Yoga exercise intervention improves balance control and prevents falls in seniors aged 65+
Article Category: Original scientific article
Published Online: Mar 21, 2022
Page range: 85 - 92
Received: Jul 14, 2021
Accepted: Jan 20, 2022
DOI: https://doi.org/10.2478/sjph-2022-0012
Keywords
© 2022 National Institute of Public Health, Slovenia, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
The European Union defines the term ‘senior’ as a person aged 65 years and above with rights to a pension, social security and healthcare (1, 2). Seniors aged 65+ are at higher risk of falling, which can be potentially devastating for maintaining independence (3, 4). Fear of falling and the consequent loss of independence are a common challenge among seniors (5). Longer life expectancy will result in a greater proportion of seniors suffering from locomotor impairment. More comprehensive rehabilitation and training practice is therefore necessary (6). From this point of view, chair-based yoga interventions could be an effective rehabilitation strategy among the elderly (7). Balance development exercises have been shown to reduce the risk of falls. Effective and safe exercises may reverse frailty in the elderly, can increase strength and power, improve balance and reduce fall incidence. From this perspective, exercise interventions should become a daily routine among the elderly (8). A lack of movement, i.e. ‘hypokinetic syndrome’, manifests itself in impulsiveness, irritability, a reduced ability to concentrate, and increased anxiety and depression (8, 9). A common problem among the elderly is fear and anxiety about the deterioration of balance control and the consequent loss of independence (10). Whereas the limbic system is involved in conscious activity, the amygdala is involved in the emotional evaluation of input information and emotion-driven behaviour, including social interaction. The information that passes from the parabrachial pathway to the amygdala brings information about pain, including information from the skin and internal organs, with the accompaniment of emotions associated with pain, anxiety, phobia, etc. (11). The efferent pathways from the amygdala go mainly to the hypothalamus, which is the site of stress transfers to the autonomic, immune, endocrine and humoral management systems. The ageing of the hypacus, eye defects and other sensory disorders lead to somatic imbalances and therefore emotional imbalances, with all the negative effects these have on social interaction. Balance intervention, which involves the leaching of endorphins and enkephalins, has a positive effect on amygdala function and, secondarily, a positive impact not only on somatic balance but also on emotional and social balance (12, 13). A combination of function-oriented challenges with balance control that stimulates the sensory and neuromuscular control mechanism, as well as muscle strength, body flexibility and joint mobility, may be realised among the elderly through the application of a short-term yoga-based intervention (14, 15). The results of a four-week yoga-based intervention indicated that participants’ body fat percentage and systolic blood pressure decreased, and that balance and the range of motion of shoulder flexion and abduction improved. It is important to note that other similar exercise intervention studies for the elderly showed that the positive effects on balance development and body composition (16, 17) lasted only four weeks. The objective is to analyse and compare changes in static, dynamic and total balance scores, changes in body composition and social indices as effects of yoga-based intervention. Based on the objective of the study, the hypothesis is that ‘applied four-week intensive intervention based on yoga exercises leads to a significant improvement in the total balance score among seniors in the experimental group’.
A study involved 500 seniors aged 65+ (234 men with an average age of 74.5 SD±7.74; 266 women with an average age of 76.9 SD±7.23), selected by stratified randomised sampling from all the regions of the Czech Republic. The participants were grouped into the experimental group (n=162; 122 males, age average 72.8, SD±7.44, median 71 (67.0, 78.0); 140 females, age average 76.1, SD±8.03, median 76.0 (69.0, 81.0) and the control group (n=112 males, age average 72.2, SD±6.54, median 71.0 (67.0, 74.0); 126 females, age average 72.9, SD±7.32, median 70.5 (67.0, 76.0). During randomising, similar numbers of participants for both samples were retained in the homes or centres at which the participants were based.
