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The Effect of Yoga on Balance and Fear of Falling in Older Adults
PM R 8 (2016) 145-151
www.pmrjournal.org
Original Research
The Effect of Yoga on Balance and Fear of Falling in Older Adults Narjes Nick, MSc, Peyman Petramfar, MD, Fariba Ghodsbin, MSc, Sareh Keshavarzi, PhD, Iran Jahanbin, MSc
Abstract Objective: To determine the effect of yoga on balance and fear of falling in older adults. Design: Randomized controlled trial. Setting: Jahandidegan Center in Shiraz, southern Iran. Participants: Forty persons (17 men and 23 women) between the ages of 60-74 years with a Modified Falls Efficacy Scale (MFES) score <8 and a Berg Balance Scale (BBS) score <45. After completing the MFES questionnaire and BBS measurement, the participants were divided into intervention and control groups. BBS measurement and the MFES questionnaire were completed again immediately after the intervention. Intervention: The intervention group participated in 2 yoga practice sessions per week for 8 weeks. The control group received no intervention. Main Outcome Measurements: Fear of falling was measured with the MFES and balance was measured with the BBS. Results: We found significant changes in both variables (P < .0001). Mean differences before and after the intervention for the BBS for yoga and control groups were 10.19 and e1.16, respectively. Mean differences before and after the intervention for the MFES for yoga and control groups were 1.62 and e0.21, respectively. Conclusion: Yoga is a potential intervention to reduce fear of falling and improve balance in older adults.
Introduction One third of people aged 65 years and older fall each year [1]. Falls are a major cause of serious injuries in older adults, leading to hospitalization, nursing home admission, and even death [2]. The number of falls and severity of injury increase with age [3]. The Centers for Disease Control and Prevention (CDC) estimates that the costs of fall-related injuries are expected to reach $54.9 billion by 2020 in the United States [4]. Balance deficits are one of the fall risk factors in community-dwelling older adults [5]. Belgen et al [6] assessed 50 people with chronic effects of stroke and reported that subjects with a history of multiple falls had poorer balance and more fear of falling (FOF) than persons who did not fall and first-time fallers. Thus, with respect to the American Geriatrics Society guideline, balance deficits should be evaluated in older adults reporting a fall [7]. Adequate balance control is required to perform mobility-related activities such as standing while doing manual tasks, rising from a chair, and walking safely
during daily life. One third to one half of the population older than 65 years experience difficulty with their balance or ambulation [8]. In older adults, falling is a multidimensional problem. Therefore, a person’s risk of falling cannot be assessed only by physical risk factors; other important aspects such as FOF must be considered [9]. FOF exists among 30% of older adults who have never experienced falling, and the rate is double in older adults who have experienced at least one fall [10]. FOF is linked to reduced participation in daily activities, lower quality of life, increased risk of institutionalization, depression, decreased social activity, and physical weakness [11]. Falls and FOF are interrelated problems, with each being a risk factor for the other [12,13]. Falls can be prevented [14,15]. A previous study showed that exercise can improve physical abilities in frail adults [16]. Barnett et al [17] showed that participation in weekly group exercises along with exercise at home improves balance and decreases the rate of falling among older adults. Yoga is a popular mind and body
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practice that concentrates on meditation, breathing, and postures [18]. The control of posture practice in yoga involves stretch and balance while maintaining a stable sitting or standing position [19]. Yoga may also have psychosocial benefits through prevention and control of common health and emotional problems linked with aging [16]. A recent evidence-based study showed the effectiveness of yoga for psychosocial and physical functioning in older adults [9]. Yoga also can improve gait speed [20] and awareness and self-esteem [21]. Therefore, it is possible to improve balance and FOF, 2 known fall risk factors, in older adults through yoga exercise. Yoga is simple to learn and can be practiced by older adults, even those who are ill or disabled. A growing body of research suggests that yoga-based interventions are readily accepted by older adults and may improve health in this population [22]. Schmid et al [23] evaluated the effect of a 12-week yoga intervention on FOF and balance in older adults and found that yoga decreased FOF by 6% and increased static balance by 4%. In this study, the change in FOF was a positive trend, although not significant. Compared with the study by Schmid et al [23], our study has a larger sample size, includes people with low Berg Balance Scale (BBS) and Modified Falls Efficacy Scale (MFES) scores, and involves both intervention (yoga) and control groups, which closely match in terms of starting MFES and BBS scores, gender, and age. The purpose of this study was to examine the effect of yoga on balance and FOF in older adults with low BBS and MFES scores. The hypothesis for this study was that the participants undergoing the yoga intervention would show significant improvement in balance and FOF. Methods A preliminary pilot study was carried out to determine the validity and reliability of the MFES [24] for Iranian older adults. The original questionnaire was translated into Persian by 3 professors of the Nursing and Midwifery School of Shiraz University of Medical Sciences, Shiraz, southern Iran. The preliminary Persian version was translated back into English by another translator. To ensure that the questionnaire was clear, the researcher discussed it with 2 older adults separately. Then, as approved by the Shiraz Welfare Organization, 30 people aged 60-74 years who were willing to participate in the pilot study were chosen from Shiraz Jahandidegan Center to complete the questionnaire twice within a time span of 3 weeks. Cronbach’s a and test-retest reliability were then calculated. Subjects All participants were older adults who visited the Jahandidegan Center in Shiraz, Iran. This Center provides activities and classes for elderly persons.
