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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% 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.
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,
flexibility 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
1
Age and Ageing 2016; 0: 1–9
doi: 10.1093/ageing/afv175
© The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society.
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benefits of yoga to include reduced hypertension [10],
reduced chronic back pain and disability [11], and improved
sleep quality [12] for general populations and specific patient
groups. Little is known, however, about yoga’s 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
fitness and self-rated health among older people after regular
yoga practice. The review compared the benefits 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 beneficial 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 difficult 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 defined as
‘the ability to maintain the projection of the body’s 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 defined 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). Conflict 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 defined 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 insufficient data included in
the publication. Duplicate publications were identified 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 Hedges’gstatistic and 95%
confidence 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
quantified using the I
2
statistic: I
2
of >75% indicates consider-
able heterogeneity, I
2
of 50–75% 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 identified.
After screening, six eligible randomised trials [24–29]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 flow 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 = 8’walk
8
Colgrove et al.[29]n=13
Mean age = 67
7 females, 6 males
Parkinson’s 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 [25–27,29]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 Parkinson’s
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 60–90 min of yoga,
1–2 times per week, for 8–24 weeks in total. The control
groups of five 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 certified 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 floor 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 flexion and rotation
(‘half-moon pose’), hip abduction with trunk lateral flexion
(‘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
Meniere’s 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 significant effect on
balance in yoga versus control participants (SMD 0.40, 95%
CI 0.15–0.65). 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
significant effect on mobility in yoga versus control partici-
pants (SMD 0.50, 95% CI 0.06–0.95). 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 identified.
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
significant, 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 identified some evidence of a beneficial
effect of yoga on balance in healthy populations [13] and on
measures of strength and fitness 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 certified yoga therapists and
instructors implemented the interventions included in these
trials. The types of yoga included in the trials varied; some
trials specifically 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 first 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], Parkinson’s 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 confidently 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 difficult 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 difficulty 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 difficult 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
beneficial 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 five trials ranged in durations from 8 to 14
weeks. In light of evidence of increased fall prevention benefit
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 confidently 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.
Authors’contributions
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 final 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.
References
1. Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS,
Fitzgerald JL. Circumstances and consequences of falls experi-
enced by a community population 70 years and over during a
prospective study. Age Ageing 1990; 19: 136–41.
2. Lord SR, Sherrington C, Menz HB, Close JCT. Falls in Older
People: Risk Factors and Strategies for Prevention. Cambridge:
Cambridge University Press, 2006.
3. Baker SP, Harvey AH. Fall injuries in the elderly. Clin Geriatr
Med 1985; 1: 501–12.
4. Lord SR. Predictors of nursing home placement and mortality
in residents in intermediate care. Age Ageing 1994; 23:
499–504.
5. Vos T, Flaxman AD, Naghavi M et al. Years lived with disabil-
ity (YLDs) for 1160 sequelae of 289 diseases and injuries
1990–2010: a systematic analysis for the Global Burden of
Disease Study 2010. Lancet 2012; 380: 2163–96.
6. Gillespie LD, Robertson MC, Gillespie WJ et al. Interventions
for preventing falls in older people living in the community.
Cochrane Database Syst Rev 2012 (Issue 9). Art. No.:
CD007146. doi:10.1002/14651858.CD007146.pub3.
7. Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR.
Exercise to prevent falls in older adults: an updated meta-
analysis and best practice recommendations. NSW Public
Health Bull 2011; 22: 78–83.
8. Patel NK, Newstead AH, Ferrer RL. The effects of yoga on
physical functioning and health related quality of life in older
adults: a systematic review and meta-analysis. J Altern
Complem Med 2012; 18: 902–17.
9. Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL.
Trends in the use of complementary health approaches among
adults: United States, 2002–2012. National health statistics
reports; no 79. Hyattsville, MD: National Center for Health
Statistics, 2015.
10. Yang K. A review of yoga programs for four leading risk
factors of chronic diseases. Evid Based Complem Altern Med
2007; 4: 487–91.
11. Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA.
