this population, particularly the strengthening of peripheral muscles using physical training and exercises such as Tai Chi [43,44] and yoga [26,44]. However, in addition to limiting lower limb function, sarcopenia is also associated with an elevated risk of developing metabolic dysregulation [42], likely due to decreased peripheral glucose uptake resulting from diminished muscle mass. ...
Article
Full-text available
Insulin resistance, which manifests as a reduction of insulin receptor signaling, is known to correlate with pathological changes in peripheral tissues as well as in the brain. Central insulin resistance has been associated with impaired cognitive performance, decreased neuronal health, and reduced brain metabolism; however, the mechanisms underlying central insulin resistance and its impact on brain regions outside of those associated with cognition remain unclear. Falls are a leading cause of both fatal and non-fatal injuries in the older population. Despite this, there is a paucity of work focused on age-dependent alterations in brain regions associated with ambulatory control or potential therapeutic approaches to target these processes. Here, we discuss age-dependent alterations in central modalities that may contribute to gait dysregulation, summarize current data supporting the role of insulin signaling in the brain, and highlight key findings that suggest insulin receptor sensitivity may be preserved in the aged brain. Finally, we present novel results showing that administration of insulin to the somatosensory cortex of aged animals can alter neuronal communication, cerebral blood flow, and the motivation to ambulate, emphasizing the need for further investigations of intranasal insulin as a clinical management strategy in the older population.
... There is evidence that older people believe yoga to be an acceptable and beneficial form of exercise (Nayak et al., 2015;Perkins et al., 2020;Tiedemann et al., 2018) and participation in yoga/Pilates increased substantially between 2001 and 2010 (Vergeer et al., 2017), among people aged 55 years and over, demonstrating yoga's growing appeal among middle-aged and older age groups. Previous systematic reviews identified the positive impact of yoga-based exercise on balance and mobility (Youkhana et al., 2016) and health-related quality of life and mental well-being (Tulloch et al., 2018) in people aged 60 years and over. Consequently, yoga has excellent potential as a strategy to reduce falls and fall-related injuries for older people ; however, no trials to date have been large enough to detect effects of yoga on falls (Lamb et al., 2005), and as such, yoga cannot yet be recommended as an evidence-based fall prevention strategy. ...
Article
Exercise that targets balance and strength is proven to prevent falls in older age. The Successful AGEing yoga trial is the first large randomized controlled trial to assess the impact of yoga on falls in people aged ≥60 years. We conducted a realist process evaluation to explain the strong participant engagement observed using interviews (21 participants and three yoga instructors) and focus groups (12 participants and four yoga instructors). Results showed that relaxation, breathing, and yoga’s mind–body connection created a satisfying internal focus on bodily sensation which was valued by participants. The mechanisms of mindfulness and embodiment appeared to facilitate this. Mindfulness and embodiment are also linked to, and enhance engagement with, other forms of physical activity. By focusing creatively on these mechanisms, we can develop a range of programs that target improvements in physical and mental health (including reducing falls and fear of falls) and appeal to older people.
... Moderate-duration yoga exercises may in fact improve balance and prevent falls. 92,93 Sudden rotational movements or excessive flexion of the spine, however, can predispose to vertebral compression fractures and should be avoided. 94 There is also moderate-quality evidence that Tai chi improves balance, reduces falls, and benefits overall bone health, particularly in older adults and women with osteoarthritis. ...
Article
Full-text available
Aging represents the single greatest risk factor for chronic diseases, including osteoporosis, a skeletal fragility syndrome that increases fracture risk. Optimizing bone strength throughout life reduces fracture risk. Factors critical for bone strength include nutrition, physical activity, and vitamin D status, whereas unhealthy lifestyles, illnesses, and certain medications (eg, glucocorticoids) are detrimental. Hormonal status is another important determinant of skeletal health, with sex steroid concentrations, particularly estrogen, having major effects on bone remodeling. Aging exacerbates bone loss in both sexes and results in imbalanced bone resorption relative to formation; it is associated with increased marrow adiposity, osteoblast/osteocyte apoptosis, and accumulation of senescent cells. The mechanisms underlying skeletal aging are as diverse as the factors that determine the strength (and thus fragility) of bone. This review updates our current understanding of the epidemiology, pathophysiology, and treatment of osteoporosis and provides an overview of the underlying hallmark mechanisms that drive skeletal aging.
