Yoga-based exercise improves health-related quality of life and mental well-being in older people: a systematic review of randomised controlled trials

Yoga-based exercise improves health-related quality of life and mental well-being in older... Abstract Objective health-related quality of life (HRQOL) and mental well-being are associated with healthy ageing. Physical activity positively impacts both HRQOL and mental well-being. Yoga is a physical activity that can be modified to suits the needs of older people and is growing in popularity. We conducted a systematic review with meta-analysis to determine the impact of yoga-based exercise on HRQOL and mental well-being in people aged 60+. Methods searches were conducted for relevant trials in the following electronic databases; MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Allied and Complementary Medicine Database, PsycINFO and the Physiotherapy Evidence Database (PEDro) from inception to January 2017. Trials that evaluated the effect of physical yoga on HRQOL and/or on mental well-being in people aged 60+ years were included. Data on HRQOL and mental well-being were extracted. Standardised mean differences and 95% confidence intervals (CI) were calculated using random effects models. Methodological quality of trials was assessed using the PEDro scale. Results twelve trials of high methodological quality (mean PEDro score 6.1), totalling 752 participants, were identified and provided data for the meta-analysis. Yoga produced a medium effect on HRQOL (Hedges’ g = 0.51, 95% CI 0.25–0.76, 12 trials) and a small effect on mental well-being (Hedges’ g = 0.38, 95% CI 0.15–0.62, 12 trials). Conclusion yoga interventions resulted in small to moderate improvements in both HRQOL and mental well-being in people aged 60+ years. Further, research is needed to determine the optimal dose of yoga to maximise health impact. PROSPERO registration number (CRD42016052458) yoga, mental well-being, older people, health-related quality of life, exercise, systematic review Introduction Population ageing is occurring worldwide and presents challenges from a public health perspective, in terms of the increased risk of chronic disease and disability with increasing age [1]. Physical activity plays an important role in reducing these risks and promoting independence in older age, as it impacts on both physical and mental health. Despite the known benefits of an active lifestyle, however, people aged 60 years and over are the most inactive segment of the population [2], highlighting a need for more effective strategies to promote physical activity in this group. Health-related quality of life (HRQOL) is a multi-dimensional concept that incorporates the different domains of health; physical, mental, emotional and social functioning, and how these impact on overall health status [3]. HRQOL encompasses more than just direct measures of population health, life expectancy and causes of death, and acknowledges that an individual’s capacity to interact and participate with their environment is important for maximising overall quality of life. Mental well-being is a related concept and is also known to impact on health status [4]. Mental well-being is more than the absence of mental illness, and involves both feeling good and functioning well. It encompasses two perspectives: (i) the subjective experience of happiness (affect) and life satisfaction; and (ii) positive psychological functioning, good relationships with others and self-realisation [5]. Mental well-being is associated with a lower risk of early mortality [6] and underpins healthy ageing [1]. Older adults with higher levels of mental well-being attribute this to higher levels of activity and better health and mobility status [7]. Despite the importance of these aspects of health, there is a paucity of research evaluating interventions to promote mental well-being and HRQOL in older age [6]. Yoga is a mind–body physical activity that includes a combination of stretching and holding movements and postures in addition to meditation and focused breathing. Yoga is growing in popularity among older people [8] and is associated with significant health benefits such as improved strength, flexibility [9], balance and mobility [10] and mood [11]. The physical and mental benefits associated with yoga suggest that it has the potential to produce improvements in the overall quality of life. However, yoga’s effect on mental well-being in people aged 65 years and older has not been properly evaluated and there is currently no published systematic review that synthesises the evidence for the effect of yoga on HRQOL and mental well-being among older people. This current systematic review builds on a previous systematic review [10] conducted by our research group that highlighted the role of yoga for improving balance and mobility among people aged 60 years and older with a broad range of health states. The current systematic reviewed aimed to answer the following questions: What is the effect of yoga-based exercise on HRQOL in adults aged 60 years and older? What is the effect of yoga-based exercise on mental well-being in adults aged 60 years and older? In order to make recommendations based on the highest level of evidence, this review only included randomised controlled trials (RCTs). Method Design We conducted a systematic review according to the PRISMA statement [12] and the review protocol was registered on PROSPERO prior to commencement (CRD42016052458). See Appendix 1 is available in Age and Ageing online for PRISMA checklist. Search strategy and study selection criteria Electronic databases including MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database (AMED), PsycINFO and the Physiotherapy Evidence Database (PEDro) were used to search for papers published up until 30 January 2017 without language restrictions. No restriction was placed on the setting or context of the included studies. Search terms included words relating to yoga, randomised controlled trial and age (see Appendix 2 is available in Age and Ageing online for search strategies). Two independent reviewers (AT and HB) initially screened potentially eligible studies using title and abstract and then examined the full texts of potentially relevant papers for inclusion against predetermined criteria (Box 1). Conflict was resolved by discussion with a third reviewer (CD). Box 1. Inclusion criteria Design: Randomised controlled trials. Participants: Mean age 60 years and over. Interventions: Physical yoga programmes (excluding meditation and breathing exercises alone). No limitation was placed on the type, duration and frequency of yoga intervention. Control: No intervention, usual care or wait-list control. Outcomes measured: HRQOL and/or mental well-being measures. Characteristics of included studies Quality The PEDro scale scores extracted from the PEDro (www.pedro.org.au) were used to evaluate the quality of included studies. The PEDro scale uses a rating scale from 0 to 10 to determine the methodological quality of randomised controlled trials [13]. A PEDro score of 8/10 is considered the maximum attainable score for yoga studies as it is not feasible to blind treating yoga instructors and participants during yoga-based interventions. Participants Trials that included participants with a mean age of 60 years and over were eligible for inclusion with no restrictions on the characteristics of the population. Intervention We included studies, where the intervention involved physical yoga and excluded those studies where the yoga involved meditation and breathing exercises alone. There were no limitations placed on the type, duration and frequency of the intervention. Session duration and frequency, yoga type and instructor qualifications were recorded in order to assess the similarity of the studies. The control group was defined as wait-list control, no intervention, education only or usual care. Outcome measures Trials were included if a HRQOL and/or mental well-being measure was taken pre- and post-intervention. Any validated, standardised clinical measure of HRQOL and/or mental well-being such as (but not limited to) the Short form-36 (SF-36) [14], or World Health Organization Quality of Life instrument (WHOQOL) [3], were included. Data extraction and analysis Data were extracted regarding trial characteristics and estimates of effect using a pilot-tested data extraction form by two reviewers (AT and HB) and cross-checked by a third reviewer (ATie). Authors were contacted via email to obtain further information if there were insufficient data included in the publication. Duplicate publications were identified and excluded by comparing authors, interventions, outcomes and sample sizes of eligible trials. The pre- and post-intervention means and standard deviations for each study group were extracted to obtain the pooled estimate of the effect of intervention. Details of the setting, participants, yoga programme components and dose, adverse events, outcome measures and PEDro score were summarised descriptively. The meta-analyses were conducted using Comprehensive Meta-analysis software (Version 2, Biostat, Englewood, NJ, USA). Intervention effect sizes for HRQOL and mental well-being, standardised mean differences (SMDs) using Hedges’ g statistic, and 95% confidence intervals (CIs) were calculated. Effect sizes were categorised as small (0.2), medium (0.5) and large (0.8 or greater). Statistical heterogeneity was quantified using the I2 statistic: I2 of more than 75% indicates considerable heterogeneity, I2 of 50–75% indicates substantial heterogeneity, and I2 of less than 40% indicates limited heterogeneity. We also investigated the presence of small study effects by using a funnel plot of the effect estimates from included studies. The funnel plot was assessed by visual inspection and by using Egger’s test, with P < 0.1 as evidence of small study effects. Results Flow of studies through the review A total of 1,350 studies (excluding duplicates) were identified. After