Recruitment began in March 2011 and ended in June 2011. The researcher took part in the center’s entertainment classes and introduced the research program, asking for willing participants. Inclusion criteria were being 60-74 years of age, having an MFES score <8 [25] and a BBS score <45, and being willing to participate in the study. Of the 120 older adults who were considered, 40 met the inclusion criteria. We excluded persons who had cognitive or neuromuscular diseases, advanced osteoporosis, or dizziness. We also excluded persons who were taking anticonvulsant, narcoleptic, or sedative drugs, used walking aids, attended yoga classes outside the research study, or experienced acute pain that prevented them from doing the exercises. The 40 participants were asked to sign a consent form. They were then randomly assigned to either the intervention (yoga) or control group, using the block randomization method size 4. The block randomization was used only on the basis of 2 groups (yoga and control). The participant flow diagram is shown in Figure 1. The sample size was calculated using the Power Analysis and Sample Size (PASS) program (NCSS, Kaysville, UT). The sample size was calculated as 16 in each group based on the following variables: mean difference ¼ 15, standard deviation (SD) 1 ¼ 15.4, SD 2 ¼ 14.5, a ¼ 0.05, and power ¼ 80% [26]. Anticipating an attrition rate of 20%, we chose to include 20 persons in each group. This study was approved by the Ethics Committee of the Shiraz University of Medical Sciences. Measures The participants were asked to complete the MFES and demographic data questionnaires. The MFES, a 14-item activity questionnaire, is an expanded version of the original 10-item activity Falls Efficacy Scale [24]. The MFES includes outdoor activities not covered by the Falls Efficacy Scale. Each item is scored on a 10-point visual analogue scale; 0 ¼ not confident/not sure at all, 5 ¼ fairly confident/fairly sure, and 10 ¼ completely confident/completely sure. The MFES score range for each individual is 0-10, with 10 being a perfect score. To obtain each subject’s MFES score, the ratings (possible range ¼ 0-140) are totaled and divided by 14. Scores <8 indicate fear of falling, and scores 8 indicate lack of fear [25]. The MFES has excellent reliability (intraclass correlation coefficients [ICC] ¼ 0.93) and internal consistency (0.95) [25]. In our pilot study, Cronbach’s a coefficient for the MFES questionnaire was 0.92, and the performed testeretest had appropriate reliability (r ¼ 0.99). A research assistant measured the postural balance of each participant using the BBS. The BBS is a 14-item scale designed to measure balance in older adults. Each item is scored on a 5-point scale from 0-4 (0 indicates the lowest level of function and 4 the highest level of function), with 56 being the highest total score.
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Figure 1. Participant flow diagram.
The Cronbach’s a of the BBS is 0.96. The interrater and intrarater reliability measurements for the test as a whole are 0.98 and 0.99, respectively [27]. The BBS has excellent reliability (ICC ¼ 0.997) and is internally consistent (0.921) for older Iranian adults. The maximum score on this scale is 56, the minimum is 0, and scores below 45 show a risk of falling [28]. A study by Thorbahn and Newton [29] showed that older adults with a BBS score >45 were less likely to fall compared with persons scoring <45. Therefore, we selected people with BBS scores <45. After 8 weeks, participants of both groups completed the MFES questionnaire, and the research assistant also measured the postural balance of each participant using the BBS. Intervention In the current study, the Hatha yoga style was used with an emphasis on Pavanamuktasana and balance movements. A certified yoga instructor led the 1-hour yoga classes twice a week for 8 weeks. Each class began with Paranayama (breath exercises) for 10 minutes and then continued with stretching and orthopedic warming exercises for 10 minutes. The main activities, Pavanamuktasana and balance movements, were then performed for 30 minutes (see Appendix 1 for
a list of the postures used in the classes). Each session concluded with savasana (ie, lying on the back, spreading the arms and legs 45 , shutting the eyes, and taking long, deep breaths) and relaxation for 10 minutes. The instructor led the participants in performing the exercises. The participants were encouraged to work within their individual abilities (eg, they were asked to keep the duration of exercises within their abilities and to try to increase the duration throughout the sessions) and use aids to keep their balance, such as leaning against a wall. After the completion of each posture the participants were asked to be aware of which groups of muscles were contracting, which were being stretched, and which were being used to keep the body steady and balanced. Two trained staff members were always present during the classes to minimize the chance of falling. Deep breathing was emphasized during all postures. All participants were in the same yoga class, and all sessions were completed in a large room near the Jahandidegan Center. Analysis Statistical analysis consisted of descriptive and inferential statistics. Results of descriptive statistics were expressed as mean value SDs for continuous variables and as frequencies and percentages for
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Table 1 Subject characteristics Yoga Group (N ¼ 20; 9 Men, 11 Women)
Control Group (N ¼ 19; 8 Men, 11 Women)
Characteristic
Mean
SD
Values MinimumMaximum
Age, y Weight, kg Height, m BMI
68 67.40 1.61 25.76
4.87 14.03 0.07 4.42
60-74 43-103 1.51-1.77 17.67-35.64
Mean
SD
Values MinimumMaximum
P Value*
68.79 68.89 1.60 27.02
4.81 14.18 0.07 5.40
60-74 50-94 1.50-1.75 19.05-39.13
.61 .74 .43 .42
SD ¼ standard deviation; BMI ¼ body mass index. * P value for gender ¼ .096.
categorical variables. Group comparison on gender was performed using the c2 test. Mean differences for age, height, weight, and body mass index (BMI) between the 2 groups were then calculated and tested by independent sample t-test. Changes in MFES and BBS scores were compared with an independent sample t-test. In all analyses, P < .05 was considered to be statistically significant. Analyses were performed using SPSS software, version 19 (IBM Corp, Armonk, NY). This study was registered in the Iranian registry of clinical trials (clinical trial registration number IRCT201109127531N1). Results Among 120 eligible older adults, 40 met the inclusion criteria and were assigned to either the intervention or control group. One participant in the control group was excluded because this person did not complete the questionnaires after 8 weeks. There were no dropouts in the intervention group. In the yoga group, all participants attended all sessions. The participants’ age, weight, height, and BMI scores are presented in Table 1. We found no significant difference between groups with respect to gender (P ¼ .96, c2 test, Table 1). Comparisons of baseline characteristics (mean age, height, weight, and BMI score) between the 2 groups are presented in Table 1. There was no difference between groups with respect to baseline characteristics. The mean score for FOF (P ¼ .33) and BBS (P ¼ .69) before the intervention was similar between the 2 groups. We found a significant difference in the change in MFES scores between the 2 groups (P < .0001,
Table 2 and Figure 2). We also found a significant difference in mean BBS scores after the intervention between the 2 groups (P < .0001, Table 2 and Figure 3). Discussion This study examined the effect of yoga on postural balance and FOF in older adults with low BBS and MFES scores. The results of the study show that yoga improves postural balance and reduces FOF in older adults. The BBS was used to measure balance. The independent sample t-test revealed a significant difference between BBS scores of 2 groups after the intervention. This result is consistent with findings of other studies [20,30]. Schmid et al [23] found an improvement in balance score, although the difference was not significant. This discrepancy may be due to the differences in sample size and the fact that our study included people with lower BBS scores. Also, in the study by Schmid et al [23], participants did not have the balance deficit as measured by the BBS at baseline. Morris [26] found that yoga exercises do not have a significant effect on the balance of older people. However, Morris recommended further studies to examine the effect of yoga on the risk factors of falling in older adults. The different results may be due to a smaller sample size and use of a different yoga style. In comparison, the type of yoga and positions used in the current study were different than those used in the studies by Schmid et al [23] and Morris [26]. In the current study, the Hatha yoga style was used with an emphasis on Pavanamukt asana and balance movements. Hatha yoga is associated with
Table 2 Comparison of variables before and after the intervention in the 2 groups BBS
Difference Before and After the Intervention
MFES
Pre-BBS
Post-BBS
Pre-MFES
Post-MFES
BBS
MFES
Group
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
n
Yoga Control
39.14 39.80
5.49 4.40
49.33 38.63
4.80 5.96
5.84 5.34
1.65 1.54
7.46 5.13
1.29 1.69
10.19* 1.16*
3.26 3.17
1.62* 0.21*
1.49 0.88
20 19
BBS ¼ Berg Balance Scale; MFES ¼ modifies falls efficacy scale; SD ¼ standard deviation. * The between-group differences for both outcomes are significant at P < .0001.
