Journal of Geriatric Physical Therapy:
Effects of a Yoga Program on Postural Control, Mobility, and Gait Speed in Community-Living Older Adults: A Pilot Study
Zettergren, Kathleen K. PT, EdD, NCS; Lubeski, Jennifer M. DPT; Viverito, Jaclyn M. DPT
Quinnipiac University, Hamden, Connecticut.
Address correspondence to: Kathleen K. Zettergren, PT, EdD, NCS, Quinnipiac University, 275 Mt Carmel Ave, Hamden, CT 06518 (Kathleen.firstname.lastname@example.org).
This research was conducted in partial fulfillment of the doctoral degree in physical therapy, Quinnipiac University, Hamden, Connecticut. Both Ms Lubeski and Ms Viverito provided assistance with acquisition, analysis, and interpretation of data; drafting of the article; and final approval of the version to be published.
This research was partially funded by a Quinnipiac University Summer Research Grant.
Objectives: To examine the impact of an 8-week therapeutic yoga program on postural control, mobility, rising from the floor, and gait speed in community-living older adults.
Design: Pretest/posttest design with an experimental group and an age-matched control group. Changes over time (pretest to posttest) were evaluated in all outcome measures using paired t tests.
Setting: The yoga class was performed at a local continuing care retirement community. All testing was performed at the site. Control-subject pretests and posttests were performed at a second continuing care retirement community.
Participants: Eight research participants, all women, with a mean age of 84 (4.6) years, 8 control participants, 5 women and 3 men, aged 81.3 (4.9) years. Research participants were naive to yoga.
Interventions: An 8-week, 80-minute, biweekly Kripalu yoga class designed specifically for community-dwelling older adults.
Main Outcome Measures: Postural control (Berg Balance Scale), mobility (time to rise from the floor to standing, Timed Up and Go), gait (usual and fast gait speed), and balance confidence (Activities-Specific Balance Scale).
Results: All subjects attended at least 10 of the 16 classes (62% attendance). Posttest differences were found for yoga participants in balance scores (P < .003) and fast walking speed (P < .031). No other significant changes were noted.
Conclusions: Improvements in postural control as measured by the Berg Balance Scale and gait as measured by fast gait speed indicate that research subjects benefited from the yoga intervention. The yoga program designed for this study included the activities of standing, sitting, and lying on the floor. Therefore, subjects perform activities during yoga that can improve postural control, mobility, and gait speed.
As many as 33% of aging adults (aged 65 years and older) who live independently in the community will experience at least 1 unexpected fall every year.1,2 In this population, falls represent the third leading cause of deaths by injury3 and are the most likely cause of fractures.4 Falls represent the single leading cause of death by injury for those aged 77 years and older.3 Risk of falling increases substantially with each subsequent fall.5
To facilitate assessment of the risk of falling, researchers categorize fall risk factors as either intrinsic or extrinsic. Extrinsic risk factors include environmental factors such as uneven walking surfaces, obstacles within the environment, and poor lighting.2 Intrinsic risk factors include physiological factors common in later life such as arthritis, depression, orthostasis, impaired cognition, impaired balance and gait, decreased muscle strength, decreased flexibility, and polypharmacy, among others.6,7–10 Tinetti6 suggests that reduction of a single risk factor reduces overall risk of falling. Strategies that lead to improvement in strength,9,11–14 functional gait, and static and dynamic standing balance have been shown to reduce incidence of falls.2,14 Group-based therapeutic exercise has been able to reduce risk of falling and fall occurrence in community-dwelling aging adults.6,12,15–18
Buchner et al19 evaluated the impact of strength and/or endurance training on balance and falls in a randomized clinical trial of 100 subjects aged 68 to 85 years. Exercise groups (strength, endurance, and both strength and endurance) met in 1-hour sessions, 3 times weekly, for 24 to 25 weeks. At posttest, those in the strength and strength plus endurance groups showed a 40% to 118% increase in 1 repetition maximum in all muscle groups tested. Over the period of the study, 60% of control subjects fell, as compared with 42% of those in the exercise groups. The authors concluded that supervised, community-based exercise programs can reduce falls in the aging adult population.19
Many aging adults have access to community-based exercise programs. Well-designed programs that incorporate strength and balance training may contribute to prevention or reduction of falls. Activities incorporating complementary and alternative therapies, including yoga, are becoming more popular alternatives to traditional exercise in the United States.20,21 Professionals recommend complementary and alternative therapies to their aging clients to maintain independence and improve mobility.22 Yoga represents one of the top-10 most commonly used alternative therapies21 available to community-dwelling aging adults.