screening, 12 eligible randomised controlled trials [15–26] were included for our systematic review and meta-analysis to evaluate the effect of yoga on HRQOL and mental well-being. Figure 1 outlines the flow of studies through the review. Figure 1 View largeDownload slide Flow of studies through the review. *Papers may have been excluded for failing to meet more than one inclusion criteria. Figure 1 View largeDownload slide Flow of studies through the review. *Papers may have been excluded for failing to meet more than one inclusion criteria. Characteristics of included trials The 12 studies included in the meta-analysis included a total of 752 participants. Table 1 provides a summary of the characteristics of the trials, including the participant’s age, gender and health status, intervention details, dose, class attendance, and outcome measures. Table 1. Summary of included studies Study country, PEDro score  Participants  Intervention  Adherencea  Outcome measures  Banasik et al. [15] USA, 4  N = 14, mean age: 63, 14 females. Breast cancer  Iyengar yoga, 90 min, 2/week, 8 weeks  88%  HRQOL: FACT-Breast, Physical well-being MW: FACT-Breast, Emotional well-being  Chen et al. [16] Taiwan, 5  N = 128, mean age: 69, 93 females. Community-dwellers  Silver (hatha) yoga, 70 min, 3/week, 24 weeks  87%  HRQOL: SF-12 Physical health perception MW: SF-12 MCS  Cheung et al. [18] USA, 7  N = 55, mean age: 72, 46 females. Knee osteoarthritis  Hatha yoga, 45 min, 1/week, 8 weeks + home practice  63% attended ≥50% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cheung et al. [17] USA, 8  N = 36, mean age: 72, 36 females. Knee osteoarthritis  Hatha yoga, 60 min, 1/week, 8 weeks + home practice  69% attended ≥75% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cramer et al. [19] Germany, 6  N = 54, mean age: 68, 21 females. Colorectal cancer  Hatha yoga, 90 min, 1/week, 10 weeks + home practice  50%  HRQOL: FACT-Colorectal, Physical well-being MW: FACT-Colorectal, Emotional well-being  Donesky-Cuenco et al. [20] USA, 5  N = 29, mean age: 70, 21 females. COPD  Iyengar yoga, 60 min, 2/week, 12 weeks + home practice  83%  HRQOL: SF-36 PCS MW: SF-36 MCS  Hariprasad et al. [21] India, 6  N = 120, mean age: 75, 72 females. Elderly care homes  Yogasana yoga, 60 min, 7/week, 4 weeks, then 60 min, 1/week, 8 weeks + home practice  Not reported  HRQOL: WHOQOL Physical health QOL MW: WHOQOL Psychological Health QOL  Littman et al. [22] USA, 6  N = 57, mean age: 60, 57 females. Breast cancer  Viniyoga, 75 min, 1/week, 26 weeks + home practice  77%  HRQOL: FACT-General Physical well-being. MW: FACT-General Emotional well-being  Ni et al. [23] USA, 5  N = 27, mean age: 73, 10 females. Parkinson’s Disease  Vinyasa yoga, 60 min, 2/week, 12 weeks  92%  HRQOL: 39-item Parkinson’s Disease Questionnaire (PDQ-39). MW: PDQ-39 Emotional well-being  Noradechanunt et al. [24] Australia, 8  N = 26, mean age: 67, 20 females. Community-dwellers  Thai yoga, 80 min, 2/week, 12 weeks  96%  HRQOL: SF-36 PCS MW: SF-36 MCS  Oken et al. [25] USA, 6  N = 88, mean age: 71, 64 females. Community-dwellers  Iyengar yoga, 90 min, 1/week, 24 weeks + daily home practice  78%  HRQOL: SF-36 PCS MW: SF-36 MCS  Teut et al. [26], Germany, 7  N = 118, mean age: 73, 106 females. Low back pain  Viniyoga, 45 min, 2/week, 12 weeks  74% attended ≥75% classes  HRQOL: SF-36 PCS MW: SF-36 MCS  Study country, PEDro score  Participants  Intervention  Adherencea  Outcome measures  Banasik et al. [15] USA, 4  N = 14, mean age: 63, 14 females. Breast cancer  Iyengar yoga, 90 min, 2/week, 8 weeks  88%  HRQOL: FACT-Breast, Physical well-being MW: FACT-Breast, Emotional well-being  Chen et al. [16] Taiwan, 5  N = 128, mean age: 69, 93 females. Community-dwellers  Silver (hatha) yoga, 70 min, 3/week, 24 weeks  87%  HRQOL: SF-12 Physical health perception MW: SF-12 MCS  Cheung et al. [18] USA, 7  N = 55, mean age: 72, 46 females. Knee osteoarthritis  Hatha yoga, 45 min, 1/week, 8 weeks + home practice  63% attended ≥50% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cheung et al. [17] USA, 8  N = 36, mean age: 72, 36 females. Knee osteoarthritis  Hatha yoga, 60 min, 1/week, 8 weeks + home practice  69% attended ≥75% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cramer et al. [19] Germany, 6  N = 54, mean age: 68, 21 females. Colorectal cancer  Hatha yoga, 90 min, 1/week, 10 weeks + home practice  50%  HRQOL: FACT-Colorectal, Physical well-being MW: FACT-Colorectal, Emotional well-being  Donesky-Cuenco et al. [20] USA, 5  N = 29, mean age: 70, 21 females. COPD  Iyengar yoga, 60 min, 2/week, 12 weeks + home practice  83%  HRQOL: SF-36 PCS MW: SF-36 MCS  Hariprasad et al. [21] India, 6  N = 120, mean age: 75, 72 females. Elderly care homes  Yogasana yoga, 60 min, 7/week, 4 weeks, then 60 min, 1/week, 8 weeks + home practice  Not reported  HRQOL: WHOQOL Physical health QOL MW: WHOQOL Psychological Health QOL  Littman et al. [22] USA, 6  N = 57, mean age: 60, 57 females. Breast cancer  Viniyoga, 75 min, 1/week, 26 weeks + home practice  77%  HRQOL: FACT-General Physical well-being. MW: FACT-General Emotional well-being  Ni et al. [23] USA, 5  N = 27, mean age: 73, 10 females. Parkinson’s Disease  Vinyasa yoga, 60 min, 2/week, 12 weeks  92%  HRQOL: 39-item Parkinson’s Disease Questionnaire (PDQ-39). MW: PDQ-39 Emotional well-being  Noradechanunt et al. [24] Australia, 8  N = 26, mean age: 67, 20 females. Community-dwellers  Thai yoga, 80 min, 2/week, 12 weeks  96%  HRQOL: SF-36 PCS MW: SF-36 MCS  Oken et al. [25] USA, 6  N = 88, mean age: 71, 64 females. Community-dwellers  Iyengar yoga, 90 min, 1/week, 24 weeks + daily home practice  78%  HRQOL: SF-36 PCS MW: SF-36 MCS  Teut et al. [26], Germany, 7  N = 118, mean age: 73, 106 females. Low back pain  Viniyoga, 45 min, 2/week, 12 weeks  74% attended ≥75% classes  HRQOL: SF-36 PCS MW: SF-36 MCS  FACT, Functional Assessment of Cancer Therapy; PCS, physical component score; MCS, mental component score; QOL, quality of life. aAverage number of classes attended across all participants. Table 1. Summary of included studies Study country, PEDro score  Participants  Intervention  Adherencea  Outcome measures  Banasik et al. [15] USA, 4  N = 14, mean age: 63, 14 females. Breast cancer  Iyengar yoga, 90 min, 2/week, 8 weeks  88%  HRQOL: FACT-Breast, Physical well-being MW: FACT-Breast, Emotional well-being  Chen et al. [16] Taiwan, 5  N = 128, mean age: 69, 93 females. Community-dwellers  Silver (hatha) yoga, 70 min, 3/week, 24 weeks  87%  HRQOL: SF-12 Physical health perception MW: SF-12 MCS  Cheung et al. [18] USA, 7  N = 55, mean age: 72, 46 females. Knee osteoarthritis  Hatha yoga, 45 min, 1/week, 8 weeks + home practice  63% attended ≥50% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cheung et al. [17] USA, 8  N = 36, mean age: 72, 36 females. Knee osteoarthritis  Hatha yoga, 60 min, 1/week, 8 weeks + home practice  69% attended ≥75% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cramer et al. [19] Germany, 6  N = 54, mean age: 68, 21 females. Colorectal cancer  Hatha yoga, 90 min, 1/week, 10 weeks + home practice  50%  HRQOL: FACT-Colorectal, Physical well-being MW: FACT-Colorectal, Emotional well-being  Donesky-Cuenco et al. [20] USA, 5  N = 29, mean age: 70, 21 females. COPD  Iyengar yoga, 60 min, 2/week, 12 weeks + home practice  83%  HRQOL: SF-36 PCS MW: SF-36 MCS  Hariprasad et al. [21] India, 6  N = 120, mean age: 75, 72 females. Elderly care homes  Yogasana yoga, 60 min, 7/week, 4 weeks, then 60 min, 1/week, 8 weeks + home practice  Not reported  HRQOL: WHOQOL Physical health QOL MW: WHOQOL Psychological Health QOL  Littman et al. [22] USA, 6  N = 57, mean age: 60, 57 females. Breast cancer  Viniyoga, 75 min, 1/week, 26 weeks + home practice  77%  HRQOL: FACT-General Physical well-being. MW: FACT-General Emotional well-being  Ni et al. [23] USA, 5  N = 27, mean age: 73, 10 females. Parkinson’s Disease  Vinyasa yoga, 60 min, 2/week, 12 weeks  92%  HRQOL: 39-item Parkinson’s Disease Questionnaire (PDQ-39). MW: PDQ-39 Emotional well-being  Noradechanunt et al. [24] Australia, 8  N = 26, mean age: 67, 20 females. Community-dwellers  Thai yoga, 80 min, 2/week, 12 weeks  96%  HRQOL: SF-36 PCS MW: SF-36 MCS  Oken et al. [25] USA, 6  N = 88, mean age: 71, 64 females. Community-dwellers  Iyengar yoga, 90 min, 1/week, 24 weeks + daily home practice  78%  HRQOL: SF-36 PCS MW: SF-36 MCS  Teut et al. [26], Germany, 7  N = 118, mean age: 73, 106 females. Low back pain  Viniyoga, 45 min, 2/week, 12 weeks  74% attended ≥75% classes  HRQOL: SF-36 PCS MW: SF-36 MCS  Study country, PEDro score  Participants  Intervention  Adherencea  Outcome measures  Banasik et al. [15] USA, 4  N = 14, mean age: 63, 14 females. Breast cancer  Iyengar yoga, 90 min, 2/week, 8 weeks  88%  HRQOL: FACT-Breast, Physical well-being MW: FACT-Breast, Emotional well-being  Chen et al. [16] Taiwan, 5  N = 128, mean age: 69, 93 females. Community-dwellers  Silver (hatha) yoga, 70 min, 3/week, 24 weeks  87%  HRQOL: SF-12 Physical health perception MW: SF-12 MCS  Cheung et al. [18] USA, 7  N = 55, mean age: 72, 46 females. Knee osteoarthritis  Hatha yoga, 45 min, 1/week, 8 weeks + home practice  63% attended ≥50% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cheung et al. [17] USA, 8  N = 36, mean age: 72, 36 females. Knee osteoarthritis  Hatha yoga, 60 min, 1/week, 8 weeks + home practice  69% attended ≥75% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cramer et al. [19] Germany, 6  N = 54, mean age: 68, 21 females. Colorectal cancer  Hatha yoga, 90 min, 1/week, 10 weeks + home practice  50%  HRQOL: FACT-Colorectal, Physical well-being MW: FACT-Colorectal, Emotional well-being  Donesky-Cuenco et al. [20] USA, 5  N = 29, mean age: 70, 21 females. COPD  Iyengar yoga, 60 min, 2/week, 12 weeks + home practice  83%  HRQOL: SF-36 PCS MW: SF-36 MCS  Hariprasad et al. [21] India, 6  N = 120, mean age: 75, 72 females. Elderly care homes  Yogasana yoga, 60 min, 7/week, 4 weeks, then 60 min, 1/week, 8 weeks + home practice  Not reported  HRQOL: WHOQOL Physical health QOL