N. Nick et al. / PM R 8 (2016) 145-151
Figure 2. MFES scores of 2 study groups before and after intervention.
postures that increase flexibility. In Hatha yoga, the postures are integrated with pranayama, a focused state of attention and awareness, and meditation [31]. Pavanamuktasana are breath-coordinated movements that are safe, rhythmic, and stretch repetitive. These practices mobilize the joints and strengthen the periarticular muscles [32]. This exercise is suitable for releasing muscular tension. It also helps to keep the body balanced and stress free during the day [33]. As a preparatory practice, it is beneficial because it opens up all the major joints and relaxes the muscles of the body [34]. Zettergren et al [20] reported that yoga improved balance in older adults, but this improvement was not
Figure 3. BBS scores of 2 study groups before and after intervention.
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above the minimal detectable change. Minimal detectable change was defined as a change of 4 points for persons who had an initial score within the range of 45-56, 5 points if they had an initial score within the range of 35-44, 7 points if they had an initial score within the range of 25-34, and 5 points if their initial score was within the range of 0-24 on the BBS [35]. In the current study, the improvement found in all yoga participants on the BBS was above the minimal detectable change. It should be noted that the BBS score for the yoga group was raised to a level above the “likely to fall” score (45) as previously mentioned in the Methods section. One of the reasons for falls in older adults is balance impairment and reduced muscle strength [5,36,37]. Yoga requires the stretching of major muscle groups to improve physical strength and flexibility [23]. Yoga increases the extension of hip and step length and decreases anterior pelvic tilt [11]. It increases the body’s flexibility and power and plays an important role in preventing falls [18]. Zettergren et al [20] reported that because the subjects demonstrated the ability to walk faster, doing more yoga exercises may be effective for improving walking speed and might reduce the risk of falling and improve mobility. The independent sample t-test revealed a significant difference between the MFES scores of intervention and control groups after yoga sessions. This finding is in line with findings of Schmidt et al [23] and Morris [26]. It is worth noting that we initially involved people with low MFES scores in our study. As previously mentioned in the Methods section, scores <8 in the MFES questionnaire indicate FOF. Although we achieved significant results, the mean value (after the intervention) of FOF scores in the yoga group did not exceed 8. In the yoga group, only 7 participants reached a score of 8 after the intervention, probably because FOF is related not only to physical characteristics and falling history but also to mental and cognitive factors [23]. Therefore, more yoga sessions may be needed to further affect FOF, and we encourage more research regarding this issue. We did not have any dropouts during the intervention because the participants were willing to attend the classes. This study has some limitations. First, the study results cannot be generalized to people of all ages because the study sample was limited to adults aged 60-74 years. Second, one needs to study the long-term effects of yoga classes by following up with the participants and studying their behavior for at least 3 to 6 months after the intervention. Third, this program requires a certified yoga instructor. Forth, the results of this study apply to those who meet the inclusion criteria. Finally, this was an unblinded study in which the control group received no intervention of any kind. Thus some of the observed improvement in the yoga group could be due to a
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placebo effect or a desire to please the investigators, for example. Conclusion This study revealed that yoga can improve balance and decrease FOF, which are associated with fall risk in older adults. Thus yoga can address known fall risk factors in older adults and can be used in fall prevention programs. Health care professionals are vital links for recognizing the fall risk factors in older people and referring them to appropriate interventions. More research is needed to better identify the effects of yoga intervention on FOF in older adults. Acknowledgment We express sincere appreciation to those who helped us with this study, including the director and staff members of the Jahandidegan center and the study participants, whose commitment was admirable. This study was done in partial fulfillment of the requirements for the MSc degree awarded to Narjes Nick. References 1. Centers for Disease Control and Prevention. STEADIdolder adult fall prevention. Available at: http://www.cdc.gov/steadi/index. html. Accessed July 15, 2015. 2. American Geriatrics Society. Updated American Geriatrics Society/ British Geriatrics Society clinical practice guideline for prevention of falls in older persons and recommendations. Available at: http://geriatricscareonline.org/ProductAbstract/updated-americangeriatrics-societybritish-geriatrics-society-clinical-practice-guidelinefor-prevention-of-falls-in-older-persons-and-recommendations/ CL014. Accessed July 15, 2015. 3. American Academy of Orthopaedic Surgeons. Guidelines for preventing falls. Available at: http://orthoinfo.aaos.org/topic.cfm? topic¼A00135. Accessed July 15, 2015. 4. Centers for Disease Control and Prevention. Costs of falls among older adults. Available at: http://www.cdc.gov/ HomeandRecreationalSafety/Falls/fallcost.html. Accessed July 15, 2015. 5. Muir SW, Berg K, Chesworth B, Klar N, Speechley M. Quantifying the magnitude of risk for balance impairment on falls in community-dwelling older adults: A systematic review and metaanalysis. J Clin Epidemiol 2010;63:389-406. 6. Belgen B, Beninato M, Sullivan PE, Narielwalla K. The association of balance capacity and falls self-efficacy with history of falling in community-dwelling people with chronic stroke. Arch Phys Med Rehabil 2006;87:554-561. 7. American Geriatrics Society. 2010 AGS/BGS clinical practice guideline: Prevention of falls in older persons: Summary of recommendations. Available at: http://www.americangeriatrics. org/files/documents/health_care_pros/Falls.Summary.Guide.pdf. Accessed July 15, 2015. 8. Zijlstra A, Mancini M, Chiari L, Zijlstra W. Biofeedback for training balance and mobility tasks in older populations: A systematic review. J Neuroeng Rehabil 2010;7:58. 9. Lopes K, Costa D, Santos L, Castro D, Bastone A. Prevalence of fear of falling among a population of older adults and its correlation with mobility, dynamic balance, risk and history of falls. Rev Bras Fisioter 2009;13:223-229.
