Yoga can help improve balance and increase confidence in older adults who are at risk for fall-related injury. The key to successful outcomes is to modify traditional poses in ways that accommodate both physical limitations and fears in this patient population.
By Arlene Schmid, PhD, OTR, Marieke Van Puymbroeck, PhD, CTRS, and Nancy L. Schalk, BA, CYTh
Balance diminishes with age. As we age, we are less able to maintain balance, or postural stability, during standing or walking and we increasingly rely on feedback from vestibular, visual, and proprioceptive systems. However, these systems too are less efficient in older adults. 1-3 Decreased balance is related to increased levels of unsteadiness.4 As balance decreases and postural sway increases, older adults are more likely to fall.
Falls are a significant concern for the older adult population. A fall is generally considered an unexpected event leading an individual to come to the ground, floor or lower level.5 Falls are the leading cause of injurious death for those over the age of 65 in the United States.6 At least 30% of those over 65 and residing in the community fall annually; 10% to 20% fall two or more times.7 After age 80, annual fall rates increase to 50%.8, 9 The elderly who fall are more likely to sustain fall related trauma and serious injury and demonstrate increased health care utilization compared to young fallers.10 Fall related trauma is more likely to be the cause of death in older fallers11 and fall related injuries are costly. It is projected that by 2020 direct and indirect costs for fall related injuries will be more than $55 billion.12
A review of the literature indicates fall risks are considered multi-factorial, with more than 400 documented risk factors.13 However, recently, Tinetti and Kumar documented balance impairments, prior falls, strength, gait, and some medications as the most potent risk factors for falls.14 Fear of falling is also a commonly documented risk factor and consequence of falls.15-17 Falls self-efficacy, or balance confidence, and fear of falling are separate constructs and researchers have found that falls self-efficacy may work as a mediator to manage fear of falling.18 Importantly, 20% to 55% of those who report a fear of falling also report that they have decreased their physical activity as a result.8, 19-21
Delbaere and colleagues examined the “vicious” cycle that exists between falls and fear of falling.22 Those with fear of falling decrease physical activity and movement, causing them to lose balance and strength, which puts them at greater risk for falls. Thus it is important to develop programs to improve balance, manage fear of falling, and decrease falls.
A recent review indicates strong evidence in support of physical exercise programs to manage balance and falls.23 A type of physical activity not included in that review, however, is yoga. Yoga may benefit older adults who have decreased balance and who are therefore at risk for falls and/or the development of fear of falling.
Yoga is an Eastern medicine that may have potential for improving the lives of older adults. As typically practiced in this country, yoga may be considered exercise or physical activity, and includes postures (asanas), meditation, and breathing (pranayama) performed to enhance relaxation, flexibility, balance, strength, overall fitness, and mental and emotional well-being. Although the exact mechanism in unknown, evidence suggests that the combination of postures and breathing are most beneficial when utilized together.24
Because of the mind-body component, it is thought that yoga, and other complementary and alternative therapies, is more therapeutic than traditional exercise.25-29 This is likely related to the active engagement of both the mind and the body. During yoga, the mind is encouraged to focus on what is occurring in the body and where the body is in space, increasing both awareness and proprioception. Its practice has been associated with increased muscle strength and endurance, flexibility, and cardiopulmonary endurance.30, 31 YIn terms of reducing FoF and addressing balance, Hatha yoga includes improvement of physical strength and flexibility, due to lengthening of major muscle groups.
Yoga and Balance
It is likely that yoga, with its gentle movements, can address known fall risk factors (poor balance, impaired mobility, reduced strength and flexibility) and focus on increased awareness and proprioception, resulting in decreased fear of falling and improved balance in older adults. The mind-body interaction of yoga is likely to help manage anxiety related to fear of falling and improve balance by helping to improve strength and flexibility. There is also a documented relationship between balance and range of motion and flexibility at the hip (extension, internal rotation, and abduction) and ankle (dorsiflexion and gastrocnemius length) in older adults.32 It is likely that yoga can improve the hip and ankle range of motion and flexibility at these joints.