MW: WHOQOL Psychological Health QOL  Littman et al. [22] USA, 6  N = 57, mean age: 60, 57 females. Breast cancer  Viniyoga, 75 min, 1/week, 26 weeks + home practice  77%  HRQOL: FACT-General Physical well-being. MW: FACT-General Emotional well-being  Ni et al. [23] USA, 5  N = 27, mean age: 73, 10 females. Parkinson’s Disease  Vinyasa yoga, 60 min, 2/week, 12 weeks  92%  HRQOL: 39-item Parkinson’s Disease Questionnaire (PDQ-39). MW: PDQ-39 Emotional well-being  Noradechanunt et al. [24] Australia, 8  N = 26, mean age: 67, 20 females. Community-dwellers  Thai yoga, 80 min, 2/week, 12 weeks  96%  HRQOL: SF-36 PCS MW: SF-36 MCS  Oken et al. [25] USA, 6  N = 88, mean age: 71, 64 females. Community-dwellers  Iyengar yoga, 90 min, 1/week, 24 weeks + daily home practice  78%  HRQOL: SF-36 PCS MW: SF-36 MCS  Teut et al. [26], Germany, 7  N = 118, mean age: 73, 106 females. Low back pain  Viniyoga, 45 min, 2/week, 12 weeks  74% attended ≥75% classes  HRQOL: SF-36 PCS MW: SF-36 MCS  FACT, Functional Assessment of Cancer Therapy; PCS, physical component score; MCS, mental component score; QOL, quality of life. aAverage number of classes attended across all participants. Quality The mean PEDro score of the included studies was 6.1 (range 4–8). Randomisation occurred in all 12 trials. One study scored four out of 10 [15], three studies scored five out of 10 [16, 20, 23], four studies scored six out of 10 [19, 21, 22, 25], two studies scored seven out of 10 [18, 26] and two studies scored eight out of 10 [17, 24]. PEDro scores are included in Table 1. Apart from lack of blinding of participants and therapists (which is not possible in these trials) the most commonly unmet item was blinding of assessors. Participants The mean age of participants ranged from 60 to 75 years. Participants were recruited from both community and residential aged care settings. Three of the studies included participants who were healthy community-dwelling older adults [16, 24, 25], two recruited participants with knee osteoarthritis [17, 18], two recruited breast cancer survivors [15, 22], one recruited participants with Parkinson’s disease [23], one recruited participants from elderly care homes [21], one recruited participants with chronic obstructive pulmonary disease (COPD) [20], one recruited participants who had completed treatment for colorectal cancer [19] and one trial recruited participants with chronic back pain [26]. Both men and women were included in all but three studies [15, 17, 22], which included females only, and 74% (560/752) of included participants were female. Intervention In all studies, the experimental group received a physical yoga intervention. The included yoga styles were Hatha [16–19], Yogasana [21], Vinyasa [23], Thai Yoga [24], Iyengar [15, 20, 25] and Viniyoga [22, 26]. Participants undertook 45–90 min of yoga per session, during 1–3 classes per week for 8–24 weeks in total. Seven [17–22, 25] of the yoga programmes included a home yoga programme for participants to complete 4–7 times per week. In nine of the studies, the control group received no intervention or wait-list control/usual care [15–17, 19–22, 25, 26] and in three studies they received education about exercise [18, 23, 24]. All yoga interventions were delivered by qualified yoga instructors, with some using props such as chairs, blankets, blocks and straps to provide comfort and support. Class content included poses carried out in standing, sitting and lying on the floor. The mean proportion of yoga sessions attended ranged from 53 to 96%. Adverse events All but one of the included trials [15] measured adverse events related to the yoga intervention. Seven of the trials reported no adverse events [16, 18, 20–23, 26]. Two of the trials reported drop out due to knee pain [17, 24]. One trial reported a minor groin strain in the yoga group however it did not preclude their participation in the study [25]. One trial [19] reported several adverse events including abdominal pain (n = 1 participant), muscle soreness (n = 3), neck pain (n = 1), minor vertigo (n = 1) and hip pain requiring analgesic (n = 1). Exploration of small study effects Visual inspection of the funnel plots suggested no indication of asymmetry and thus a low likelihood of small study effects in the results for both HRQOL and mental well-being. Egger’s test confirmed this assumption for both HRQOL and mental well-being (P = 0.33 and P = 0.28, respectively). However, given the small numbers of studies involved, these analyses may be underpowered. Outcome measures HRQOL and mental well-being were measured in all included trials. For measures of HRQOL four studies used the SF-36 physical composite summary [20, 24–26], three studies used the SF-12 physical component summary score [16–18], one study used the WHOQOL physical health QOL score [21], one study used the PDQ-39 sum score [3] and three studies used variations of the physical well-being subscale of the Functional Assessment of Cancer Therapy (FACT) for general [22], breast cancer [15] and for colorectal cancer [19]. Despite the different scales used, on examination of their content we considered that there was sufficient consistency in the types of questions included and the aspects of QOL assessed for the data to be pooled for analysis. Mental well-being was measured with the SF-36 mental component summary score in four studies [20, 24–26], three studies used the SF-12 mental composite score [16–18], one study used the WHOQOL psychological health QOL score [21], one study used the PDQ-39 emotional well-being score [23], and three studies variations of the emotional well-being subscale of the FACT for general [22], breast cancer [15] and for colorectal cancer [19]. Despite the different scales used, on examination of their content we considered that there was sufficient consistency in the types of questions included and the aspects of mental well-being assessed for the data to be pooled for analysis. Effect of yoga on HRQOL The effect sizes from individual trials for the effect of yoga on HRQOL involving 12 trials and 752 participants are shown in Figure 2. The pooled estimate of the effect of yoga on HRQOL indicates a medium and statistically significant effect on HRQOL compared to control participants (SMD 0.51, 95% CI 0.25–0.76, P < 0.001). There was an indication of moderate heterogeneity in the estimate of the effect of the intervention (I2 = 62.9%, P = 0.002). Figure 2 View largeDownload slide Effect size (95% CI) of yoga on HRQOL by pooling data from 12 studies comparing yoga versus control using random effects meta-analysis (n = 752). Figure 2 View largeDownload slide Effect size (95% CI) of yoga on HRQOL by pooling data from 12 studies comparing yoga versus control using random effects meta-analysis (n = 752). Effect of yoga on mental well-being The effect sizes from individual trials for the effect of yoga on mental well-being involving 12 trials and 752 participants are shown in Figure 3. The pooled estimate of the effect of yoga on mental well-being indicates a small and statistically significant effect on mental well-being compared to control participants (SMD 0.38, 95% CI 0.15–0.62, P = 0.001). There was an indication of moderate heterogeneity in the estimate of the effect of the intervention (I2=56.3%, P = 0.009). Figure 3 View largeDownload slide Effect size (95% CI) of yoga on mental well-being by pooling data from 12 studies comparing yoga versus control using random effects meta-analysis (n = 752). Figure 3 View largeDownload slide Effect size (95% CI) of yoga on mental well-being by pooling data from 12 studies comparing yoga versus control using random effects meta-analysis (n = 752). The review also aimed to assess the differential impact of yoga-based exercise on HRQOL and mental well-being in people aged 60 and older on the basis of programme or population characteristics. However, we could not achieve this due to the small number of trials identified. Discussion This systematic review and meta-analysis included 12 trials of moderate to high methodological quality that found physical yoga improved HRQOL and mental well-being in people aged 60 years and over. The magnitude of the effect of yoga interventions on HRQOL (SMD = 0.51) and mental well-being (SMD = 0.38) demonstrates a small to moderate potential of physical yoga to improve these outcomes in older people. These results are in accordance with the previous research that has identified yoga as a form of physical activity that older people enjoy and perceive to be appropriate [27], and that has a beneficial effect on important aspects of health such as balance and mobility [10] and symptoms of depression [28]. The trials included in this review used modified postures in standing, seated and supine and some utilised props such as blocks, blankets and straps to adapt the yoga poses to the needs of older people. All trial interventions were implemented by trained yoga therapists and instructors, and several modes of yoga were included. Yoga was also found to be safe and feasible for older people to take part in with no serious adverse events reported. It is not clear how much of the impact on HRQOL and mental well-being can be attributed to the practice of yoga poses as opposed to the relaxation and meditation aspects of yoga that were included alongside each other in many of the included trials. Further research is required to determine the specific attributes of yoga programmes that contribute the most to improvements in HRQOL and mental well-being in older age. To our knowledge, this is the first meta-analysis of randomised controlled trials to evaluate the impact of physical yoga on HRQOL and mental well-being in older adults. This systematic review was prospectively registered with PROSPERO prior to screening the data and was not restricted by publication language or date. A key strength of this study is that included trials involved participants with a broad range of health conditions, including chronic back pain [26], Parkinson’s disease [23], osteoarthritis [17, 