Yoga for Quality of Life and Balance in Postmenopausal Osteoporosis
Abstract & Commentary
By Judith L. Balk, MD. Dr. Balk is Associate Professor, Magee-Women's Hospital, University of Pittsburgh; she reports no financial relationship to this field of study.
Synopsis: Yoga and exercise are commonly recommended for patients with osteoporosis. Yoga improves balance, and both yoga and exercise improve quality of life in postmenopausal women with osteoporosis. However, the study is limited by small sample size and lack of detail in the research methodology.
Source: Tüzün S, et al. Yoga might be an alternative training for the quality of life and balance in postmenopausal osteoporosis. Eur J Phys Rehabil Med 2010;46:69-72.
Yoga may be beneficial for women with osteoporosis as suggested by prior studies showing positive effects on strength, balance, and quality of life. This study aimed to evaluate the effect of yoga exercises on balance and life quality in postmenopausal osteoporotic women, and to compare the results with a classic exercise program used to forestall or prevent osteoporosis.
Twenty-six postmenopausal osteoporotic women older than age 55 were enrolled in the study. Subjects in this study also were participating in a drug trial being performed in the Division of Osteoporosis at Istanbul University Cerrahpasa School of Medicine. The study is described as being both observational and randomized; the methodology is unclear. The yoga group received Hatha yoga education for 1 hour, twice per week, for 12 weeks. The exercise group received strengthening and stretching exercise education for 1 hour, twice per week, for 12 weeks. The outcome variables were balance, as measured by a neuromuscular test battery, and quality of life, as measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). A classic osteoporosis exercise program was the comparison group.
Groups were similar at baseline. Balance improved significantly from baseline to the end of the intervention in the yoga group but not in the exercise group; however, the differences between groups at the end of the intervention were not statistically different. Three variables within the quality-of-life measurement improved in the exercise group (pain, household activities, and total score), whereas every variable improved in the yoga group (pain, daily living, household activities, mobility, social activities, general health assessment, mental health, and total score).
The authors concluded that yoga may be an appropriate physical activity for those with osteoporosis.
Commentary
The idea of using yoga for women with osteoporosis is well-supported. Yoga has the potential to reduce the risk of fracture via several mechanisms: improving bone mass1 due to the weight-bearing nature of yoga, reducing the risk of falls due to improved strength and balance,2-4 and improving daily functioning via enhanced quality of life, improved body mechanics, and reduced pain.5,6 Decreased functional impairment facilitates exercise, decreases medication usage, and lessens depression and the associated stress hormones, which can induce bone loss.7 Hyperkyphosis improves with yoga, thus improving posture, and decreasing pain and the likelihood of falling.8-10
Strength-training exercise often is recommended for improving bone density; however, it is not known what the ideal form of exercise is in the settings of osteopenia and osteoporosis. Perhaps it is a standard strength- training regimen using handweights. Perhaps it is yoga, with its beneficial effects on strength and capacity to induce a sense of relaxation. Perhaps it is the exercise form with which the patient will enjoy and thus be compliant over the long term. A fairly long, adequately powered, randomized, controlled trial will be necessary to answer the question of whether yoga is better than standard strength training; many trials likely will be necessary to find the "ideal" exercise regimen, if one exists.
Unfortunately, this study does not lead us closer to the answer. It is described by the authors as being "an observational cohort study comprised of subject and control groups with outcome." However, the methods section also notes that "patients were randomly divided into two treatment groups," which were yoga and exercise. The authors also note that one of the limitations of the study is that it is an observational study, with results primarily reflecting their clinical practice. Thus, whether a selection bias exists is impossible to ascertain. Another large limitation is that the subjects already were participating in a drug trial, and were taking risedronate, calcium, and vitamin D. Details of the drug trial were not specified, and we do not know if any of the components of the drug trial might have had an effect on the study outcomes.
The findings are consistent with other yoga studies. Balance improved in the yoga group, and it did not improve in a standard exercise program focused on strength and flexibility. Quality of life improved in both yoga and in standard exercise, with more variables in the yoga group improving from baseline. This is a small study, and one may wonder about the power. No power analysis is presented; thus, it is impossible to say whether a larger sample size would have been required for the outcomes being studied.
The study enrolled the appropriate population. Each subject had osteoporosis, documented by a DXA T-score less than -2.5. Subjects had an average age of 60, with menopause occurring at an age of 46, which is young. One question is why subjects had a DXA measurement done; it is not clear if screening begins in Turkey at a younger age than what is recommended in the United States, or if the subjects had osteoporosis risk factors. Exclusion criteria were having systemic or psychiatric disorders, or abnormal laboratory values. An important factor is the safety of the proposed intervention in a group at high risk for fracture, and safety was not assessed for. Presumably, the subjects were trained appropriately, because yoga was taught by a professional yoga trainer, and the exercise group was supervised by the staff physiotherapist. In addition, the authors note that the study reflected clinical care, so the classes likely reflect usual care. A safety assessment or a documentation of adverse events would have provided valuable information.
In conclusion, this study provides some additional support that yoga improves balance and quality of life in postmenopausal women with osteoporosis. When compared with a standard exercise group, it appears to be superior in balance and several aspects of quality of life. An adequately powered, well-described, randomized study comparing yoga to a standard exercise program would be helpful to answer remaining questions.
References
1. Fishman L. Yoga for osteoporosis. A pilot study. Topics Geriatric Rehab 2009;25:244-250.
2. Gauchard GC, et al. Beneficial effect of proprioceptive physical activities on balance control in elderly human subjects. Neurosci Letters 1999;273:81-84.
3. Manjunath N, Telles S. Effects of yoga and Ayurveda preparation on gait, balance, and mobility in older persons. Med Sci Monit 2007;13:LE19-20.
4. Schmid AA, et al. Effect of a 12-week yoga intervention on fear of falling and balance in older adults: A pilot study. Arch Phys Medicine Rehabil 2010;91:576-583.
5. Oken BS, et al. Randomized, controlled, six-month trial of yoga in healthy seniors: Effects on cognition and quality of life. Altern Ther Health Med 2006;12:40-47.
6. Chen KM, et al. Physical fitness of older adults in senior activity centres after 24-week silver yoga exercises. J Clin Nurs 2008;17:2634-2646.
7. Yirmiya R, et al. Depression induces bone loss through stimulation of the sympathetic nervous system. Proc Natl Acad Sci USA 2006;103:16876-16881.
8. Kado DM, et al. Hyperkyphosis predicts mortality independent of vertebral osteoporosis in older women. Study of Osteoporotic Fractures. Ann Intern Med 2009;150:681-687.
9. Kado DM, et al. Narrative review: Hyperkyphosis in older persons. Ann Intern Med 2007;147:330-338.
10. Greendale G, et al. Yoga decreases kyphosis in senior women and men and with adult-onset hyperkyphosis: Results of a randomized controlled trial. J Am Geriatr Soc 2009;57:1569-1579.
Yoga and exercise are commonly recommended for patients with osteoporosis. Yoga improves balance, and both yoga and exercise improve quality of life in postmenopausal women with osteoporosis. However, the study is limited by small sample size and lack of detail in the research methodology.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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