10. Legters K. Fear of falling. Phys Ther 2002;82:264-272. 11. Boyd R, Stevens JA. Falls and fear of falling: Burden, beliefs and behaviours. Age Ageing 2009;38:423-428. 12. Fletcher PC, Hirdes JP. Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing 2004;33:273-279. 13. Scheffer AC, Schuurmans MJ, van Dijk N. van Der Hooft T, De Rooij SE. Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 2008;37:19-24. 14. Kannus P, Sieva ¨nen H, Palvanen M, Ja ¨rvinen T, Parkkari J. Prevention of falls and consequent injuries in elderly people. Lancet 2005;366:1885-1893. 15. Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ 2002;325:128. 16. 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 Complement Med 2012;18:902-917. 17. Barnett A, Smith B, Lord SR, Williams M, Baumand A. Communitybased group exercise improves balance and reduces falls in at-risk older people: A randomised controlled trial. Age Ageing 2003;32: 407-414. 18. 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. 19. Miyamura M, Nishimura K, Ishida K, Katayama K, Shimaoka M, Hiruta S. Is man able to breathe once a minute for an hour? The effect of yoga respiration on blood gases. Jpn J Physiol 2002;52: 313-316. 20. Zettergren KK, Lubeski JM, Viverito JM. Effects of a yoga program on postural control, mobility, and gait speed in community-living older adults: A pilot study. J Geriatr Phys Ther 2011;34:88-94. 21. Sethi JK, Nagendra HR, Sham Ganpat T. Yoga improves attention and self-esteem in underprivileged girl student. J Educ Health Promot 2013;2:55. 22. DiBenedetto M, Innes KE, Taylor AG, et al. Effect of a gentle Iyengar yoga program on gait in the elderly: An exploratory study. Arch Phys Med Rehabil 2005;86:1830-1837. 23. Schmid AA, Van Puymbroeck M, Koceja DM. Effect of a 12-week yoga intervention on fear of falling and balance in older adults: A pilot study. Arch Phys Med Rehabil 2010;91:576-583. 24. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol 1990;45:P239-P243. 25. Hill KD, Schwarz JA, Kalogeropoulos AJ, Gibson SJ. Fear of falling revisited. Arch Phys Med Rehabil 1996;77:1025-1029. 26. Morris DM. An evaluation of yoga for the reduction of fall risk factors in older adults 2. [dissertation]. Florida: Florida State University: Tallahassee, FL; 2008. 27. Berg K. Measuring balance in the elderly: Preliminary development of an instrument. Physiother Can 1989;41:304-311. 28. Davatgaran Taghipoor K. Translation and Validation of a Persian Version of Berg Balance Scale in an Iranian Elderly Population [master’s thesis]. Tehran: Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences; 2006. 29. Thorbahn LDB, Newton RA. Use of the Berg Balance Test to predict falls in elderly persons. Phys Ther 1996;76:576-583. 30. 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;68:1068-1075. 31. Oken B. Complementary Therapies in Neurology. Boston, MA: Parthenon Publishing Group; 2005. 32. Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effect of integrated yoga therapy on pain, morning stiffness and anxiety in osteoarthritis of the knee joint: A randomized control study. Int J Yoga 2012;5:28.
N. Nick et al. / PM R 8 (2016) 145-151 33. Shankar G. Role of Yogic attitudes for mental wellbeing. World J Psychother 2011;1:91. 34. Saraswati SS, Hiti JK. Asana Pranayama Mudra Bandha Bihar, India. Munger, India: Yoga Publication Trust; 1996. 35. Donoghue D, Stokes EK. How much change is true change? The minimum detectable change of the Berg Balance Scale in elderly people. J Rehabil Med 2009;41:343-346.
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36. Bird ML, Pittaway JK, Cuisick I, Rattray M, Ahuja KD. Age-related changes in physical fall risk factors: Results from a 3 year follow-up of community dwelling older adults in Tasmania, Australia. Int J Environ Res Public Health 2013;10:5989-5997. 37. Woollacott MH, Shumway-Cook A. Changes in posture control across the life spanda systems approach. Phys Ther 1990;70: 799-807.
Disclosure N.N. Community Health Department, Fatemeh (P.B.U.H) School of Nursing & Midwifery, Shiraz University of Medical Sciences, Namazi Square, Shiraz, Iran Disclosure: nothing to disclose
S.K. Epidemiology Department, School of Health and Nutrition, Shiraz University of Medical Sciences, Shiraz, Iran Disclosure: nothing to disclose
P.P. Department of Neurology, Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Disclosure: nothing to disclose
I.J. Community Health Department, Fatemeh (P.B.U.H) School of Nursing & Midwifery, Shiraz University of Medical Sciences, Namazi Square, Shiraz, Iran. Address correspondence to: I.J.; e-mail: [email protected] Disclosure: nothing to disclose
F.G. Community Health Department, Fatemeh (P.B.U.H) School of Nursing & Midwifery, Shiraz University of Medical Sciences, Namazi Square, Shiraz, Iran Disclosure: nothing to disclose
Supported by Shiraz University of Medical Sciences, Shiraz, Iran. grant number: 89-5519 Submitted for publication January 14, 2015; accepted June 28, 2015.