18], COPD [20], cancer [15, 19, 22] and also included people residing in elderly care homes [21] as well as healthy community-dwelling older adults [16, 24, 25], demonstrating the suitability of yoga-based exercise for older people with differing health states and abilities as well as for healthy older people. This result indicates to health professionals that yoga interventions are a safe and feasible exercise option for people aged 60 years and over to improve HRQOL and mental well-being. We acknowledge there are limitations to this review. We only included trials where the intervention was some form of physical yoga, since we sought to determine the impact of exercise-based yoga on the outcomes of interest, hence we excluded trials that evaluated the impact of relaxation/ meditation type yoga as a single intervention. Therefore, the impact of other forms of yoga on HRQOL and mental well-being cannot be determined from our results. Additionally, the measures of HRQOL analysed in this review mainly focused on the physical domains of HRQOL, obtained from a number of different general and disease-specific, validated tools. The results therefore provide less certainty about the impact of yoga on other important domains of HRQOL such as emotional and social functioning. We chose to use the PEDro scale to measure risk of bias; however, the Cochrane risk of bias tool could also have been used. The best way to assess risk of bias in trials of yoga interventions is not clear and warrants further investigation. A source of bias in the studies of this review was the inability to blind therapists and patients, however this is unavoidable in trials that seek to determine the impact of exercise-based interventions. The included trials also had small sample sizes, with a total of 752 participants for all eight trials. This makes it difficult to draw conclusions about the implications of the results for the broader population of older people. Additionally, the heterogeneity among the studies was moderate which creates uncertainty about the generalisability of these results. Due to the small number of studies included in this review, we were unable to complete a meta-regression analysis which makes it difficult to determine if there are differential effects of yoga on the outcome measures with higher doses of yoga and in different clinical populations. While this review provides evidence of the beneficial effect of physical yoga on HRQOL and mental well-being in people aged 60 years and over, further research is required to identify the optimal dose, type and frequency of yoga programme that maximises health outcomes. Future studies should include a longer duration intervention to explore the potential additional impact on HRQOL and mental well-being. Conclusion Maintenance of HRQOL and mental well-being in older age is associated with healthy ageing, making strategies that promote these outcomes important. The results of this systematic review demonstrate that adults aged 60 years and over can improve their HRQOL and mental well-being through participation in yoga programmes. Future research is needed to identify the optimal frequency and duration of yoga programmes for maximising improvements in HRQOL and mental well-being. Key Points Health professionals can confidently recommend physical yoga to improve health-related quality of life (HRQOL) and mental well-being in adults aged 60 years and over. Yoga is a safe and feasible physical activity option for older adults. Research is required to identify the optimal yoga dose, type and intensity to maximise health-related quality of life (HRQOL) and mental well-being. Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Author’s contribution ATie and CD conceived the study and contributed to study design and interpretation of the data. AT and HB coordinated the literature search and data collection with assistance from ATie and CD. ATie, HB and AT contributed to the data analysis, interpretation of the data and drafted the manuscript. All authors had access to the data and data analysis, contributed to revisions and approved the final manuscript. ATie is the guarantor of the study. Conflicts of interest None. Funding A Tiedemann is supported by a Research Fellowship from the National Health and Medical Research Council of Australia (APP1110768). References 1 World Health Organization. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. 2016. 2 Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet  2012; 380: 247– 57. Google Scholar CrossRef Search ADS PubMed  3 The World Health Organization quality of life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med  1995; 41: 1403– 9. CrossRef Search ADS PubMed  4 Tennant R, Hiller L, Fishwick R et al.  . The Warwick-Edinburgh mental well-being scale (WEMWBS): development and UK validation. Health Qual life Outcomes  2007; 5: 63. Google Scholar CrossRef Search ADS PubMed  5 Ryan MR, Deci EL. On happiness and human potentials: a review of research on hedonic and eudaimonic well-being. Annu Rev Psychol  2001; 52: 141– 66. Google Scholar CrossRef Search ADS PubMed  6 Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health and ageing. Lancet  2014; 385: 640– 8. Google Scholar CrossRef Search ADS PubMed  7 Lampinen P, Heikkinen R-L, Kauppinen M, Heikkinen E. Activity as a predictor of mental well-being among older adults. Aging Mental Health  2006; 10: 454– 66. Google Scholar CrossRef Search ADS PubMed  8 Vergeer I, Bennie JA, Charity MJ et al.  . Participation trends in holistic movement practices: a 10-year comparison of yoga/ Pilates and t’ai chi/qigong use among a national sample of 195,926 Australians. BMC Complement Altern Med  2017; 17: 296. Google Scholar CrossRef Search ADS PubMed  9 Tran MD, Holly RG, Lashbrook J, Amsterdam EA. Effects of Hatha yoga practice on the health‐related aspects of physical fitness. Preventive Cardiol  2001; 4: 165– 70. Google Scholar CrossRef Search ADS   10 Youkhana S, Dean CM, Wolff M, Sherrington C, Tiedemann A. Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis. Age Ageing  2016; 45: 21– 9. Google Scholar CrossRef Search ADS PubMed  11 Berger BG, Owen DR. Mood alteration with yoga and swimming: aerobic exercise may not be necessary. Perceptual Motor skills  1992; 75: 1331– 43. Google Scholar CrossRef Search ADS PubMed  12 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ  2009; 339, b2535. 13 Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther  2003; 83: 713– 21. Google Scholar PubMed  14 Stewart A, Greenfield S, Hays R et al.  . Functional status and well being of patients with chronic conditions. Results from the Medical Outcomes Study [published erratum appears in JAMA 1989 Nov 10;262(18):2542]. JAMA  1989; 262: 907– 13. Google Scholar CrossRef Search ADS PubMed  15 Banasik J, Williams H, Haberman M, Blank SE, Bendel R. Effect of Iyengar yoga practice on fatigue and diurnal salivary cortisol concentration in breast cancer survivors. J Am Acad Nurse Pract  2011; 23: 135– 42. Google Scholar CrossRef Search ADS PubMed  16 Chen KM, Chen MH, Chao HC, Hung HM, Lin HS, Li CH. Sleep quality, depression state, and health status of older adults after silver yoga exercises: cluster randomized trial. Int J Nurs Stud  2009; 46: 154– 63. Google Scholar CrossRef Search ADS PubMed  17 Cheung C, Wyman JF, Resnick B, Savik K. Yoga for managing knee osteoarthritis in older women: a pilot randomized controlled trial. BMC Complement Altern Med  2014; 14: 160. Google Scholar CrossRef Search ADS PubMed  18 Cheung C, Wyman JF, Bronas U, McCarthy T, Rudser K, Mathiason MA. Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatol Int  2017; 37: 389– 98. Google Scholar CrossRef Search ADS PubMed  19 Cramer H, Pokhrel B, Fester C et al.  . A randomized controlled bicenter trial of yoga for patients with colorectal cancer. Psychooncology  2016; 25: 412– 20. Google Scholar CrossRef Search ADS PubMed  20 Donesky-Cuenco D, Nguyen HQ, Paul S, Carrieri-Kohlman V. Yoga therapy decreases dyspnea-related distress and improves functional performance in people with chronic obstructive pulmonary disease: a pilot study. J Altern Complement Med  2009; 15: 225– 34. Google Scholar CrossRef Search ADS PubMed  21 Hariprasad VR, Sivakumar PT, Koparde V et al.  . Effects of yoga intervention on sleep and quality-of-life in elderly: a randomized controlled trial. Indian J Psychiatry  2013; 55: S364– 368. Google Scholar CrossRef Search ADS PubMed  22 Littman AJ, Bertram LC, Ceballos R et al.  . Randomized controlled pilot trial of yoga in overweight and obese breast cancer survivors: effects on quality of life and anthropometric measures. Support Care Cancer  2012; 20: 267– 77. Google Scholar CrossRef Search ADS PubMed  23 Ni M, Mooney K, Signorile JF. Controlled pilot study of the effects of power yoga in Parkinson’s disease. Complement Ther Med  2016; 25: 126– 31. Google Scholar CrossRef Search ADS PubMed  24 Noradechanunt C, Worsley A, Groeller H. Thai Yoga improves physical function and well-being in older adults: a randomised controlled trial. J Sci Med Sport  2017; 20: 494– 501. Google Scholar CrossRef Search ADS PubMed  25 Oken BS, Zajdel D, Kishiyama S et al.  . Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life. Altern Ther Health Med  2006; 12: 40– 7. Google Scholar PubMed  26 Teut M, Knilli J, Daus D, Roll S, Witt CM. Qigong or yoga versus no intervention in older adults with chronic low back pain-a randomized controlled trial. J Pain  2016; 17: 796– 805. Google Scholar CrossRef Search ADS PubMed  27 Tiedemann A, O’Rourke S, Sherrington C. Is a yoga-based program with potential to decrease falls perceived to be acceptable to community-dwelling people aged 60+? Public Health Res Pract  2018. Epub ahead of print 16.2.18 28 Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: a systematic review and meta-analysis. Depress Anxiety  2013; 30: 1068– 83. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Age and Ageing Oxford University Press