While there are many yoga postures to choose from, we have focused on a few for improving hip and ankle range of motion. With the older adult population who have some level of disability or limited abilities, we do not use typical standing postures, rather we focus on improving balance by improving core stability through sitting postures and in the supported lunge.
Specifically, for hip flexibility, we use seated modified versions of pigeon pose (eka pada rajakapotasana), with first steps simply to include crossing the legs at the ankle, and moving up from there. Slowly and over time we focus on increasing the range of motion to allow the foot of one leg to rest on the knee of the other leg. We also work on general hip flexion in sitting by using the arms to lift the leg. Anecdotally, we see improvement in hip flexion within the first few weeks of the intervention.
We work on ankle range of motion while sitting by doing ankle movements (circles, toe pointing, etc) with the legs in extension and flexion or while in pigeon. Once individuals feel comfortable, we move into a standing lunge with the support of a wall or chair to increase safety and decrease the risk of falls. We chose to include lunges because of the movement and stretching involved at both the ankles and the hip. We also use the standing lunge to help improve overall balance in standing.
There is currently limited evidence to support yoga to improve balance and manage fear of falling and falls in older adults, but the existing evidence is encouraging. Research completed in young adults supports the idea that yoga does improve balance. For example Hart and Tracy studied young adults (mean age 29) and found that in those who completed yoga, balance improved by 228% for the experimental group, while in the control group balance did not change.33 Others found that young adults (mean age 33) who were randomized to a yoga group improved significantly in one-leg standing balance, as well as improved proprioception and ankle strength.34
Previous studies have demonstrated a relationship between yoga and falls and yoga and balance.33, 35-38 While this research has been completed and has demonstrated positive results, all of these studies have been small pilot studies or case studies. For instance, Schmid et al found improved balance and fear of falling in adults over the age of 65 after a bi-weekly 12-week yoga intervention.38 Interestingly, participants also reported fewer physical constraints. However, while study participants felt that they improved and enjoyed the program, only 14 people completed the study.
Tatum et al included 45 older adults and focused the yoga intervention on balance and improving the participants’ ability to transfer from the floor.39 Subjects attended one 90-minute yoga session per week and were also given a 30-minute video with which to practice at home for five days per week. This group found improved ability to transfer from the floor and perception of general fitness. Improved balance was found to the most important contributor to floor transfer ability.
Zettergreen and colleagues included nine older women who lived in the community in a study to assess the effectiveness of a four-week yoga intervention, including one supervised session per week plus a home therapy program.40 They found improvement in balance in those who did yoga, whereas a control group of four subjects who did no yoga demonstrated no change in balance. Falls efficacy did not change significantly in either group.
A small cross-sectional study included people already doing yoga, or other varies forms of exercise.41 They found that those doing yoga or Tai Chi had significantly better balance and ability to complete the Timed Stand to Floor Test and reach test than those not engaging in exercise. Also, Brown et al studied the impact of yoga on balance and balance confidence in 27 older adults from a retirement community.35 Their results also supported the use of yoga to improve balance and confidence.
In summary, published results indicate positive effects of yoga on balance, fear of falling, and falls. It is likely that balance is improved due to improved flexibility and range of motion at the hip and ankle. It should also be noted that there is great disparity between dosing of yoga for each of these studies. Studies ranged from four to 12 weeks of yoga with frequency ranging from one time per week to daily sessions. Dosing is an important part of establishing the benefits of any physical intervention. Further research needs to be funded and completed to include large randomized trials to better understand the direct benefits of yoga on balance, fear of falling, and falls in older adults.
It is likely that posture modifications will be used in the older adult population. Many older adults refuse to move to the floor to perform postures out of fear that they will not be able get off of the floor. We are finding that some of our older adults with stroke are willing to move to the floor, but only after we have spent time building a trusting relationship and after they have already seen positive changes and successfully completed other seated and standing postures.