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Background Yoga movements involve a series of motions of the core and lower limb muscles that require constant body adjustments to maintain balance and proper body alignment. Inertial measurement unit, a wearable device that is consisted of 3-axis accelerometers, 3-axis gyroscopes and 3-axis magnetometers, can provide objective data for motion analysis. This study aimed to investigate gait symmetry and single-leg stance balance of professional yoga instructors versus age-matched normal controls using inertial measurement unit (IMU) - based evaluation. Methods Twenty-five yoga instructors and twenty-five healthy control subjects were recruited to conduct the walking experiments and single-leg stance tests. Kinematic data were measured by attaching IMUs to the lower limbs and trunk. The asymmetry of swing phases during gait cycles was assessed using the normal walk and tandem walk tests with eyes open and closed, respectively. The subjects subsequently conducted four single-leg stance tests, including a single-leg stance on both legs with eyes open and closed. Two balance indexes regarding the angular velocities of the waist and chest were defined to assess postural stability. Results The gait asymmetry indexes of yoga instructors were significantly lower than those of the normal controls on normal walk and open-eye tandem walk tests. The asymmetry indexes also showed a smaller value in the yoga instructors on close-eye tandem gait; however, it did not reach statistical significance. Similarly, the yoga instructors had better body balance, that is, smaller angular velocities on both the waist and chest, in all four single-leg stance tests. This indicates superior postural stability over both the waist and chest levels of yoga instructors during the single-leg stance. Conclusion The findings of this study suggest that yoga practice improves gait asymmetry and balance ability in healthy adults. However, further intervention studies are needed to confirm the effect of yoga training. Trial Registration: This study was registered with an ClinicalTrials.gov Identifier: NCT05449730.
Article
Aim: To explore the effectiveness of home-based exercise programs with e-devices (HEPEs) on falls among community-dwelling older adults. Methods: Twelve randomized controlled trials were included in the meta-analysis considering four fall-related outcomes. Results: HEPEs significantly reduced the rate of falls (risk ratio: 0.82; 95% CI: 0.72-0.95; p = 0.006) and improved lower extremity strength (mean difference: -0.94; 95% CI: -1.71 to -0.47; p < 0.001). There was a significant improvement favoring HEPEs on balance if the participants were aged >75 years (mean difference: -0.55; 95% CI: -1.05 to -0.05; p = 0.03), or the intervention duration was at least 16 weeks (mean difference: -0.81; 95% CI: -1.58 to -0.05; p = 0.04). Conclusion: HEPEs demonstrated an overall positive effect on falls among community-dwelling older adults.
Article
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Falls amongst older people is a global public health concern. Whilst falling is not a typical feature of ageing, older people are more likely to fall. Fall injuries amongst older people are a leading cause of death and disability. Many older people do not do regular exercise so that they lose muscle tone, strength, and flexibility which affect balance and predispose them to falls. The management of falls in residential care settings is a major concern with strategies for prevention and monitoring a focus in this setting. Yoga and tai chi have shown potential to improve balance and prevent falls in older adults. They also have potential to improve pain and quality of life. The aim of this study was to determine the feasibility of conducting a three-arm randomised controlled trial (RCT) with frail older people in a residential care setting to test the hypothesis that a 14-week modified tai chi or yoga programme is more effective than usual care activity in improving balance function, quality of life, pain experience and in reducing number of falls. There were no statistically significant differences between the three groups in the occurrence of falls. Yoga demonstrated a slight decrease in fall incidence; quality of life improved for the tai chi group. Only the yoga group experienced a reduction in average pain scores though not statistically significant. The findings of the study suggest it is possible to safely implement modified yoga and tai chi in a residential care setting and evaluate this using RCT design. They show positive changes to balance, pain and quality of life and a high level of interest through attendance amongst the older participants. The results support offering tai chi and yoga to older people who are frail and dependent with physical and cognitive limitations.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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Injuries are the sixth leading cause of death in the 75-and-over population, with falls the leading cause of injury-related deaths. Hospitals and residential centers for the elderly have high rates of falls and injuries. With increasing age, patients in nursing homes have a corresponding increase in the proportion of fatal falls. The patterns of reduction of injury and mortality in the past two decades are likely to have been the result of our medical and trauma care system's impact on the outcome of less severe injuries. Major improvements in the future will come through prevention.
Article
Background and purpose: Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions. Method: In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]). Results: The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was.56 (95% confidence interval=.47-.65) for ratings by individuals, and the ICC for consensus ratings was.68 (95% confidence interval=.57-.76). Discussion and conclusion: The reliability of ratings of PEDro scale items varied from "fair" to "substantial," and the reliability of the total PEDro score was "fair" to "good."
Article
Since the first edition of this very successful book was written to synthesise and review the enormous body of work covering falls in older people, there has been an even greater wealth of informative and promising studies designed to increase our understanding of risk factors and prevention strategies. This new edition is written in three parts: epidemiology, strategies for prevention, and future research directions. New material includes the most recent studies covering: balance studies using tripping, slipping and stepping paradigms; sensitivity and depth perception visual risk factors; neurophysiological research on automatic or reflex balance activities; and the roles of syncope, vitamin D, cataract surgery, health and safety education, and exercise programs. This new edition will be an invaluable update for clinicians, physiotherapists, occupational therapists, nurses, researchers, and all those working in community, hospital and residential or rehabilitation aged care settings.