Yoga-based exercise improves health-related quality of life and mental well-being in older people: a systematic review of randomised controlled trials

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© The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
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Abstract

Abstract Objective health-related quality of life (HRQOL) and mental well-being are associated with healthy ageing. Physical activity positively impacts both HRQOL and mental well-being. Yoga is a physical activity that can be modified to suits the needs of older people and is growing in popularity. We conducted a systematic review with meta-analysis to determine the impact of yoga-based exercise on HRQOL and mental well-being in people aged 60+. Methods searches were conducted for relevant trials in the following electronic databases; MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Allied and Complementary Medicine Database, PsycINFO and the Physiotherapy Evidence Database (PEDro) from inception to January 2017. Trials that evaluated the effect of physical yoga on HRQOL and/or on mental well-being in people aged 60+ years were included. Data on HRQOL and mental well-being were extracted. Standardised mean differences and 95% confidence intervals (CI) were calculated using random effects models. Methodological quality of trials was assessed using the PEDro scale. Results twelve trials of high methodological quality (mean PEDro score 6.1), totalling 752 participants, were identified and provided data for the meta-analysis. Yoga produced a medium effect on HRQOL (Hedges’ g = 0.51, 95% CI 0.25–0.76, 12 trials) and a small effect on mental well-being (Hedges’ g = 0.38, 95% CI 0.15–0.62, 12 trials). Conclusion yoga interventions resulted in small to moderate improvements in both HRQOL and mental well-being in people aged 60+ years. Further, research is needed to determine the optimal dose of yoga to maximise health impact. PROSPERO registration number (CRD42016052458) yoga, mental well-being, older people, health-related quality of life, exercise, systematic review Introduction Population ageing is occurring worldwide and presents challenges from a public health perspective, in terms of the increased risk of chronic disease and disability with increasing age [1]. Physical activity plays an important role in reducing these risks and promoting independence in older age, as it impacts on both physical and mental health. Despite the known benefits of an active lifestyle, however, people aged 60 years and over are the most inactive segment of the population [2], highlighting a need for more effective strategies to promote physical activity in this group. Health-related quality of life (HRQOL) is a multi-dimensional concept that incorporates the different domains of health; physical, mental, emotional and social functioning, and how these impact on overall health status [3]. HRQOL encompasses more than just direct measures of population health, life expectancy and causes of death, and acknowledges that an individual’s capacity to interact and participate with their environment is important for maximising overall quality of life. Mental well-being is a related concept and is also known to impact on health status [4]. Mental well-being is more than the absence of mental illness, and involves both feeling good and functioning well. It encompasses two perspectives: (i) the subjective experience of happiness (affect) and life satisfaction; and (ii) positive psychological functioning, good relationships with others and self-realisation [5]. Mental well-being is associated with a lower risk of early mortality [6] and underpins healthy ageing [1]. Older adults with higher levels of mental well-being attribute this to higher levels of activity and better health and mobility status [7]. Despite the importance of these aspects of health, there is a paucity of research evaluating interventions to promote mental well-being and HRQOL in older age [6]. Yoga is a mind–body physical activity that includes a combination of stretching and holding movements and postures in addition to meditation and focused breathing. Yoga is growing in popularity among older people [8] and is associated with significant health benefits such as improved strength, flexibility [9], balance and mobility [10] and mood [11]. The physical and mental benefits associated with yoga suggest that it has the potential to produce improvements in the overall quality of life. However, yoga’s effect on mental well-being in people aged 65 years and older has not been properly evaluated and there is currently no published systematic review that synthesises the evidence for the effect of yoga on HRQOL and mental well-being among older people. This current systematic review builds on a previous systematic review [10] conducted by our research group that highlighted the role of yoga for improving balance and mobility among people aged 60 years and older with a broad range of health states. The current systematic reviewed aimed to answer the following questions: What is the effect of yoga-based exercise on HRQOL in adults aged 60 years and older? What is the effect of yoga-based exercise on mental well-being in adults aged 60 years and older? In order to make recommendations based on the highest level of evidence, this review only included randomised controlled trials (RCTs). Method Design We conducted a systematic review according to the PRISMA statement [12] and the review protocol was registered on PROSPERO prior to commencement (CRD42016052458). See Appendix 1 is available in Age and Ageing online for PRISMA checklist. Search strategy and study selection criteria Electronic databases including MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database (AMED), PsycINFO and the Physiotherapy Evidence Database (PEDro) were used to search for papers published up until 30 January 2017 without language restrictions. No restriction was placed on the setting or context of the included studies. Search terms included words relating to yoga, randomised controlled trial and age (see Appendix 2 is available in Age and Ageing online for search strategies). Two independent reviewers (AT and HB) initially screened potentially eligible studies using title and abstract and then examined the full texts of potentially relevant papers for inclusion against predetermined criteria (Box 1). Conflict was resolved by discussion with a third reviewer (CD). Box 1. Inclusion criteria Design: Randomised controlled trials. Participants: Mean age 60 years and over. Interventions: Physical yoga programmes (excluding meditation and breathing exercises alone). No limitation was placed on the type, duration and frequency of yoga intervention. Control: No intervention, usual care or wait-list control. Outcomes measured: HRQOL and/or mental well-being measures. Characteristics of included studies Quality The PEDro scale scores extracted from the PEDro (www.pedro.org.au) were used to evaluate the quality of included studies. The PEDro scale uses a rating scale from 0 to 10 to determine the methodological quality of randomised controlled trials [13]. A PEDro score of 8/10 is considered the maximum attainable score for yoga studies as it is not feasible to blind treating yoga instructors and participants during yoga-based interventions. Participants Trials that included participants with a mean age of 60 years and over were eligible for inclusion with no restrictions on the characteristics of the population. Intervention We included studies, where the intervention involved physical yoga and excluded those studies where the yoga involved meditation and breathing exercises alone. There were no limitations placed on the type, duration and frequency of the intervention. Session duration and frequency, yoga type and instructor qualifications were recorded in order to assess the similarity of the studies. The control group was defined as wait-list control, no intervention, education only or usual care. Outcome measures Trials were included if a HRQOL and/or mental well-being measure was taken pre- and post-intervention. Any validated, standardised clinical measure of HRQOL and/or mental well-being such as (but not limited to) the Short form-36 (SF-36) [14], or World Health Organization Quality of Life instrument (WHOQOL) [3], were included. Data extraction and analysis Data were extracted regarding trial characteristics and estimates of effect using a pilot-tested data extraction form by two reviewers (AT and HB) and cross-checked by a third reviewer (ATie). Authors were contacted via email to obtain further information if there were insufficient data included in the publication. Duplicate publications were identified and excluded by comparing authors, interventions, outcomes and sample sizes of eligible trials. The pre- and post-intervention means and standard deviations for each study group were extracted to obtain the pooled estimate of the effect of intervention. Details of the setting, participants, yoga programme components and dose, adverse events, outcome measures and PEDro score were summarised descriptively. The meta-analyses were conducted using Comprehensive Meta-analysis software (Version 2, Biostat, Englewood, NJ, USA). Intervention effect sizes for HRQOL and mental well-being, standardised mean differences (SMDs) using Hedges’ g statistic, and 95% confidence intervals (CIs) were calculated. Effect sizes were categorised as small (0.2), medium (0.5) and large (0.8 or greater). Statistical heterogeneity was quantified using the I2 statistic: I2 of more than 75% indicates considerable heterogeneity, I2 of 50–75% indicates substantial heterogeneity, and I2 of less than 40% indicates limited heterogeneity. We also investigated the presence of small study effects by using a funnel plot of the effect estimates from included studies. The funnel plot was assessed by visual inspection and by using Egger’s test, with P < 0.1 as evidence of small study effects. Results Flow of studies through the review A total of 1,350 studies (excluding duplicates) were identified. After