Researchers have examined the effects of yoga on cardiorespiratory function,23–25 anxiety and depression,26–28 stress,28 low back pain,29,30 and quality of life.31 General results indicate that yoga reduces anxiety, stress, symptoms of depression, and low back pain.26,29,30 Yoga also improves quality of life as measured by the 36-Item Short Form Health Survey, with improvements on 5 subscales: vitality/energy, fatigue, physical role, bodily pain, and social functioning.31 Bastille and Gill-Body32 examined 4 subjects recovering from stroke using a single-case study design. Each participant completed a 90-minute yoga class, 2 times per week for 8 weeks, in their homes. All subjects had clinically meaningful improvements on Berg Balance Scale (BBS) scores.32
DiBenedetto et al33 studied 19 healthy adults older than 62 years participating in a 90-minute, biweekly, Iyengar-based yoga class over an 8-week period. Subjects also completed 20 minutes of yoga on days in which they did not attend the program. Peak hip extension and stride length at self-selected gait speed, which typically decline with age, improved after intervention. The work of DiBenedetto et al33 provides early evidence that a group-based yoga class can improve gait in aging adults. Hip extension range of motion and stride length have been identified as physical impairments that predispose aging adults to falls.34,35 Improvements in gait and balance reduce the risk of falling in aging adults.2,14 Health care providers who develop interventions for aging adults would benefit from research that evaluates the effectiveness of yoga on impairments that limit mobility, postural control, and gait.
To date, there appear to be no studies evaluating the effects of yoga on postural control, mobility, speed of gait, and balance confidence. Investigation of yoga as a method for general exercise and strategy to improve mobility, postural control, speed of gait, and balance confidence is warranted. The purpose of this study was to examine the effects of a biweekly therapeutic group yoga program on performance of commonly used measures of functional balance and gait in a group of community-dwelling aging adults as compared with age-matched controls.
Healthy adults aged 65 years and older were recruited from 2 local continuing care retirement communities. Recruitment began in February of 2007 with outcome assessments completed in December of 2007. Twenty residents attended an initial lunch and informational session at one of the facilities and 14 agreed to participate. Age-matched controls were then recruited from the second facility.
Eligibility for the study was determined by several factors. All subjects were aged 65 years or older, able to maintain static standing with eyes open, arms crossed, and feet bare independently for 30 seconds without a device. In addition, subjects presented with intact lower extremity sensation, visual acuity 20/20 (with or without correction), and Mini-Mental State Examination (MMSE) score of 24 or more. Exclusion criteria included history of neurologic pathology, recent (within the past 3 years) orthopedic surgery of the lower extremities, serious visual impairments (ie, cataracts) or being diagnosed as legally blind, and a preferred gait speed more than 4.4 ft/s for men or 4.2 ft/s for women.36,37 The study was approved by the Human Subjects Review Board at Quinnipiac University. Prospective participants were provided with an informed consent form, which was explained to the participants and then signed by the participants.
Fourteen subjects (all women) were initially screened and deemed eligible to participate in the yoga program. Eight subjects, with mean age of 84 (4.6) years completed a biweekly yoga program over an 8-week period. Research subjects were allowed to continue with any ongoing physical activities but were not given additional home exercises. Subjects were also asked not to attend other yoga classes.
Eight control subjects, with mean age 81 (4.9) years were recruited from a second facility after the completion of the yoga intervention. These subjects continued with their usual activity but did not attend yoga classes.
All prospective participants were screened for medical problems via an intake questionnaire, and then the MMSE was administered. Individuals who scored 24 or more on the MMSE then completed the Activities-Specific Balance Scale with assistance. The primary investigator (PI) administered all intake questionnaires and survey forms. After filling out intake forms, both yoga participants and control subjects underwent a series of tests and measures: monofilament testing for lower extremity sensation, the 4-Square Step Test, the BBS, and the Timed Up and Go (TUG) test. Subjects were timed while moving from the floor to standing, and gait speed was determined (mean of 2 trials at self-selected speed and mean of 2 trials while walking fast). The tests were administered by physical therapists with 5 or more years of experience who were trained in the use of the stated mobility measures. A single physical therapist performed the same test for all subjects. Tests were performed in random order. The PI was blinded to results of all physical measures. After 8 weeks, both yoga participants and control subjects were retested on all measures except the MMSE.
Yoga by the sessions consisted of 80 minutes of yoga based on the Kripalu style of yoga.38 Sessions included pranayama (breathing exercises) and body awareness (10 minutes); warm-up activities (10 minutes); asana (physical poses) in the supine, seated, and standing positions (50 minutes); meditation; and shavasana (corpse pose) (10 minutes). All yoga classes were taught by the PI, a physical therapist, and a certified Kripalu yoga teacher. Classes were specifically designed for older adults with impaired mobility and postural control. Props and modifications were provided to participants when needed. Common props included a chair to modify standing poses, use of the wall during some standing poses, and use of a yoga block when necessary.