All the participants signed up for the research voluntarily, which they confirmed by signing a consent form in the medical record. Before they signed the form, all participants were given information on the method, measurements and exercise itself. However, participants were not informed of the purpose of the research. The research institution’s ethics committee expressed its full agreement and indicated that the research conformed with the requirements stipulated in the Declaration of Helsinki. The exclusion criteria for the involvement of participants in the experimental study were determined according to the White Book on Physical and Rehabilitation Medicine in Europe (18) and were as follows: (i) human-to-human infectious diseases and bacillus carriers, (ii) all acute-stage diseases and conditions in which destabilisation of health status can be reasonably expected, (iii) cachexia of various aetiologies, (iv) malignant tumours, (v) active attacks or phases of psychoses and mental disorders with asocial manifestations or with reduced communication, (vi) 2nd and 3rd degree of urinary incontinence and stool incontinence.
The pre/post examination started with the medical anamnesis provided by a physician, followed by a bioimpedance assessment of body composition provided by an anthropologist. Subsequently, a balance exam using the Tinetti Balance Assessment Tool was provided. Each participant then completed an SF-36 survey with the assistance of a researcher. The survey was used according to its official manual (19).
The medical anamnesis protocol was performed by a physician (20) using a standardised protocol specifically focused on the current health status of seniors and on drugs, injuries and surgeries. Finally, the physician made a medical recommendation as to whether to include an individual in the study.
Body height was measured using the Tanita Leicester Height Measure device (Invicta Plastics, Leicester, United Kingdom) with an accuracy of 0.1 cm. The InBody 230 tetrapolar multi-frequency bioelectrical impedance device (InBody, Seoul, South Korea) was used to assess body weight, BMI, body fat percentage and total muscle mass (21), performed at the same time and under the same conditions, in underwear, barefoot, standing upright.
The Tinetti Balance Assessment Tool was used to measure the static, dynamic and total balance score (18). The static balance test is assessed on the basis of the observation of an individual’s somatic behaviour during sitting and standing positions and the changes to that behaviour, which are defined by nine items. Dynamic balance is judged by eight items that involve characteristics of gait manifested in an individual during a walk across a 4.5 m walkway, first at their usual pace, then at a rapid pace. The maximum total scores are 16 and 12 points for static balance and dynamic balance (gait), respectively. The higher the score, the better the performance. The Tinetti Balance Assessment Tool reported good to excellent intra- and inter-rater reliability, an intraclass correlation coefficient > .80, and medium sensitivity and specificity to identify fallers (22, 23).
SF-36 represents a valid and reliable indicator of overall health status and is used globally. It comprises 36 items, including social health and general health perceptions. The survey has a reliability of r=.65 to .94 across the scales, with a median of .85, resulting in very good internal consistency and item-discriminant validity (24).
The experimental group’s four-week intervention was focused on body posture, balance control, flexibility, muscle strength, breathing and relaxation. The exercises were carried out using the Yoga in Daily Life System (25), without contraindications to the elderly (Sarvahita Asanas), while sitting on a chair or standing by a chair. They included: pulling arms up, turning the shoulders, leg stretch, hamstring stretch, shoulder stretch, finger stretch, toe stretch, bottom lift, knee bends, forward bend, balance exercises standing behind a chair with support, standing on one leg, diaphragm breathing, modified ‘cat pose’ breathing, ‘lion grimace’ breathing, exercises to relax the muscles of the face and neck, and vibration exercises with vibrational effects in the diaphragm, lung and brain areas. Once per week, a main training lesson lasting 90 minutes was conducted with 10–12 participants under the guidance of a coach and two assistants. After this training, each participant received an educational sheet for the specific week. They featured the following mottos: Week 1 ‘You are never alone’, Week 2 ‘Change is always possible’, Week 3 ‘Movement is life’, Week 4 ‘Enjoy life and every moment’ (26). During the week, participants repeated the learned exercises daily for 30 minutes under the supervision of the assistants. The participants were present and supervised at the care centre on a daily basis. During the intervention, the control group had their usual daily regime at the same care centres.
ANOVA model consisting of the factor Subject (explaining inter-individual variability), the between-subject factor Group (experimental vs. control groups), and the within-subject factor Stage (before intervention vs. after intervention). Before the ANOVA processing, the original data was transformed by means of a power transformation to attain symmetrical distribution and constant variance (homoscedasticity) in data and residuals (27). Data distribution symmetry and data homogeneity were checked as described elsewhere (28). The statistical software Statgraphics Centurion 18 from Statgraphics Technologies, Inc. (The Plains, Maryland, USA) was used for the calculations.