screening, 12 eligible randomised controlled trials [15–26] were included for our systematic review and meta-analysis to evaluate the effect of yoga on HRQOL and mental well-being. Figure 1 outlines the flow of studies through the review. Figure 1 View largeDownload slide Flow of studies through the review. *Papers may have been excluded for failing to meet more than one inclusion criteria. Figure 1 View largeDownload slide Flow of studies through the review. *Papers may have been excluded for failing to meet more than one inclusion criteria. Characteristics of included trials The 12 studies included in the meta-analysis included a total of 752 participants. Table 1 provides a summary of the characteristics of the trials, including the participant’s age, gender and health status, intervention details, dose, class attendance, and outcome measures. Table 1. Summary of included studies Study country, PEDro score  Participants  Intervention  Adherencea  Outcome measures  Banasik et al. [15] USA, 4  N = 14, mean age: 63, 14 females. Breast cancer  Iyengar yoga, 90 min, 2/week, 8 weeks  88%  HRQOL: FACT-Breast, Physical well-being MW: FACT-Breast, Emotional well-being  Chen et al. [16] Taiwan, 5  N = 128, mean age: 69, 93 females. Community-dwellers  Silver (hatha) yoga, 70 min, 3/week, 24 weeks  87%  HRQOL: SF-12 Physical health perception MW: SF-12 MCS  Cheung et al. [18] USA, 7  N = 55, mean age: 72, 46 females. Knee osteoarthritis  Hatha yoga, 45 min, 1/week, 8 weeks + home practice  63% attended ≥50% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cheung et al. [17] USA, 8  N = 36, mean age: 72, 36 females. Knee osteoarthritis  Hatha yoga, 60 min, 1/week, 8 weeks + home practice  69% attended ≥75% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cramer et al. [19] Germany, 6  N = 54, mean age: 68, 21 females. Colorectal cancer  Hatha yoga, 90 min, 1/week, 10 weeks + home practice  50%  HRQOL: FACT-Colorectal, Physical well-being MW: FACT-Colorectal, Emotional well-being  Donesky-Cuenco et al. [20] USA, 5  N = 29, mean age: 70, 21 females. COPD  Iyengar yoga, 60 min, 2/week, 12 weeks + home practice  83%  HRQOL: SF-36 PCS MW: SF-36 MCS  Hariprasad et al. [21] India, 6  N = 120, mean age: 75, 72 females. Elderly care homes  Yogasana yoga, 60 min, 7/week, 4 weeks, then 60 min, 1/week, 8 weeks + home practice  Not reported  HRQOL: WHOQOL Physical health QOL MW: WHOQOL Psychological Health QOL  Littman et al. [22] USA, 6  N = 57, mean age: 60, 57 females. Breast cancer  Viniyoga, 75 min, 1/week, 26 weeks + home practice  77%  HRQOL: FACT-General Physical well-being. MW: FACT-General Emotional well-being  Ni et al. [23] USA, 5  N = 27, mean age: 73, 10 females. Parkinson’s Disease  Vinyasa yoga, 60 min, 2/week, 12 weeks  92%  HRQOL: 39-item Parkinson’s Disease Questionnaire (PDQ-39). MW: PDQ-39 Emotional well-being  Noradechanunt et al. [24] Australia, 8  N = 26, mean age: 67, 20 females. Community-dwellers  Thai yoga, 80 min, 2/week, 12 weeks  96%  HRQOL: SF-36 PCS MW: SF-36 MCS  Oken et al. [25] USA, 6  N = 88, mean age: 71, 64 females. Community-dwellers  Iyengar yoga, 90 min, 1/week, 24 weeks + daily home practice  78%  HRQOL: SF-36 PCS MW: SF-36 MCS  Teut et al. [26], Germany, 7  N = 118, mean age: 73, 106 females. Low back pain  Viniyoga, 45 min, 2/week, 12 weeks  74% attended ≥75% classes  HRQOL: SF-36 PCS MW: SF-36 MCS  Study country, PEDro score  Participants  Intervention  Adherencea  Outcome measures  Banasik et al. [15] USA, 4  N = 14, mean age: 63, 14 females. Breast cancer  Iyengar yoga, 90 min, 2/week, 8 weeks  88%  HRQOL: FACT-Breast, Physical well-being MW: FACT-Breast, Emotional well-being  Chen et al. [16] Taiwan, 5  N = 128, mean age: 69, 93 females. Community-dwellers  Silver (hatha) yoga, 70 min, 3/week, 24 weeks  87%  HRQOL: SF-12 Physical health perception MW: SF-12 MCS  Cheung et al. [18] USA, 7  N = 55, mean age: 72, 46 females. Knee osteoarthritis  Hatha yoga, 45 min, 1/week, 8 weeks + home practice  63% attended ≥50% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cheung et al. [17] USA, 8  N = 36, mean age: 72, 36 females. Knee osteoarthritis  Hatha yoga, 60 min, 1/week, 8 weeks + home practice  69% attended ≥75% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cramer et al. [19] Germany, 6  N = 54, mean age: 68, 21 females. Colorectal cancer  Hatha yoga, 90 min, 1/week, 10 weeks + home practice  50%  HRQOL: FACT-Colorectal, Physical well-being MW: FACT-Colorectal, Emotional well-being  Donesky-Cuenco et al. [20] USA, 5  N = 29, mean age: 70, 21 females. COPD  Iyengar yoga, 60 min, 2/week, 12 weeks + home practice  83%  HRQOL: SF-36 PCS MW: SF-36 MCS  Hariprasad et al. [21] India, 6  N = 120, mean age: 75, 72 females. Elderly care homes  Yogasana yoga, 60 min, 7/week, 4 weeks, then 60 min, 1/week, 8 weeks + home practice  Not reported  HRQOL: WHOQOL Physical health QOL MW: WHOQOL Psychological Health QOL  Littman et al. [22] USA, 6  N = 57, mean age: 60, 57 females. Breast cancer  Viniyoga, 75 min, 1/week, 26 weeks + home practice  77%  HRQOL: FACT-General Physical well-being. MW: FACT-General Emotional well-being  Ni et al. [23] USA, 5  N = 27, mean age: 73, 10 females. Parkinson’s Disease  Vinyasa yoga, 60 min, 2/week, 12 weeks  92%  HRQOL: 39-item Parkinson’s Disease Questionnaire (PDQ-39). MW: PDQ-39 Emotional well-being  Noradechanunt et al. [24] Australia, 8  N = 26, mean age: 67, 20 females. Community-dwellers  Thai yoga, 80 min, 2/week, 12 weeks  96%  HRQOL: SF-36 PCS MW: SF-36 MCS  Oken et al. [25] USA, 6  N = 88, mean age: 71, 64 females. Community-dwellers  Iyengar yoga, 90 min, 1/week, 24 weeks + daily home practice  78%  HRQOL: SF-36 PCS MW: SF-36 MCS  Teut et al. [26], Germany, 7  N = 118, mean age: 73, 106 females. Low back pain  Viniyoga, 45 min, 2/week, 12 weeks  74% attended ≥75% classes  HRQOL: SF-36 PCS MW: SF-36 MCS  FACT, Functional Assessment of Cancer Therapy; PCS, physical component score; MCS, mental component score; QOL, quality of life. aAverage number of classes attended across all participants. Table 1. Summary of included studies Study country, PEDro score  Participants  Intervention  Adherencea  Outcome measures  Banasik et al. [15] USA, 4  N = 14, mean age: 63, 14 females. Breast cancer  Iyengar yoga, 90 min, 2/week, 8 weeks  88%  HRQOL: FACT-Breast, Physical well-being MW: FACT-Breast, Emotional well-being  Chen et al. [16] Taiwan, 5  N = 128, mean age: 69, 93 females. Community-dwellers  Silver (hatha) yoga, 70 min, 3/week, 24 weeks  87%  HRQOL: SF-12 Physical health perception MW: SF-12 MCS  Cheung et al. [18] USA, 7  N = 55, mean age: 72, 46 females. Knee osteoarthritis  Hatha yoga, 45 min, 1/week, 8 weeks + home practice  63% attended ≥50% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cheung et al. [17] USA, 8  N = 36, mean age: 72, 36 females. Knee osteoarthritis  Hatha yoga, 60 min, 1/week, 8 weeks + home practice  69% attended ≥75% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cramer et al. [19] Germany, 6  N = 54, mean age: 68, 21 females. Colorectal cancer  Hatha yoga, 90 min, 1/week, 10 weeks + home practice  50%  HRQOL: FACT-Colorectal, Physical well-being MW: FACT-Colorectal, Emotional well-being  Donesky-Cuenco et al. [20] USA, 5  N = 29, mean age: 70, 21 females. COPD  Iyengar yoga, 60 min, 2/week, 12 weeks + home practice  83%  HRQOL: SF-36 PCS MW: SF-36 MCS  Hariprasad et al. [21] India, 6  N = 120, mean age: 75, 72 females. Elderly care homes  Yogasana yoga, 60 min, 7/week, 4 weeks, then 60 min, 1/week, 8 weeks + home practice  Not reported  HRQOL: WHOQOL Physical health QOL MW: WHOQOL Psychological Health QOL  Littman et al. [22] USA, 6  N = 57, mean age: 60, 57 females. Breast cancer  Viniyoga, 75 min, 1/week, 26 weeks + home practice  77%  HRQOL: FACT-General Physical well-being. MW: FACT-General Emotional well-being  Ni et al. [23] USA, 5  N = 27, mean age: 73, 10 females. Parkinson’s Disease  Vinyasa yoga, 60 min, 2/week, 12 weeks  92%  HRQOL: 39-item Parkinson’s Disease Questionnaire (PDQ-39). MW: PDQ-39 Emotional well-being  Noradechanunt et al. [24] Australia, 8  N = 26, mean age: 67, 20 females. Community-dwellers  Thai yoga, 80 min, 2/week, 12 weeks  96%  HRQOL: SF-36 PCS MW: SF-36 MCS  Oken et al. [25] USA, 6  N = 88, mean age: 71, 64 females. Community-dwellers  Iyengar yoga, 90 min, 1/week, 24 weeks + daily home practice  78%  HRQOL: SF-36 PCS MW: SF-36 MCS  Teut et al. [26], Germany, 7  N = 118, mean age: 73, 106 females. Low back pain  Viniyoga, 45 min, 2/week, 12 weeks  74% attended ≥75% classes  HRQOL: SF-36 PCS MW: SF-36 MCS  Study country, PEDro score  Participants  Intervention  Adherencea  Outcome measures  Banasik et al. [15] USA, 4  N = 14, mean age: 63, 14 females. Breast cancer  Iyengar yoga, 90 min, 2/week, 8 weeks  88%  HRQOL: FACT-Breast, Physical well-being MW: FACT-Breast, Emotional well-being  Chen et al. [16] Taiwan, 5  N = 128, mean age: 69, 93 females. Community-dwellers  Silver (hatha) yoga, 70 min, 3/week, 24 weeks  87%  HRQOL: SF-12 Physical health perception MW: SF-12 MCS  Cheung et al. [18] USA, 7  N = 55, mean age: 72, 46 females. Knee osteoarthritis  Hatha yoga, 45 min, 1/week, 8 weeks + home practice  63% attended ≥50% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cheung et al. [17] USA, 8  N = 36, mean age: 72, 36 females. Knee osteoarthritis  Hatha yoga, 60 min, 1/week, 8 weeks + home practice  69% attended ≥75% classes  HRQOL: SF-12 PCS MW: SF-12 MCS  Cramer et al. [19] Germany, 6  N = 54, mean age: 68, 21 females. Colorectal cancer  Hatha yoga, 90 min, 1/week, 10 weeks + home practice  50%  HRQOL: FACT-Colorectal, Physical well-being MW: FACT-Colorectal, Emotional well-being  Donesky-Cuenco et al. [20] USA, 5  N = 29, mean age: 70, 21 females. COPD  Iyengar yoga, 60 min, 2/week, 12 weeks + home practice  83%  HRQOL: SF-36 PCS MW: SF-36 MCS  Hariprasad et al. [21] India, 6  N = 120, mean age: 75, 72 females. Elderly care homes  Yogasana yoga, 60 min, 7/week, 4 weeks, then 60 min, 1/week, 8 weeks + home practice  Not reported  HRQOL: WHOQOL Physical health QOL MW: WHOQOL Psychological Health QOL  Littman et al. [22] USA, 6  N = 57, mean age: 60, 57 females. Breast cancer  Viniyoga, 75 min, 1/week, 26 weeks + home practice  77%  HRQOL: FACT-General Physical well-being. MW: FACT-General Emotional well-being  Ni et al. [23] USA, 5  N = 27, mean age: 73, 10 females. Parkinson’s Disease  Vinyasa yoga, 60 min, 2/week, 12 weeks  92%  HRQOL: 39-item Parkinson’s Disease Questionnaire (PDQ-39). MW: PDQ-39 Emotional well-being  Noradechanunt et al. [24] Australia, 8  N = 26, mean age: 67, 20 females. Community-dwellers  Thai yoga, 80 min, 2/week, 12 weeks  96%  HRQOL: SF-36 PCS MW: SF-36 MCS  Oken et al. [25] USA, 6  N = 88, mean age: 71, 64 females. Community-dwellers  Iyengar yoga, 90 min, 1/week, 24 weeks + daily home practice  78%  HRQOL: SF-36 PCS MW: SF-36 MCS  Teut et al. [26], Germany, 7  N = 118, mean age: 73, 106 females. Low back pain  Viniyoga, 45 min, 2/week, 12 weeks  74% attended ≥75% classes  HRQOL: SF-36 PCS MW: SF-36 MCS  FACT, Functional Assessment of Cancer Therapy; PCS, physical component score; MCS, mental component score; QOL, quality of life. aAverage number of classes attended across all participants. Quality The mean PEDro score of the included studies was 6.1 (range 4–8). Randomisation occurred in all 12 trials. One study scored four out of 10 [15], three studies scored five out of 10 [16, 20, 23], four studies scored six out of 10 [19, 21, 22, 25], two studies scored seven out of 10 [18, 26] and two studies scored eight out of 10 [17, 24]. PEDro scores are included in Table 1. Apart from lack of blinding of participants and therapists (which is not possible in these trials) the most commonly unmet item was blinding of assessors. Participants The mean age of participants ranged from 60 to 75 years. Participants were recruited from both community and residential aged care settings. Three of the studies included participants who were healthy community-dwelling older adults [16, 24, 25], two recruited participants with knee osteoarthritis [17, 18], two recruited breast cancer survivors [15, 22], one recruited participants with Parkinson’s disease [23], one recruited participants from elderly care homes [21], one recruited participants with chronic obstructive pulmonary disease (COPD) [20], one recruited participants who had completed treatment for colorectal cancer [19] and one trial recruited participants with chronic back pain [26]. Both men and women were included in all but three studies [15, 17, 22], which included females only, and 74% (560/752) of included participants were female. Intervention In all studies, the experimental group received a physical yoga intervention. The included yoga styles were Hatha [16–19], Yogasana [21], Vinyasa [23], Thai Yoga [24], Iyengar [15, 20, 25] and Viniyoga [22, 26]. Participants undertook 45–90 min of yoga per session, during 1–3 classes per week for 8–24 weeks in total. Seven [17–22, 25] of the yoga programmes included a home yoga programme for participants to complete 4–7 times per week. In nine of the studies, the control group received no intervention or wait-list control/usual care [15–17, 19–22, 25, 26] and in three studies they received education about exercise [18, 23, 24]. All yoga interventions were delivered by qualified yoga instructors, with some using props such as chairs, blankets, blocks and straps to provide comfort and support. Class content included poses carried out in standing, sitting and lying on the floor. The mean proportion of yoga sessions attended ranged from 53 to 96%. Adverse events All but one of the included trials [15] measured adverse events related to the yoga intervention. Seven of the trials reported no adverse events [16, 18, 20–23, 26]. Two of the trials reported drop out due to knee pain [17, 24]. One trial reported a minor groin strain in the yoga group however it did not preclude their participation in the study [25]. One trial [19] reported several adverse events including abdominal pain (n = 1 participant), muscle soreness (n = 3), neck pain (n = 1), minor vertigo (n = 1) and hip pain requiring analgesic (n = 1). Exploration of small study effects Visual inspection of the funnel plots suggested no indication of asymmetry and thus a low likelihood of small study effects in the results for both HRQOL and mental well-being. Egger’s test confirmed this assumption for both HRQOL and mental well-being (P = 0.33 and P = 0.28, respectively). However, given the small numbers of studies involved, these analyses may be underpowered. Outcome measures HRQOL and mental well-being were measured in all included trials. For measures of HRQOL four studies used the SF-36 physical composite summary [20, 24–26], three studies used the SF-12 physical component summary score [16–18], one study used the WHOQOL physical health QOL score [21], one study used the PDQ-39 sum score [3] and three studies used variations of the physical well-being subscale of the Functional Assessment of Cancer Therapy (FACT) for general [22], breast cancer [15] and for colorectal cancer [19]. Despite the different scales used, on examination of their content we considered that there was sufficient consistency in the types of questions included and the aspects of QOL assessed for the data to be pooled for analysis. Mental well-being was measured with the SF-36 mental component summary score in four studies [20, 24–26], three studies used the SF-12 mental composite score [16–18], one study used the WHOQOL psychological health QOL score [21], one study used the PDQ-39 emotional well-being score [23], and three studies variations of the emotional well-being subscale of the FACT for general [22], breast cancer [15] and for colorectal cancer [19]. Despite the different scales used, on examination of their content we considered that there was sufficient consistency in the types of questions included and the aspects of mental well-being assessed for the data to be pooled for analysis. Effect of yoga on HRQOL The effect sizes from individual trials for the effect of yoga on HRQOL involving 12 trials and 752 participants are shown in Figure 2. The pooled estimate of the effect of yoga on HRQOL indicates a medium and statistically significant effect on HRQOL compared to control participants (SMD 0.51, 95% CI 0.25–0.76, P < 0.001). There was an indication of moderate heterogeneity in the estimate of the effect of the intervention (I2 = 62.9%, P = 0.002). Figure 2 View largeDownload slide Effect size (95% CI) of yoga on HRQOL by pooling data from 12 studies comparing yoga versus control using random effects meta-analysis (n = 752). Figure 2 View largeDownload slide Effect size (95% CI) of yoga on HRQOL by pooling data from 12 studies comparing yoga versus control using random effects meta-analysis (n = 752). Effect of yoga on mental well-being The effect sizes from individual trials for the effect of yoga on mental well-being involving 12 trials and 752 participants are shown in Figure 3. The pooled estimate of the effect of yoga on mental well-being indicates a small and statistically significant effect on mental well-being compared to control participants (SMD 0.38, 95% CI 0.15–0.62, P = 0.001). There was an indication of moderate heterogeneity in the estimate of the effect of the intervention (I2=56.3%, P = 0.009). Figure 3 View largeDownload slide Effect size (95% CI) of yoga on mental well-being by pooling data from 12 studies comparing yoga versus control using random effects meta-analysis (n = 752). Figure 3 View largeDownload slide Effect size (95% CI) of yoga on mental well-being by pooling data from 12 studies comparing yoga versus control using random effects meta-analysis (n = 752). The review also aimed to assess the differential impact of yoga-based exercise on HRQOL and mental well-being in people aged 60 and older on the basis of programme or population characteristics. However, we could not achieve this due to the small number of trials identified. Discussion This systematic review and meta-analysis included 12 trials of moderate to high methodological quality that found physical yoga improved HRQOL and mental well-being in people aged 60 years and over. The magnitude of the effect of yoga interventions on HRQOL (SMD = 0.51) and mental well-being (SMD = 0.38) demonstrates a small to moderate potential of physical yoga to improve these outcomes in older people. These results are in accordance with the previous research that has identified yoga as a form of physical activity that older people enjoy and perceive to be appropriate [27], and that has a beneficial effect on important aspects of health such as balance and mobility [10] and symptoms of depression [28]. The trials included in this review used modified postures in standing, seated and supine and some utilised props such as blocks, blankets and straps to adapt the yoga poses to the needs of older people. All trial interventions were implemented by trained yoga therapists and instructors, and several modes of yoga were included. Yoga was also found to be safe and feasible for older people to take part in with no serious adverse events reported. It is not clear how much of the impact on HRQOL and mental well-being can be attributed to the practice of yoga poses as opposed to the relaxation and meditation aspects of yoga that were included alongside each other in many of the included trials. Further research is required to determine the specific attributes of yoga programmes that contribute the most to improvements in HRQOL and mental well-being in older age. To our knowledge, this is the first meta-analysis of randomised controlled trials to evaluate the impact of physical yoga on HRQOL and mental well-being in older adults. This systematic review was prospectively registered with PROSPERO prior to screening the data and was not restricted by publication language or date. A key strength of this study is that included trials involved participants with a broad range of health conditions, including chronic back pain [26], Parkinson’s disease [23], osteoarthritis [17, 