Comparing yoga, exercise, and a self-care book for chronic low
back pain: a randomized, controlled trial. Ann Intern Med
2005; 143: 849–56.
12. Manjunath NK, Telles S. Influence of Yoga and Ayurveda on
self-rated sleep in a geriatric population. Indian J Med Res
2005; 121: 683–90.
13. Jeter PE, Nikodo A, Moonaz SH, Dagnelie G. A systematic
review of yoga for balance in a healthy population. J Altern
Complem Med 2014; 20: 221–32.
14. Winter DA. ABC (Anatomy, Biomechanics and Control) of
Balance During Standing and Walking. Ontario: Waterloo
Biomechanics, 1995.
15. International Classification of Functioning, Disability and Health
(ICF). http://www.who.int/classifications/icf/icf_more/en/ (18
August 2015, date last accessed).
16. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred report-
ing items for systematic reviews and meta-analyses: the
PRISMA statement. BMJ 2009; 339: b2535.
17. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins
M. Reliability of the PEDro scale for rating quality of rando-
mized controlled trials. Phys Ther 2003; 83: 713–21.
18. Berg K, Wood-Dauphinee S, Williams JI. The Balance Scale:
reliability assessment with elderly residents and patients with
an acute stroke. Scand J Rehabil Med 1995; 27: 27–36.
19. Vellas BJ, Rubenstein LZ, Ousset PJ et al. One-leg standing
balance and functional status in a population of 512 community-
living elderly persons. Aging (Milano) 1997; 9: 95–8.
20. Guralnik JM, Simonsick EM, Ferrucci L et al. A short physic-
al performance battery assessing lower extremity function: as-
sociation with self-reported disability and prediction of
mortality and nursing home admission. J Gerontol 1994; 49:
M85–94.
21. Tiedemann A, Shimada H, Sherrington C, Murray S, Lord S.
The comparative ability of eight functional mobility tests for
predicting falls in community-dwelling older people. Age
Ageing 2008; 37: 1–6.
22. Cohen J. Statistical Power Analysis for the Behavioral Sciences.
Hillside, NJ: Lawrence Erlbaum, 1988.
23. Higgins J. Cochrane Handbook for Systematic Reviews of
Interventions. Version 5.1.0. Oxford, UK: The Cochrane
Collaboration, 2011.
8
S. Youkhana et al.
by guest on December 30, 2015http://ageing.oxfordjournals.org/Downloaded from
24. Tiedemann A, O’Rourke S, Sesto R, Sherrington C. A 12-week
Iyengar yoga program improved balance and mobility in older
community-dwelling people: a pilot randomized controlled
trial. J Gerontol A Biol Sci Med Sci 2013; 68: 1068–75.
25. Schmid AA, van Puymbroeck M, Altenburger PA et al.
Poststroke balance improves with yoga: a pilot study. Stroke
2012; 43: 2402–7.
26. Oken BS, Zajdel D, Kishiyama S et al. Randomized, controlled,
six-month trial of yoga in healthy seniors: effects on
cognition and quality of life. Altern Ther Health Med 2006;
12: 40–7.
27. Saravanakumar P, Higgins IJ, van der Riet PJ, Marquez J,
Sibbritt D. The influence of Tai Chi and yoga on balance and
falls in a residential care setting: a randomised controlled trial.
Contemp Nurse 2014; 48: 76–87.
28. Cheung C, Wyman JF, Resnick B, Savik K. Yoga for manag-
ing knee osteoarthritis in older women: a pilot randomized
controlled trial. BMC Complemen Altern Med 2014; 14:
1472–6882.
29. Colgrove YS, Sharma N, Kluding P et al. Effect of yoga
on motor function in people with Parkinson’s disease: a
randomized, controlled pilot study. J Yoga Phys Ther 2012;
2: 112.
Received 12 July 2015; accepted in revised form
12 November 2015
9
Yoga-based exercise improves balance and mobility in older people
by guest on December 30, 2015http://ageing.oxfordjournals.org/Downloaded from