A good randomised experiment is an essential tool for testing the efficacy of any intervention. We therefore tried to generate comparable intervention groups that would be alike in all important aspects (except for the intervention). The basic values of the subjects assigned to the control and experimental groups are presented according to sex, i.e. basic values of monitored men (Table 1) and monitored women (Table 2). The values presented displayed a high level of accordance before the intervention in the monitored groups.
Basal values (shown as median with quartiles) of monitored groups of male seniors (N=234; Experimental group: 122 males; Control group: 112 males).
| Variable | Control group | Experimental group | p-value Mann-Whitney test |
|---|---|---|---|
| 71 (67.1, 74.3) | 73 (68, 80) | 0.186 | |
| 174 (170, 178) | 174 (170, 180) | 0.790 | |
| 82 (73.8, 94.3) | 85 (77.8, 90) | 0.575 | |
| 26 (22, 35) | 26 (22, 33.3) | 0.838 | |
| 34 (29, 39) | 35 (30, 40) | 0.388 | |
| 14.5 (11, 16) | 14 (10.8, 15) | 0.394 | |
| 10 (9, 12) | 10 (8, 12) | 0.195 | |
| 25 (21, 27) | 24 (18, 27) | 0.280 |
Basal values (shown as median with quartiles) of monitored groups of female seniors (N=266; Experimental group: 140 females; Control group: 126 females).
| ID | KS | ES | p-valuew |
|---|---|---|---|
| 70 (67, 76) | 73 (68, 80) | 0.034 | |
| 164 (160, 168) | 163 (158, 166) | 0.409 | |
| 73 (64, 81.2) | 71.4 (62.5, 83) | 0.487 | |
| 33.5 (30, 42) | 35 (27, 45.2) | 0.959 | |
| 30 (25.3, 32.1) | 30 (24, 32) | 0.528 | |
| 14 (11, 16) | 15 (10, 16) | 0.872 | |
| 10.5 (9, 12) | 11 (8, 12) | 0.800 | |
| 24 (21, 27.8) | 25 (18, 28) | 0.823 |
In both, i.e. among the monitored males and females, the intervention effect on balance was found to be significant for the performance of the static and dynamic balance test, p<.001. The Group × Measurement interaction (p<.001) showed significant improvements of static and dynamic balance in the experimental group compared to the control group of monitored male and female seniors. A significant positive effect of the intervention was also indicated by the Group × Measurement interaction for the total balance score (p<.001), see Tables 3 and 4.
Significant differences in pre-post changes (significant Group × Stage interaction) in the Tinetti balance test scores, body composition and social indicators after the balance-exercise intervention when a comparison is made between the experimental and control groups of monitored male seniors (N=234; experimental group: 122 males; control group: 112 males).