Each session began with seated centering and pranayama. The specific pranayamas used were diaphragmatic breathing and the full yogic breath (3-part breath).38,39 After pranayama, a 10-minute warm-up was performed. Warm-up activities included seated shoulder circles, wrist rolls, standing heel and toe raises, abduction, and heel walking. Yoga postures used in the program included tadasana (mountain pose), virabhadrasana I (warrior 1), virabhadrasana II (warrior 2), trikonoasana (triangle pose), vrikshasana (tree pose) (Figures 1 and 2). Standing poses were chosen for their ability to increase strength in the quadriceps, tibialis anterior, and gastrocnemius to target potential gait and balance deficits. Subjects were encouraged to engage the ankle dorsiflexors by lifting their toes during mountain pose. Vrikshasna (tree pose) requires the subject to attain and maintain unilateral standing. Although subjects were allowed to use a chair for support during this pose, they were also encouraged to try the pose without support. Other poses included adho mukha shavanasana (downward facing dog) (Figures 3 and 4) to increase upper extremity weight bearing and promote stretching of the gastrocnemius/soleus groups and hamstrings, setu bandhasana (bridge pose) for overall lower extremity strengthening and baddakonasana (bound-angle pose) to increase hip range of motion. Subjects also performed sphinx pose, salabasana (locust pose), and supta matsyendrasana (supine spinal twist) and ended each session with relaxation in shavasana (corpse pose).
Data were analyzed using Statistical Package for the Social Sciences, version 16 (SPSS, Inc., Chicago, Illinois). Paired t tests were used to assess the following outcome variables: 4-Square Step Test, BBS, Activities-Specific Balance Scale, timed floor-to-stand, and gait speed (self-selected and fast).
Fourteen subjects began the initial yoga program with 8 subjects (all women) completing the full 8-week program. Two subjects dropped out, stating that the program was too difficult; 2 subjects dropped out because of other extensive time commitments, and 2 subjects dropped out because of medical reasons.
Subjects who completed the study did not differ significantly from subjects who dropped out of the study in age or other measures. Independent t tests revealed that control subjects did not differ significantly from the yoga group in age or measures of postural control, mobility, rising from the floor, or gait speed. However, the control subjects included 3 men and 5 women, as opposed to the research subjects who were all women (Table 1).
All subjects scored 24 or more on the MMSE and appreciated at least the 4.31 filament, bilaterally, on the plantar surface of the great toe, fifth metatarsal head, and heel. All subjects were independent in rising from the floor at the time of initial pretesting. Yoga participants attended at least 10 of the 16 classes (62% attendance). Five of the 8 yoga participants attended 12 of the 16 classes (75% attendance). No yoga participant attended 100% of classes.
Paired t tests revealed an improvement in the yoga group on postural control as measured by BBS (t = 4.51, P = .0003) and fast gait speed (t = 2.69, P = .03). Although time to rise from the floor and TUG also decreased (a clinically relevant finding), these changes did not reach statistical significance. Neither the yoga group nor the control group showed significant changes in any other measures at posttest (Table 2).
This study examined the effects of yoga on postural control, mobility, and walking in community-living older adults. Yoga participants reported positive experiences with the intervention program. The results of the study support that yoga improved several measures of postural control, mobility, and walking.
The BBS was used to measure postural control. Paired t tests revealed a statistically significant difference of the BBS scores of yoga participants after 8 weeks of yoga. Although statistical significance was reached, the minimal detectable change (MDC) was not reached. Donoghue et al40 report that the MDC for BBS scores in aging adults is 5.7. Minimal detectable change is the smallest amount of change that reflects a true difference above measurement error.41 According to Donoghue et al,40 to report a true difference in BBS scores, beyond measurement error, subjects must demonstrate at least a 5.7-point change in BBS scores. Yoga participant scores increased an average of 3.5 points on the BBS. Several factors may have contributed to this small change in BBS scores. Average BBS scores for subjects aged 80 to 89 years have been reported as 46.3 (4.2).42 Yoga participants averaged 51.5 at pretest, indicating above-average BBS scores for their age range. A ceiling effect may have prevented measurement of the full array of functional improvement. The small sample size and high initial BBS scores may also have affected the ability to show MDC in BBS scores after 8 weeks of yoga. Similar findings occurred with both the TUG and Rise from Floor test.