We recommend that a slow progression of yoga practice needs to be initiated with most older adults. For example, we recommend beginning with only seated poses, and slowly moving into static standing postures, and then increase movement, and possibly move to the floor. When possible, the use of a strap, or towel, will help people get into postures that would otherwise be too challenging. Straps are particularly helpful to improve leg movements such as crossing the legs and hamstring stretches while in the seated position. We also include breathing exercises that can be done while seated or during other movements. This helps to calm the individuals but also may positively affect blood flow in the brain. Such exercises can be done by almost anyone at any time.
Yoga and other populations
As yoga research progresses, we will see yoga studies focused on different diagnostic populations. For instance, there is some research on people with Parkinson’s Disease that is demonstrating yoga may be effective for this group.42, 43 There is also substantial work in the cancer population.
We have begun to focus our own research efforts on balance, falls, and fear of falling in individuals who have sustained a stroke. We are currently running a randomized trial of an eight-week, twice-weekly yoga program for adults with stroke. We are focusing on hip and ankle range of motion and flexibility to help manage balance, fear of falling, and falls. Because we have previously found fear of falling, activity restriction, and anxiety to be related in stroke,44, 45 we are also including breathing and stress reduction exercises. At this time we are focused on chair-based and some standing postures due to the medical complexity of these study participants. However, we are attempting to increase the number of standing postures and will also begin to move into floor postures as possible, with a focus on safe floor transfers.
While we are still completing the intervention and data collection, the subjective comments from the participants are very encouraging. For instance, one participant has stated that the yoga balance therapy program was the best thing he had done for himself since his stroke. Yoga will likely be part of our next fall prevention intervention.
Because there is a significant amount of work on blood pressure and yoga, and because hypertension and orthostasis are risk factors for falls, we have also focused on blood pressure reduction in this trial. There are more than 40 studies of yoga as a mechanism to lower blood pressure; including 24 controlled studies.46 Recent reviews indicate evidence to support the use of yoga in multiple populations (healthy subjects as well as patients with hypertension, cardiovascular disease, or type 2 diabetes) to manage stroke risk factors, including blood pressure, stress, depression, fatigue, sleep, insulin resistance, glucose tolerance, and lipids.46-49
The use of yoga practice to manage blood pressure was first demonstrated to be effective in 1973, in a study where yoga was added to blood pressure management/medication for 20 people with uncontrolled hypertension.50 Five subjects discontinued all blood pressure medication and seven were able to reduce medication requirements. Furthermore, overall blood pressure was significantly reduced from 160/102 to 134/86. In 1975, Patel and colleagues completed a randomized controlled trial of yoga to manage blood pressure and found differences between blood pressure readings taken at the beginning and end of every session.51 They found significant changes in pre and post intervention blood pressure for those in the yoga intervention: 168/100 to 141/84 (systolic p<0.005, diastolic p<0.001).
The benefits of yoga for many populations is likely numerous. However it is necessary to demonstrate the effectiveness of yoga with high quality research before it becomes part of everyday practice.
The limited existing research supports the use of yoga as part of balance therapy programming. We would encourage therapists to use yoga as part of therapy only after being trained in yoga postures and modification to reduce adverse events. Most importantly, there is a need for further research on yoga as it is becoming more mainstream in healthcare. This will lead to policy changes to help make yoga more readily available to the masses, improve billing procedures for the therapeutic use of yoga, and a better establishment of the evidence for yoga in healthcare.
Arlene Schmid, PhD, OTR, is an assistant professor in the department of occupational therapy at Indiana University Purdue University at Indianapolis (IUPUI) and a core investigator at the Roudebush VAMC Center of Excellence in Indianapolis. She is also affiliated with the Regenstrief Institute, and Indiana University Center for Aging Research, both in Indianapolis. Marieke Van Puymbroeck, PhD, CTRS, is an assistant professor in the department of recreation, park, and tourism studies at Indiana University in Bloomington. Nancy L. Schalk, BA, CYTh, is a certified yoga therapist and the director of the therapeutic yoga program at the Indiana University Simon Cancer Center in Indianapolis, IN.
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