| Variable | Experiment | ANOVA, factors and interaction | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Stage |
Group |
Pre-Post |
Group × Stage |
Subj(Group) |
|||||||||||
| Pre | Post | ||||||||||||||
| 13.8 (13.7, 13.9) | 13.9 (13.8, 14) | 30.2 | <0.001 | 0.17 | 29.7 | <0.001 | 0.167 | 11.1 | 0.001 | 0.07 | 46.1 | <0.001 | 0.979 | ||
| 13.2 (13.2, 13.3) | 13.8 (13.7, 13.8) | ||||||||||||||
| 10.4 (10.3, 10.5) | 10.3 (10.3, 10.4) | 32 | <0.001 | 0.173 | 6.9 | 0.01 | 0.043 | 13.3 < | 0.001 | 0.08 | 34.2 | <0.001 | 0.972 | ||
| 9.9 (9.83, 9.96) | 10.2 (10.2, 10.3) | ||||||||||||||
| 24.1 (24, 24.3) | 24.2 (24.1, 24.3) | 61 | <0.001 | 0.29 | 24.5 | <0.001 | 0.141 | 18.1 < | 0.001 | 0.108 | 66.2 | <0.001 | 0.985 | ||
| 23.1 (23, 23.2) | 23.9 (23.8, 24) | ||||||||||||||
| 26.6 (26.3, 26.9) | 26.9 (26.6, 27.2) | 14.3 | <0.001 | 0.113 | 14.9 | <0.001 | 0.117 | 30.5 < | 0.001 | 0.214 | 60.3 | <0.001 | 0.984 | ||
| 26.9 (26.7, 27.2) | 25.2 (25, 25.5) | ||||||||||||||
| 33.9 (33.8, 34.1) | 33.9 (33.7, 34) | 243.8 | <0.001 | 0.683 | 40.9 | <0.001 | 0.266 | 48.7 < | 0.001 | 0.301 | 155.6 | <0.001 | 0.994 | ||
| 34.8 (34.7, 34.9) | 36.1 (36, 36.2) | ||||||||||||||
| 2.96 (2.95, 2.98) | 2.93 (2.92, 2.94) | 61.8 | <0.001 | 0.288 | 3.6 | 0.061 | 0.023 | 7.3 | 0.008 | 0.046 | 19 | <0.001 | 0.95 | ||
| 2.88 (2.87, 2.89) | 2.89 (2.88, 2.9) | ||||||||||||||
| 1.85 (1.83, 1.87) | 1.82 (1.8, 1.85) | 20 | <0.001 | 0.115 | 0.2 | 0.624 | <0.01 | 4.8 | 0.03 | 0.03 | 14.5 | <0.001 | 0.936 | ||
| 1.75 (1.73, 1.77) | 1.79 (1.77, 1.81) | ||||||||||||||
| 1.85 (1.83, 1.87) | 1.85 (1.83, 1.87) | 54.5 | <0.001 | 0.263 | 4.7 | 0.032 | 0.03 | 4.7 | 0.032 | 0.03 | 19.7 | <0.001 | 0.952 | ||
| 1.72 (1.7, 1.73) | 1.78 (1.76, 1.8) | ||||||||||||||
| 2.94 (2.85, 3.04) | 2.64 (2.55, 2.73) | 27.5 | <0.001 | 0.153 | 7.3 | 0.008 | 0.046 | 5.8 | 0.018 | 0.036 | 11.9 | <0.001 | 0.923 | ||
| 2.49 (2.42, 2.56) | 2.47 (2.4, 2.54) | ||||||||||||||
| 3.08 (2.98, 3.18) | 2.83 (2.73, 2.92) | 38 | <0.001 | 0.199 | 2.1 | 0.151 | 0.013 | 6.6 | 0.012 | 0.041 | 11.7 | <0.001 | 0.922 | ||
| 2.53 (2.45, 2.6) | 2.6 (2.52, 2.67) | ||||||||||||||
F, p, and ηp2 represent F-statistics, p-values, and effect sizes, respectively. For the effect size: 0.01 ~ small effect, 0.06 ~ medium effect,
>0.14 ~ large effect.
*Retransformed mean with 95% confidence intervals
Significant differences in pre-post changes (significant Group × Pre-Post interaction) in the Tinetti balance test scores, body composition and social indicators after the balance-exercise intervention when a comparison is made between the experimental and control groups of monitored female seniors (N=266; experimental group: 140 females; control group: 126 females).