Both the TUG and the ability to arise from the floor were used to measure mobility. Yoga participants scored an average of 9.38 (3.21) seconds on pretest TUG. Lusardi and Chui43 report average TUG scores for healthy older adults aged 80 to 89 years as 9.5 (3.2) seconds. Yoga participants decreased their TUG scores by an average of 0.97 seconds. This change was not statistically significance. The MDC for TUG scores has been reported as 1 to 2.49 seconds.43 Therefore, yoga participants began the study with average TUG scores and, after 8 weeks of yoga, decreased these scores by 0.97 seconds. Although not statistically significant, this does approach the MDC of 1 to 2.49 seconds. The small sample size may have prevented detection of statistical significance. A longer intervention of yoga may also continue to decrease TUG scores. As subjects continue to experience improved mobility through yoga, they may also experience a decrease in TUG scores.
Yoga participants decreased their time to rise from the floor by an average of 2.42 seconds. This change was not statistically significant. Although the test has previously been described in the literature,44–46 no data are available regarding typical time to complete the task, the MDC, or the MDIC. Knutzen et al44 found that lower extremity strength is correlated with the ability to rise from the floor. Murphy et al46 and Tinetti et al47 found that subjects with a history of a fall had difficulty rising from the floor. However, Galvao and Taaffe48 reported that a 20-week progressive resistance-training program did not improve the floor-to-stand time. Because the sample size was small, we may not have had sufficient power to evaluate whether participation in an 8-week yoga program contributes to improved ability to rise from the floor (P < .09). Strengthening of the upper and lower extremities and practice of the task during yoga may have contributed to this improvement. The ability to rise from the floor has been related to reduced injury in individuals who fall47 and is therefore an important skill to both study and train. More data are needed on this variable.
Paired t tests revealed a statistically significant difference in fast walking speed of yoga participants after 8 weeks of yoga. Adults aged 80 to 89 years have an average fast walking speed of 0.88 m/s.42 Yoga participants began the program with a fast gait speed of 1.38 m/s and ended with an average speed of 1.55 m/s. The change from pretest to posttest is 0.17 m/s. The MDC of fast gait speed in adults aged 80 to 89 years has been reported as 0.18 m/s.43 As with BBS score, fast gait speed scores showed a statistically significant difference, indicating an increase in fast gait speed and a change that did approach the published MDC. Slow-walking speed has been shown to be a risk factor for recurrent falls49 with known participants with history of falls having slower self-selected walking speed than those who do not have a history of falls.50 Because subjects' ability to walk fast increased, we propose that yoga may be an effective means to improve walking speed and perhaps reduce risk of falling and improve mobility.
The use of complementary and alternative therapies is on the rise in the United States20,21 with up to 7.5% of the adult population participating in yoga.20 Studies examining the impact of yoga on body functions and structures have concentrated on the upper extremities,51–53 lower extremity hip extension,33 or general fitness.44 To date, no studies appear to have examined the effects of yoga on balance and risk of falling in community-dwelling older adults. The yoga program used was specifically designed for older adults at risk for a fall. Postures chosen targeted all major lower extremity muscles identified as important to prevent falls.54–58
The program was extremely well received and, at the conclusion of the study, was continued at the participating facility. Research subject 6 stated at the end of the program, “I feel a lot better since yoga, both in the house and going out.” Research subject 2 declared during the posttest, “I can do tree pose now!” Yoga may provide a safe and effective means of exercise to improve balance and posture and reduce the risk of falling in community-dwelling older adults.
This study had a number of limitations that may have impacted on results. The sample used was a sample of convenience, rather than a randomly selected sample. The sample size was small, and as a result, power to determine difference in function on posttest was likely insufficient. Replication using this study's methods, with a larger sample randomized into yoga and control groups, would be more effective in determining the impact of yoga on functional performance. Yoga sessions were limited to only 8 weeks; there is no clear evidence for determining dose, frequency, and duration for the most effective yoga program. A longer postexercise follow-up would be needed to determine whether improvement in function was stable over time. Other measures of function and gait associated with risk of falls (eg, postural sway, quality of gait, overall lower extremity strength, and sit-to-stand time) might be used. Because yoga impacts both body and mind, indicators of quality of life and/or fear of falling may show changes even when physical measures do not. Qualitative inquiry may reveal the benefits of yoga more accurately.
Subjects who participated in the study demonstrated significant improvement on the BBS and fast gait speed. Time to rise from the floor decreased, suggesting improvement in function during this task. This preliminary study suggests that yoga may be a safe and effective alternative intervention for aging adults. Replication in a larger, controlled study is warranted to clarify the efficacy of yoga in improving postural control and reducing risk of falling in community-dwelling older adults.
The authors certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on them or on any organization with which we are associated and, if applicable, we certify that all financial and material support for this research (eg, NIH or NHS grants) and work are clearly identified in the title page of the manuscript.
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balance; older adults; risk of falling; yoga
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