18], COPD [20], cancer [15, 19, 22] and also included people residing in elderly care homes [21] as well as healthy community-dwelling older adults [16, 24, 25], demonstrating the suitability of yoga-based exercise for older people with differing health states and abilities as well as for healthy older people. This result indicates to health professionals that yoga interventions are a safe and feasible exercise option for people aged 60 years and over to improve HRQOL and mental well-being. We acknowledge there are limitations to this review. We only included trials where the intervention was some form of physical yoga, since we sought to determine the impact of exercise-based yoga on the outcomes of interest, hence we excluded trials that evaluated the impact of relaxation/ meditation type yoga as a single intervention. Therefore, the impact of other forms of yoga on HRQOL and mental well-being cannot be determined from our results. Additionally, the measures of HRQOL analysed in this review mainly focused on the physical domains of HRQOL, obtained from a number of different general and disease-specific, validated tools. The results therefore provide less certainty about the impact of yoga on other important domains of HRQOL such as emotional and social functioning. We chose to use the PEDro scale to measure risk of bias; however, the Cochrane risk of bias tool could also have been used. The best way to assess risk of bias in trials of yoga interventions is not clear and warrants further investigation. A source of bias in the studies of this review was the inability to blind therapists and patients, however this is unavoidable in trials that seek to determine the impact of exercise-based interventions. The included trials also had small sample sizes, with a total of 752 participants for all eight trials. This makes it difficult to draw conclusions about the implications of the results for the broader population of older people. Additionally, the heterogeneity among the studies was moderate which creates uncertainty about the generalisability of these results. Due to the small number of studies included in this review, we were unable to complete a meta-regression analysis which makes it difficult to determine if there are differential effects of yoga on the outcome measures with higher doses of yoga and in different clinical populations. While this review provides evidence of the beneficial effect of physical yoga on HRQOL and mental well-being in people aged 60 years and over, further research is required to identify the optimal dose, type and frequency of yoga programme that maximises health outcomes. Future studies should include a longer duration intervention to explore the potential additional impact on HRQOL and mental well-being. Conclusion Maintenance of HRQOL and mental well-being in older age is associated with healthy ageing, making strategies that promote these outcomes important. The results of this systematic review demonstrate that adults aged 60 years and over can improve their HRQOL and mental well-being through participation in yoga programmes. Future research is needed to identify the optimal frequency and duration of yoga programmes for maximising improvements in HRQOL and mental well-being. Key Points Health professionals can confidently recommend physical yoga to improve health-related quality of life (HRQOL) and mental well-being in adults aged 60 years and over. Yoga is a safe and feasible physical activity option for older adults. Research is required to identify the optimal yoga dose, type and intensity to maximise health-related quality of life (HRQOL) and mental well-being. Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Author’s contribution ATie and CD conceived the study and contributed to study design and interpretation of the data. AT and HB coordinated the literature search and data collection with assistance from ATie and CD. ATie, HB and AT contributed to the data analysis, interpretation of the data and drafted the manuscript. All authors had access to the data and data analysis, contributed to revisions and approved the final manuscript. ATie is the guarantor of the study. Conflicts of interest None. Funding A Tiedemann is supported by a Research Fellowship from the National Health and Medical Research Council of Australia (APP1110768). References 1 World Health Organization. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. 2016. 2 Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet  2012; 380: 247– 57. Google Scholar CrossRef Search ADS PubMed  3 The World Health Organization quality of life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med  1995; 41: 1403– 9. CrossRef Search ADS PubMed  4 Tennant R, Hiller L, Fishwick R et al.  . The Warwick-Edinburgh mental well-being scale (WEMWBS): development and UK validation. Health Qual life Outcomes  2007; 5: 63. Google Scholar CrossRef Search ADS PubMed  5 Ryan MR, Deci EL. On happiness and human potentials: a review of research on hedonic and eudaimonic well-being. Annu Rev Psychol  2001; 52: 141– 66. Google Scholar CrossRef Search ADS PubMed  6 Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health and ageing. Lancet  2014; 385: 640– 8. Google Scholar CrossRef Search ADS PubMed  7 Lampinen P, Heikkinen R-L, Kauppinen M, Heikkinen E. Activity as a predictor of mental well-being among older adults. Aging Mental Health  2006; 10: 454– 66. Google Scholar CrossRef Search ADS PubMed  8 Vergeer I, Bennie JA, Charity MJ et al.  . Participation trends in holistic movement practices: a 10-year comparison of yoga/ Pilates and t’ai chi/qigong use among a national sample of 195,926 Australians. BMC Complement Altern Med  2017; 17: 296. Google Scholar CrossRef Search ADS PubMed  9 Tran MD, Holly RG, Lashbrook J, Amsterdam EA. Effects of Hatha yoga practice on the health‐related aspects of physical fitness. Preventive Cardiol  2001; 4: 165– 70. Google Scholar CrossRef Search ADS   10 Youkhana S, Dean CM, Wolff M, Sherrington C, Tiedemann A. Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis. Age Ageing  2016; 45: 21– 9. Google Scholar CrossRef Search ADS PubMed  11 Berger BG, Owen DR. Mood alteration with yoga and swimming: aerobic exercise may not be necessary. Perceptual Motor skills  1992; 75: 1331– 43. Google Scholar CrossRef Search ADS PubMed  12 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ  2009; 339, b2535. 13 Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther  2003; 83: 713– 21. Google Scholar PubMed  14 Stewart A, Greenfield S, Hays R et al.  . Functional status and well being of patients with chronic conditions. Results from the Medical Outcomes Study [published erratum appears in JAMA 1989 Nov 10;262(18):2542]. JAMA  1989; 262: 907– 13. Google Scholar CrossRef Search ADS PubMed  15 Banasik J, Williams H, Haberman M, Blank SE, Bendel R. Effect of Iyengar yoga practice on fatigue and diurnal salivary cortisol concentration in breast cancer survivors. J Am Acad Nurse Pract  2011; 23: 135– 42. Google Scholar CrossRef Search ADS PubMed  16 Chen KM, Chen MH, Chao HC, Hung HM, Lin HS, Li CH. Sleep quality, depression state, and health status of older adults after silver yoga exercises: cluster randomized trial. Int J Nurs Stud  2009; 46: 154– 63. Google Scholar CrossRef Search ADS PubMed  17 Cheung C, Wyman JF, Resnick B, Savik K. Yoga for managing knee osteoarthritis in older women: a pilot randomized controlled trial. BMC Complement Altern Med  2014; 14: 160. Google Scholar CrossRef Search ADS PubMed  18 Cheung C, Wyman JF, Bronas U, McCarthy T, Rudser K, Mathiason MA. Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatol Int  2017; 37: 389– 98. Google Scholar CrossRef Search ADS PubMed  19 Cramer H, Pokhrel B, Fester C et al.  . A randomized controlled bicenter trial of yoga for patients with colorectal cancer. Psychooncology  2016; 25: 412– 20. Google Scholar CrossRef Search ADS PubMed  20 Donesky-Cuenco D, Nguyen HQ, Paul S, Carrieri-Kohlman V. Yoga therapy decreases dyspnea-related distress and improves functional performance in people with chronic obstructive pulmonary disease: a pilot study. J Altern Complement Med  2009; 15: 225– 34. Google Scholar CrossRef Search ADS PubMed  21 Hariprasad VR, Sivakumar PT, Koparde V et al.  . Effects of yoga intervention on sleep and quality-of-life in elderly: a randomized controlled trial. Indian J Psychiatry  2013; 55: S364– 368. Google Scholar CrossRef Search ADS PubMed  22 Littman AJ, Bertram LC, Ceballos R et al.  . Randomized controlled pilot trial of yoga in overweight and obese breast cancer survivors: effects on quality of life and anthropometric measures. Support Care Cancer  2012; 20: 267– 77. Google Scholar CrossRef Search ADS PubMed  23 Ni M, Mooney K, Signorile JF. Controlled pilot study of the effects of power yoga in Parkinson’s disease. Complement Ther Med  2016; 25: 126– 31. Google Scholar CrossRef Search ADS PubMed  24 Noradechanunt C, Worsley A, Groeller H. Thai Yoga improves physical function and well-being in older adults: a randomised controlled trial. J Sci Med Sport  2017; 20: 494– 501. Google Scholar CrossRef Search ADS PubMed  25 Oken BS, Zajdel D, Kishiyama S et al.  . Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life. Altern Ther Health Med  2006; 12: 40– 7. Google Scholar PubMed  26 Teut M, Knilli J, Daus D, Roll S, Witt CM. Qigong or yoga versus no intervention in older adults with chronic low back pain-a randomized controlled trial. J Pain  2016; 17: 796– 805. Google Scholar CrossRef Search ADS PubMed  27 Tiedemann A, O’Rourke S, Sherrington C. Is a yoga-based program with potential to decrease falls perceived to be acceptable to community-dwelling people aged 60+? Public Health Res Pract  2018. Epub ahead of print 16.2.18 28 Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: a systematic review and meta-analysis. Depress Anxiety  2013; 30: 1068– 83. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Age and AgeingOxford University Press

Published: Mar 23, 2018

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