Appendix 1. Names of the Asanas (Poses) Used in the Yoga Intervention Sessions Talasana (Palm Tree Pose) Ardha titaliasana (Butterfly Pose) Poorna titaliasana (Butterfly Pose) Chaki chalasana (running a grinding wheel) Kushta chakrasana Nauka sanchalanasana (rowing the boat) Tadsana (Mountain Pose) Savasana (Corpse Pose) Locust Pose Virkshasana (Tree Pose)
Bhujangasana (Cobra Pose) Akarna Dhanurasana (Shooting Bow Pose) Trikonasana (Triangle Pose) Dandasana (Staff Pose or Stick Pose) Half Boat Pose Janu Sirsasana (Head to Knee Pose) Virabhardrasana (Warrior) Yoga eye exercise Lizard Pose Matsyasana (Fish Pose) Sphinx Pose Savasana Pranayama
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Original Research
The Effect of Yoga on Balance and Fear of Falling in Older Adults Narjes Nick, MSc, Peyman Petramfar, MD, Fariba Ghodsbin, MSc, Sareh Keshavarzi, PhD, Iran Jahanbin, MSc
Abstract Objective: To determine the effect of yoga on balance and fear of falling in older adults. Design: Randomized controlled trial. Setting: Jahandidegan Center in Shiraz, southern Iran. Participants: Forty persons (17 men and 23 women) between the ages of 60-74 years with a Modified Falls Efficacy Scale (MFES) score <8 and a Berg Balance Scale (BBS) score <45. After completing the MFES questionnaire and BBS measurement, the participants were divided into intervention and control groups. BBS measurement and the MFES questionnaire were completed again immediately after the intervention. Intervention: The intervention group participated in 2 yoga practice sessions per week for 8 weeks. The control group received no intervention. Main Outcome Measurements: Fear of falling was measured with the MFES and balance was measured with the BBS. Results: We found significant changes in both variables (P < .0001). Mean differences before and after the intervention for the BBS for yoga and control groups were 10.19 and e1.16, respectively. Mean differences before and after the intervention for the MFES for yoga and control groups were 1.62 and e0.21, respectively. Conclusion: Yoga is a potential intervention to reduce fear of falling and improve balance in older adults.
Introduction One third of people aged 65 years and older fall each year [1]. Falls are a major cause of serious injuries in older adults, leading to hospitalization, nursing home admission, and even death [2]. The number of falls and severity of injury increase with age [3]. The Centers for Disease Control and Prevention (CDC) estimates that the costs of fall-related injuries are expected to reach $54.9 billion by 2020 in the United States [4]. Balance deficits are one of the fall risk factors in community-dwelling older adults [5]. Belgen et al [6] assessed 50 people with chronic effects of stroke and reported that subjects with a history of multiple falls had poorer balance and more fear of falling (FOF) than persons who did not fall and first-time fallers. Thus, with respect to the American Geriatrics Society guideline, balance deficits should be evaluated in older adults reporting a fall [7]. Adequate balance control is required to perform mobility-related activities such as standing while doing manual tasks, rising from a chair, and walking safely
during daily life. One third to one half of the population older than 65 years experience difficulty with their balance or ambulation [8]. In older adults, falling is a multidimensional problem. Therefore, a person’s risk of falling cannot be assessed only by physical risk factors; other important aspects such as FOF must be considered [9]. FOF exists among 30% of older adults who have never experienced falling, and the rate is double in older adults who have experienced at least one fall [10]. FOF is linked to reduced participation in daily activities, lower quality of life, increased risk of institutionalization, depression, decreased social activity, and physical weakness [11]. Falls and FOF are interrelated problems, with each being a risk factor for the other [12,13]. Falls can be prevented [14,15]. A previous study showed that exercise can improve physical abilities in frail adults [16]. Barnett et al [17] showed that participation in weekly group exercises along with exercise at home improves balance and decreases the rate of falling among older adults. Yoga is a popular mind and body
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practice that concentrates on meditation, breathing, and postures [18]. The control of posture practice in yoga involves stretch and balance while maintaining a stable sitting or standing position [19]. Yoga may also have psychosocial benefits through prevention and control of common health and emotional problems linked with aging [16]. A recent evidence-based study showed the effectiveness of yoga for psychosocial and physical functioning in older adults [9]. Yoga also can improve gait speed [20] and awareness and self-esteem [21]. Therefore, it is possible to improve balance and FOF, 2 known fall risk factors, in older adults through yoga exercise. Yoga is simple to learn and can be practiced by older adults, even those who are ill or disabled. A growing body of research suggests that yoga-based interventions are readily accepted by older adults and may improve health in this population [22]. Schmid et al [23] evaluated the effect of a 12-week yoga intervention on FOF and balance in older adults and found that yoga decreased FOF by 6% and increased static balance by 4%. In this study, the change in FOF was a positive trend, although not significant. Compared with the study by Schmid et al [23], our study has a larger sample size, includes people with low Berg Balance Scale (BBS) and Modified Falls Efficacy Scale (MFES) scores, and involves both intervention (yoga) and control groups, which closely match in terms of starting MFES and BBS scores, gender, and age. The purpose of this study was to examine the effect of yoga on balance and FOF in older adults with low BBS and MFES scores. The hypothesis for this study was that the participants undergoing the yoga intervention would show significant improvement in balance and FOF. Methods A preliminary pilot study was carried out to determine the validity and reliability of the MFES [24] for Iranian older adults. The original questionnaire was translated into Persian by 3 professors of the Nursing and Midwifery School of Shiraz University of Medical Sciences, Shiraz, southern Iran. The preliminary Persian version was translated back into English by another translator. To ensure that the questionnaire was clear, the researcher discussed it with 2 older adults separately. Then, as approved by the Shiraz Welfare Organization, 30 people aged 60-74 years who were willing to participate in the pilot study were chosen from Shiraz Jahandidegan Center to complete the questionnaire twice within a time span of 3 weeks. Cronbach’s a and test-retest reliability were then calculated. Subjects All participants were older adults who visited the Jahandidegan Center in Shiraz, Iran. This Center provides activities and classes for elderly persons.