| Variable | Experiment | ANOVA, factors and interaction | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Stage |
Group |
Pre-Post |
Group × Stage |
Subj( Group) |
|||||||||||
| Pre | Post | ||||||||||||||
| 13.5 (13.4, 13.5) | 13.6 (13.5, 13.6) | 16.9 | <0.001 | 0.063 | 23.3 | <0.001 | 0.084 | 0.7 | 0.404 | <0.01 | 161.5 | <0.001 | 0.994 | ||
| 13.6 (13.5, 13.6) | 13.7 (13.7, 13.8) | ||||||||||||||
| 10.4 (10.3, 10.4) | 10.4 (10.4, 10.5) | <0.1 | 0.906 | <0.01 | 11.5 | <0.001 | 0.041 | 4.9 | 0.027 | 0.018 | 38.4 | <0.001 | 0.975 | ||
| 10.3 (10.2, 10.3) | 10.5 (10.5, 10.5) | ||||||||||||||
| 23.8 (23.7, 23.9) | 24 (23.9, 24.1) | 4.6 | 0.032 | 0.017 | 35.5 | <0.001 | 0.116 | 9.7 | 0.002 | 0.035 | 84 | <0.001 | 0.988 | ||
| 23.8 (23.7, 23.8) | 24.3 (24.3, 24.4) | ||||||||||||||
| 35 (34.8, 35.3) | 34.9 (34.6, 35.1) | 29.5 | <0.001 | 0.121 | 47.2 | <0.001 | 0.18 | 34.3 | <0.001 | 0.138 | 95.8 | <0.001 | 0.99 | ||
| 35.1 (34.9, 35.3) | 33.2 (33.1, 33.4) | ||||||||||||||
| 29.2 (29.1, 29.3) | 29.5 (29.4, 29.6) | 2.2 | 0.142 | 0.01 | 102.6 | <0.001 | 0.328 | 32.4 | <0.001 | 0.134 | 106 | <0.001 | 0.991 | ||
| 29 (28.9, 29) | 30 (29.9, 30.1) | ||||||||||||||
| 1.76 (1.74, 1.78) | 1.73 (1.71, 1.75) | 2.9 | 0.089 | 0.011 | <0.1 | 0.94 | <0.01 | 5.2 | 0.023 | 0.019 | 15.2 | <0.001 | 0.938 | ||
| 1.71 (1.69, 1.73) | 1.74 (1.73, 1.76) | ||||||||||||||
| 2.57 (2.54, 2.59) | 2.55 (2.52, 2.57) | 57.3 | <0.001 | 0.175 | 1.9 | 0.173 | <0.01 | 6.7 | 0.01 | 0.024 | 30.3 | <0.001 | 0.968 | ||
| 2.4 (2.38, 2.42) | 2.47 (2.45, 2.49) | ||||||||||||||
| 4.44 (4.37, 4.52) | 4.33 (4.25, 4.4) | 0.5 | 0.489 | <0.01 | <0.1 | 0.907 | <0.01 | 5.7 | 0.018 | 0.021 | 9.8 | <0.001 | 0.907 | ||
| 4.36 (4.31, 4.42) | 4.47 (4.42, 4.52) | ||||||||||||||
| 5.32 (5.26, 5.38) | 5.25 (5.19, 5.31) | 6.2 | 0.013 | 0.022 | 0.1 | 0.819 | <0.01 | 4.5 | 0.034 | 0.017 | 11.9 | <0.001 | 0.923 | ||
| 5.15 (5.1, 5.19) | 5.24 (5.19, 5.28) | ||||||||||||||
| 3.66 (3.6, 3.72) | 3.55 (3.49, 3.62) | 22.9 | <0.001 | 0.078 | 0.3 | 0.596 | <0.01 | 4.3 | 0.039 | 0.016 | 13.5 | <0.001 | 0.931 | ||
| 3.76 (3.72, 3.81) | 3.82 (3.78, 3.87) | ||||||||||||||
F, p, and ηp2 represent F-statistics, p-values, and effect sizes, respectively. For the effect size: 0.01 ~ small effect, 0.06 ~ medium effect,
>0.14 ~ large effect.
*Retransformed mean with 95% confidence intervals
On the basis of statistical analyses of body composition, the data verified that both, i.e. male and female seniors in the experimental group, had more muscle mass after the intervention compared to males and female seniors in the control group. The intervention led to a significant improvement in two body composition measurements. In the experimental group, the body fat percentage decreased among the monitored seniors (males by 1.7%, females by 1.9%) while in the control group, the median of this variable increased (males by 0.3%, females by 0.15%). The analysis showed that the measurement had a significant effect on body fat percentage, p<.001, with a large effect size.
In seniors in the experimental group, total muscle mass increased (males by median 1.3 kg, females by median 1.03 kg) after the intervention, while seniors in the control group remained at the same mean values (Tables 3 and 4).