Recruitment began in March 2011 and ended in June 2011. The researcher took part in the center’s entertainment classes and introduced the research program, asking for willing participants. Inclusion criteria were being 60-74 years of age, having an MFES score <8 [25] and a BBS score <45, and being willing to participate in the study. Of the 120 older adults who were considered, 40 met the inclusion criteria. We excluded persons who had cognitive or neuromuscular diseases, advanced osteoporosis, or dizziness. We also excluded persons who were taking anticonvulsant, narcoleptic, or sedative drugs, used walking aids, attended yoga classes outside the research study, or experienced acute pain that prevented them from doing the exercises. The 40 participants were asked to sign a consent form. They were then randomly assigned to either the intervention (yoga) or control group, using the block randomization method size 4. The block randomization was used only on the basis of 2 groups (yoga and control). The participant flow diagram is shown in Figure 1. The sample size was calculated using the Power Analysis and Sample Size (PASS) program (NCSS, Kaysville, UT). The sample size was calculated as 16 in each group based on the following variables: mean difference ¼ 15, standard deviation (SD) 1 ¼ 15.4, SD 2 ¼ 14.5, a ¼ 0.05, and power ¼ 80% [26]. Anticipating an attrition rate of 20%, we chose to include 20 persons in each group. This study was approved by the Ethics Committee of the Shiraz University of Medical Sciences. Measures The participants were asked to complete the MFES and demographic data questionnaires. The MFES, a 14-item activity questionnaire, is an expanded version of the original 10-item activity Falls Efficacy Scale [24]. The MFES includes outdoor activities not covered by the Falls Efficacy Scale. Each item is scored on a 10-point visual analogue scale; 0 ¼ not confident/not sure at all, 5 ¼ fairly confident/fairly sure, and 10 ¼ completely confident/completely sure. The MFES score range for each individual is 0-10, with 10 being a perfect score. To obtain each subject’s MFES score, the ratings (possible range ¼ 0-140) are totaled and divided by 14. Scores <8 indicate fear of falling, and scores 8 indicate lack of fear [25]. The MFES has excellent reliability (intraclass correlation coefficients [ICC] ¼ 0.93) and internal consistency (0.95) [25]. In our pilot study, Cronbach’s a coefficient for the MFES questionnaire was 0.92, and the performed testeretest had appropriate reliability (r ¼ 0.99). A research assistant measured the postural balance of each participant using the BBS. The BBS is a 14-item scale designed to measure balance in older adults. Each item is scored on a 5-point scale from 0-4 (0 indicates the lowest level of function and 4 the highest level of function), with 56 being the highest total score.
N. Nick et al. / PM R 8 (2016) 145-151
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Figure 1. Participant flow diagram.
The Cronbach’s a of the BBS is 0.96. The interrater and intrarater reliability measurements for the test as a whole are 0.98 and 0.99, respectively [27]. The BBS has excellent reliability (ICC ¼ 0.997) and is internally consistent (0.921) for older Iranian adults. The maximum score on this scale is 56, the minimum is 0, and scores below 45 show a risk of falling [28]. A study by Thorbahn and Newton [29] showed that older adults with a BBS score >45 were less likely to fall compared with persons scoring <45. Therefore, we selected people with BBS scores <45. After 8 weeks, participants of both groups completed the MFES questionnaire, and the research assistant also measured the postural balance of each participant using the BBS. Intervention In the current study, the Hatha yoga style was used with an emphasis on Pavanamuktasana and balance movements. A certified yoga instructor led the 1-hour yoga classes twice a week for 8 weeks. Each class began with Paranayama (breath exercises) for 10 minutes and then continued with stretching and orthopedic warming exercises for 10 minutes. The main activities, Pavanamuktasana and balance movements, were then performed for 30 minutes (see Appendix 1 for
a list of the postures used in the classes). Each session concluded with savasana (ie, lying on the back, spreading the arms and legs 45 , shutting the eyes, and taking long, deep breaths) and relaxation for 10 minutes. The instructor led the participants in performing the exercises. The participants were encouraged to work within their individual abilities (eg, they were asked to keep the duration of exercises within their abilities and to try to increase the duration throughout the sessions) and use aids to keep their balance, such as leaning against a wall. After the completion of each posture the participants were asked to be aware of which groups of muscles were contracting, which were being stretched, and which were being used to keep the body steady and balanced. Two trained staff members were always present during the classes to minimize the chance of falling. Deep breathing was emphasized during all postures. All participants were in the same yoga class, and all sessions were completed in a large room near the Jahandidegan Center. Analysis Statistical analysis consisted of descriptive and inferential statistics. Results of descriptive statistics were expressed as mean value SDs for continuous variables and as frequencies and percentages for
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Table 1 Subject characteristics Yoga Group (N ¼ 20; 9 Men, 11 Women)
Control Group (N ¼ 19; 8 Men, 11 Women)
Characteristic
Mean
SD
Values MinimumMaximum
Age, y Weight, kg Height, m BMI
68 67.40 1.61 25.76
4.87 14.03 0.07 4.42
60-74 43-103 1.51-1.77 17.67-35.64
Mean
SD
Values MinimumMaximum
P Value*
68.79 68.89 1.60 27.02
4.81 14.18 0.07 5.40
60-74 50-94 1.50-1.75 19.05-39.13
.61 .74 .43 .42
SD ¼ standard deviation; BMI ¼ body mass index. * P value for gender ¼ .096.
categorical variables. Group comparison on gender was performed using the c2 test. Mean differences for age, height, weight, and body mass index (BMI) between the 2 groups were then calculated and tested by independent sample t-test. Changes in MFES and BBS scores were compared with an independent sample t-test. In all analyses, P < .05 was considered to be statistically significant. Analyses were performed using SPSS software, version 19 (IBM Corp, Armonk, NY). This study was registered in the Iranian registry of clinical trials (clinical trial registration number IRCT201109127531N1). Results Among 120 eligible older adults, 40 met the inclusion criteria and were assigned to either the intervention or control group. One participant in the control group was excluded because this person did not complete the questionnaires after 8 weeks. There were no dropouts in the intervention group. In the yoga group, all participants attended all sessions. The participants’ age, weight, height, and BMI scores are presented in Table 1. We found no significant difference between groups with respect to gender (P ¼ .96, c2 test, Table 1). Comparisons of baseline characteristics (mean age, height, weight, and BMI score) between the 2 groups are presented in Table 1. There was no difference between groups with respect to baseline characteristics. The mean score for FOF (P ¼ .33) and BBS (P ¼ .69) before the intervention was similar between the 2 groups. We found a significant difference in the change in MFES scores between the 2 groups (P < .0001,
Table 2 and Figure 2). We also found a significant difference in mean BBS scores after the intervention between the 2 groups (P < .0001, Table 2 and Figure 3). Discussion This study examined the effect of yoga on postural balance and FOF in older adults with low BBS and MFES scores. The results of the study show that yoga improves postural balance and reduces FOF in older adults. The BBS was used to measure balance. The independent sample t-test revealed a significant difference between BBS scores of 2 groups after the intervention. This result is consistent with findings of other studies [20,30]. Schmid et al [23] found an improvement in balance score, although the difference was not significant. This discrepancy may be due to the differences in sample size and the fact that our study included people with lower BBS scores. Also, in the study by Schmid et al [23], participants did not have the balance deficit as measured by the BBS at baseline. Morris [26] found that yoga exercises do not have a significant effect on the balance of older people. However, Morris recommended further studies to examine the effect of yoga on the risk factors of falling in older adults. The different results may be due to a smaller sample size and use of a different yoga style. In comparison, the type of yoga and positions used in the current study were different than those used in the studies by Schmid et al [23] and Morris [26]. In the current study, the Hatha yoga style was used with an emphasis on Pavanamukt asana and balance movements. Hatha yoga is associated with
Table 2 Comparison of variables before and after the intervention in the 2 groups BBS
Difference Before and After the Intervention
MFES
Pre-BBS
Post-BBS
Pre-MFES
Post-MFES
BBS
MFES
Group
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
n
Yoga Control
39.14 39.80
5.49 4.40
49.33 38.63
4.80 5.96
5.84 5.34
1.65 1.54
7.46 5.13
1.29 1.69
10.19* 1.16*
3.26 3.17
1.62* 0.21*
1.49 0.88
20 19
BBS ¼ Berg Balance Scale; MFES ¼ modifies falls efficacy scale; SD ¼ standard deviation. * The between-group differences for both outcomes are significant at P < .0001.
N. Nick et al. / PM R 8 (2016) 145-151
Figure 2. MFES scores of 2 study groups before and after intervention.
postures that increase flexibility. In Hatha yoga, the postures are integrated with pranayama, a focused state of attention and awareness, and meditation [31]. Pavanamuktasana are breath-coordinated movements that are safe, rhythmic, and stretch repetitive. These practices mobilize the joints and strengthen the periarticular muscles [32]. This exercise is suitable for releasing muscular tension. It also helps to keep the body balanced and stress free during the day [33]. As a preparatory practice, it is beneficial because it opens up all the major joints and relaxes the muscles of the body [34]. Zettergren et al [20] reported that yoga improved balance in older adults, but this improvement was not
Figure 3. BBS scores of 2 study groups before and after intervention.
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above the minimal detectable change. Minimal detectable change was defined as a change of 4 points for persons who had an initial score within the range of 45-56, 5 points if they had an initial score within the range of 35-44, 7 points if they had an initial score within the range of 25-34, and 5 points if their initial score was within the range of 0-24 on the BBS [35]. In the current study, the improvement found in all yoga participants on the BBS was above the minimal detectable change. It should be noted that the BBS score for the yoga group was raised to a level above the “likely to fall” score (45) as previously mentioned in the Methods section. One of the reasons for falls in older adults is balance impairment and reduced muscle strength [5,36,37]. Yoga requires the stretching of major muscle groups to improve physical strength and flexibility [23]. Yoga increases the extension of hip and step length and decreases anterior pelvic tilt [11]. It increases the body’s flexibility and power and plays an important role in preventing falls [18]. Zettergren et al [20] reported that because the subjects demonstrated the ability to walk faster, doing more yoga exercises may be effective for improving walking speed and might reduce the risk of falling and improve mobility. The independent sample t-test revealed a significant difference between the MFES scores of intervention and control groups after yoga sessions. This finding is in line with findings of Schmidt et al [23] and Morris [26]. It is worth noting that we initially involved people with low MFES scores in our study. As previously mentioned in the Methods section, scores <8 in the MFES questionnaire indicate FOF. Although we achieved significant results, the mean value (after the intervention) of FOF scores in the yoga group did not exceed 8. In the yoga group, only 7 participants reached a score of 8 after the intervention, probably because FOF is related not only to physical characteristics and falling history but also to mental and cognitive factors [23]. Therefore, more yoga sessions may be needed to further affect FOF, and we encourage more research regarding this issue. We did not have any dropouts during the intervention because the participants were willing to attend the classes. This study has some limitations. First, the study results cannot be generalized to people of all ages because the study sample was limited to adults aged 60-74 years. Second, one needs to study the long-term effects of yoga classes by following up with the participants and studying their behavior for at least 3 to 6 months after the intervention. Third, this program requires a certified yoga instructor. Forth, the results of this study apply to those who meet the inclusion criteria. Finally, this was an unblinded study in which the control group received no intervention of any kind. Thus some of the observed improvement in the yoga group could be due to a
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placebo effect or a desire to please the investigators, for example. Conclusion This study revealed that yoga can improve balance and decrease FOF, which are associated with fall risk in older adults. Thus yoga can address known fall risk factors in older adults and can be used in fall prevention programs. Health care professionals are vital links for recognizing the fall risk factors in older people and referring them to appropriate interventions. More research is needed to better identify the effects of yoga intervention on FOF in older adults. Acknowledgment We express sincere appreciation to those who helped us with this study, including the director and staff members of the Jahandidegan center and the study participants, whose commitment was admirable. This study was done in partial fulfillment of the requirements for the MSc degree awarded to Narjes Nick. References 1. Centers for Disease Control and Prevention. STEADIdolder adult fall prevention. Available at: http://www.cdc.gov/steadi/index. html. Accessed July 15, 2015. 2. American Geriatrics Society. Updated American Geriatrics Society/ British Geriatrics Society clinical practice guideline for prevention of falls in older persons and recommendations. Available at: http://geriatricscareonline.org/ProductAbstract/updated-americangeriatrics-societybritish-geriatrics-society-clinical-practice-guidelinefor-prevention-of-falls-in-older-persons-and-recommendations/ CL014. Accessed July 15, 2015. 3. American Academy of Orthopaedic Surgeons. Guidelines for preventing falls. Available at: http://orthoinfo.aaos.org/topic.cfm? topic¼A00135. Accessed July 15, 2015. 4. Centers for Disease Control and Prevention. Costs of falls among older adults. Available at: http://www.cdc.gov/ HomeandRecreationalSafety/Falls/fallcost.html. Accessed July 15, 2015. 5. Muir SW, Berg K, Chesworth B, Klar N, Speechley M. Quantifying the magnitude of risk for balance impairment on falls in community-dwelling older adults: A systematic review and metaanalysis. J Clin Epidemiol 2010;63:389-406. 6. Belgen B, Beninato M, Sullivan PE, Narielwalla K. The association of balance capacity and falls self-efficacy with history of falling in community-dwelling people with chronic stroke. Arch Phys Med Rehabil 2006;87:554-561. 7. American Geriatrics Society. 2010 AGS/BGS clinical practice guideline: Prevention of falls in older persons: Summary of recommendations. Available at: http://www.americangeriatrics. org/files/documents/health_care_pros/Falls.Summary.Guide.pdf. Accessed July 15, 2015. 8. Zijlstra A, Mancini M, Chiari L, Zijlstra W. Biofeedback for training balance and mobility tasks in older populations: A systematic review. J Neuroeng Rehabil 2010;7:58. 9. Lopes K, Costa D, Santos L, Castro D, Bastone A. Prevalence of fear of falling among a population of older adults and its correlation with mobility, dynamic balance, risk and history of falls. Rev Bras Fisioter 2009;13:223-229.