The post-intervention results of the social indicators among monitored male seniors showed that the intervention had significant positive effects on self-help abilities (Table 3). The yoga-based intervention led to positive changes in performance and in concentration on work and other activities, and in emotional balance, i.e. feelings of calmness and happiness (Table 3). By contrast, there were no psychosocial changes among male seniors in the control group.
From the statistical analyses of the SF-36 survey, the females in the experimental group displayed higher post-intervention emotional and social progress. Compared to females in the control group, they enjoyed a reduction in fatigue, nervousness, sadness, and depression (see Table 4), thereby increasing their potential for social interaction. Progress in physical fitness, such as ‘climbing one staircase’, also indicates a significant improvement in independence and possible social interactions among female seniors in the experimental group (Table 4).
Postural control is essential for active daily activities and is an integral part of elderly independence and mobility. The personal, social and economic burden of health complications caused by falls and balance problems among seniors is still an issue globally, as highlighted by authors (29, 30) in the USA, EU and Canada within the context of chronic diseases and disabilities. As our findings show, the Tinetti Balance Assessment Tool may be used to evaluate the risk of falls as well as the measures and interventions taken to prevent falls and to develop gait in the elderly. This is consistent with the statement that gait ability prior to fracture had a significant impact on an elderly person’s ability to survive after suffering a hip fracture (31).
It is therefore possible to recommend regular yoga-based exercises for seniors aged 65+, as it helps to reduce the number of fall-related cases. The results of the present study demonstrate that yoga-based interventions can have significant positive effects, and can therefore be recommended to seniors aged 65+ to help them develop postural control in a relatively short time. In this study, a short-term yoga-based intervention also led to an improvement in the dynamic balance of monitored seniors aged 65+, and can therefore help optimise walking. These results are consistent with the results of other studies that have highlighted the positive effects of yoga-based intervention and that make similar recommendations for improving balance confidence and stability among older people after a six-week multimodal balance-enhancing exercise programme (32, 33).
It seems plausible that regular yoga training can support anabolic processes in the elderly. This statement is consistent with the results of the studies (34, 35). Accordingly, it can be argued that men aged 65+ can respond positively to exercise intervention, including reductions in body fat and increases in muscle mass, because of testosterone. However, we should also address the increase in muscle mass and fat loss in women aged 65+. The authors (36, 37) state that routine yoga exercises affect the use of protein throughout the body in healthy older women. After yoga-based intervention, the participants had lower body fat and higher muscle mass than those who did not practise yoga; moreover, they also tended to have better balance. Practising yoga can improve protein utilisation and lead to the maintenance of muscle mass in females later in life, when muscle loss is common.
The study looks at the social effects within the context of positive changes in balance control and body composition. The results are consistent with the results of studies (38, 39) that highlight the psychosocial health benefits of yoga-based interventions. The present study is unique in that it examines the effects after a four-week intervention.
There were also positive increases in subjective feelings of happiness, vitality, energy and social balance. The results may inspire future research applications in the field of kinanthropology, healthcare and social care. Applied yoga techniques, which promote total balance performance in seniors aged 65+ in a simple and effective way, may be the subject of further research, with a particular focus on intersexual interactions with balance improvement.
The findings should be interpreted with caution. Further validation of the research is required. Although the results are promising and the number of subjects was relatively high, they may not be representative of the general senior public at the age under observation. Another limitation of the present study was the potential influence of the actual state of anxiety on the performance of static and dynamic balance. However, it should be emphasised that measurements using the Tinetti tool are adequate for the seniors monitored.
The significant positive improvements in static and dynamic balance, with significant body integration, including decreases in fat and increases in muscle mass, point to the importance of simple yoga exercises, which could constitute a safe physical activity for the over 65s.
Chair-yoga based intervention represents a financially and spatially undemanding, physically well manageable, feasible, well-tolerated, and safe intervention, and one that may help seniors to develop the balance condition necessary for mobility and social interactions. Using yoga-based intervention to increase social balance is a highly relevant topic for the over 65s.
The findings of the study are new, and provide a basis for future research interventions to promote active ageing.