10. Legters K. Fear of falling. Phys Ther 2002;82:264-272. 11. Boyd R, Stevens JA. Falls and fear of falling: Burden, beliefs and behaviours. Age Ageing 2009;38:423-428. 12. Fletcher PC, Hirdes JP. Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing 2004;33:273-279. 13. Scheffer AC, Schuurmans MJ, van Dijk N. van Der Hooft T, De Rooij SE. Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 2008;37:19-24. 14. Kannus P, Sieva ¨nen H, Palvanen M, Ja ¨rvinen T, Parkkari J. Prevention of falls and consequent injuries in elderly people. Lancet 2005;366:1885-1893. 15. Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ 2002;325:128. 16. 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 Complement Med 2012;18:902-917. 17. Barnett A, Smith B, Lord SR, Williams M, Baumand A. Communitybased group exercise improves balance and reduces falls in at-risk older people: A randomised controlled trial. Age Ageing 2003;32: 407-414. 18. 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. 19. Miyamura M, Nishimura K, Ishida K, Katayama K, Shimaoka M, Hiruta S. Is man able to breathe once a minute for an hour? The effect of yoga respiration on blood gases. Jpn J Physiol 2002;52: 313-316. 20. Zettergren KK, Lubeski JM, Viverito JM. Effects of a yoga program on postural control, mobility, and gait speed in community-living older adults: A pilot study. J Geriatr Phys Ther 2011;34:88-94. 21. Sethi JK, Nagendra HR, Sham Ganpat T. Yoga improves attention and self-esteem in underprivileged girl student. J Educ Health Promot 2013;2:55. 22. DiBenedetto M, Innes KE, Taylor AG, et al. Effect of a gentle Iyengar yoga program on gait in the elderly: An exploratory study. Arch Phys Med Rehabil 2005;86:1830-1837. 23. Schmid AA, Van Puymbroeck M, Koceja DM. Effect of a 12-week yoga intervention on fear of falling and balance in older adults: A pilot study. Arch Phys Med Rehabil 2010;91:576-583. 24. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol 1990;45:P239-P243. 25. Hill KD, Schwarz JA, Kalogeropoulos AJ, Gibson SJ. Fear of falling revisited. Arch Phys Med Rehabil 1996;77:1025-1029. 26. Morris DM. An evaluation of yoga for the reduction of fall risk factors in older adults 2. [dissertation]. Florida: Florida State University: Tallahassee, FL; 2008. 27. Berg K. Measuring balance in the elderly: Preliminary development of an instrument. Physiother Can 1989;41:304-311. 28. Davatgaran Taghipoor K. Translation and Validation of a Persian Version of Berg Balance Scale in an Iranian Elderly Population [master’s thesis]. Tehran: Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences; 2006. 29. Thorbahn LDB, Newton RA. Use of the Berg Balance Test to predict falls in elderly persons. Phys Ther 1996;76:576-583. 30. 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;68:1068-1075. 31. Oken B. Complementary Therapies in Neurology. Boston, MA: Parthenon Publishing Group; 2005. 32. Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effect of integrated yoga therapy on pain, morning stiffness and anxiety in osteoarthritis of the knee joint: A randomized control study. Int J Yoga 2012;5:28.
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Disclosure N.N. Community Health Department, Fatemeh (P.B.U.H) School of Nursing & Midwifery, Shiraz University of Medical Sciences, Namazi Square, Shiraz, Iran Disclosure: nothing to disclose
S.K. Epidemiology Department, School of Health and Nutrition, Shiraz University of Medical Sciences, Shiraz, Iran Disclosure: nothing to disclose
P.P. Department of Neurology, Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Disclosure: nothing to disclose
I.J. Community Health Department, Fatemeh (P.B.U.H) School of Nursing & Midwifery, Shiraz University of Medical Sciences, Namazi Square, Shiraz, Iran. Address correspondence to: I.J.; e-mail: [email protected] Disclosure: nothing to disclose
F.G. Community Health Department, Fatemeh (P.B.U.H) School of Nursing & Midwifery, Shiraz University of Medical Sciences, Namazi Square, Shiraz, Iran Disclosure: nothing to disclose
Supported by Shiraz University of Medical Sciences, Shiraz, Iran. grant number: 89-5519 Submitted for publication January 14, 2015; accepted June 28, 2015.
Appendix 1. Names of the Asanas (Poses) Used in the Yoga Intervention Sessions Talasana (Palm Tree Pose) Ardha titaliasana (Butterfly Pose) Poorna titaliasana (Butterfly Pose) Chaki chalasana (running a grinding wheel) Kushta chakrasana Nauka sanchalanasana (rowing the boat) Tadsana (Mountain Pose) Savasana (Corpse Pose) Locust Pose Virkshasana (Tree Pose)
Bhujangasana (Cobra Pose) Akarna Dhanurasana (Shooting Bow Pose) Trikonasana (Triangle Pose) Dandasana (Staff Pose or Stick Pose) Half Boat Pose Janu Sirsasana (Head to Knee Pose) Virabhardrasana (Warrior) Yoga eye exercise Lizard Pose Matsyasana (Fish Pose) Sphinx Pose Savasana Pranayama