Take a Seat for Yoga with Seniors: A Scoping Review
Sacred Heart University 5151 Park Avenue, Fairfield, United States of America
University of Hartford 200 Bloomfield Avenue, Hartford, United States of America
Academic Editor: Marieke Van Puymbroeck
Collection: Yoga in Older Adults
Received: October 07, 2021 | Accepted: May 04, 2022 | Published: May 16, 2022
OBM Geriatrics 2022, Volume 6, Issue 2, doi:10.21926/obm.geriatr.2202197
Recommended citation: Veneri D, Gannotti M. Take a Seat for Yoga with Seniors: A Scoping Review. OBM Geriatrics 2022; 6(2): 197; doi:10.21926/obm.geriatr.2202197.
© 2022 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
Healthcare practitioners have studied complementary and integrative health across a wide range of ages, diagnoses, physical and mental impairments . Considering the International Classification of Functioning, Disability and Health (ICF) model, healthcare practitioners are drawn to yoga because of its multifaceted approach. Yoga improves physical capacity like other forms of exercise, but offers a spiritual component as well. Breathwork and meditation have been proven to promote relaxation, decrease stress with demonstrated improvements at the physiological levels [2,3,4,5,6]. The ICF is a framework for describing and organizing information, providing a standard language and a conceptual basis for the definition and measurement of health and disability. The three domains of the ICF include body structure and function, activity and participation . The practice of yoga has demonstrated improvements across all three of these domains [8,9,10,11,12,13]. The body of knowledge has grown sufficiently enough to support the rigour of systematic reviews and meta-analyses [14,15,16]. In 2013, McCall published an overview of systematic reviews of yoga as an intervention with adults with acute and chronic health conditions including pain, psychiatric and psychological disorders and various forms of arthritis . There were 13 studies with quantitative data included in the analysis and 16 reported health conditions. The findings were that the quality of the literature was high but the support for the yoga intervention was low, similar to the findings of others [1,11,14,18]. Researchers are beginning to explore complementary and integrative methods to not only treat certain conditions and diagnoses, but also to optimize the physical and mental well-being of the healthy population.
Chair yoga is a specific form of yoga practiced while sitting on a chair, or standing using a chair for support. The poses are often adaptations of asanas in modern yoga as exercise . The use of a chair allows those with impaired ability to stand or impaired standing balance to perform yoga safely. It has been used with pediatric populations, those with stroke, intellectual disabilities, multiple sclerosis, lower limb amputation, Parkinson’s, breathing impairment, arthritis, cancer and psychiatric disorders as both a exercise modality and adjunct to therapy [20,21,22,23,24]. In a 2016 study with 108 community dwelling, sedentary older adults, it was determined that adapted yoga was more amenable to conventional exercise because it required less equipment and was more easily adapted .
A review of the literature has yet to be performed with chair yoga as the topic. This scoping review seeks to answer the question “What is known from existing empirical literature about chair yoga used therapeutically with older adults?” The review’s objectives are to explore the breadth and extent of the evidence, map and summarize the evidence, and identify knowledge and research gaps in this evidence.
2. Materials and Methods
2.1 Data Sources and Searches
The search strategy for this review was developed in consultation with the College of Health Profession’s experienced librarian. The search was conducted in the months of November and December of 2021 by two researchers; the search terms used were “chair yoga AND older adult,” “chair yoga OR adapted yoga AND older adult* OR elderly* OR senior* OR geriatric*” “adaptive yoga AND older adult* OR elderly* OR senior* OR geriatric*”and “modified yoga AND older adult* OR elderly* OR senior* OR geriatric.*” When available, search limits were set to include peer-reviewed, English language with the dates of 2011-2021. Databases included in the search strategy were PubMed Central, MEDLINE Full Text, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Nursing and Allied Health, SPORT discus and TRIP.
2.2 Study Selection
Studies were included if they met the following criteria: (1) research included subject populations who were older adults, defined as 50 years of age or greater; and (2) pre-test/post-test design studies using chair or adapted yoga that targeted the psychomotor domain and recorded outcome measures; and/or (3) pre-test/post-test design studies using chair or adapted yoga that targeted the cognitive domain and measured outcomes; and/or (4) pre-test/post-test design studies using chair or adapted yoga that targeted the affective domain and measured outcomes. However, studies were excluded from analysis if: (1) the subject population were adults less than 50 years of age; (2) the seated exercise was not specific to yoga; (3) mindfulness or breathing techniques did not include physical activity; (4) a chair was not used as a modification; (5) were published in a language other than English; (6) populations were not exclusive to older adults and included other ages groups; (7) were a published study protocol without results; (8) were published before January 2011; (9) were not peer reviewed; (10) the design was a review of any type or (11) were opinion or perspective papers.
Covidence, a systematic review production tool, was utilized to aid article analysis. The search results were exported to Covidence and duplications were automatically removed. Two reviewers independently analyzed article titles and abstracts to determine their eligibility using the inclusion criteria. If deemed eligible by both reviewers, the full text of the article was then considered. A study was excluded when the reviewers agreed to exclude the article for the same reason. Discrepancies between reviewers regarding article eligibility were resolved through discussion. Full text articles were read of those meeting the inclusion criteria. Refer to Figure 1 for the search result (PRISMA). There were 75 studies included in the analysis.
Figure 1 PRISMA Flow Chart: Chair/adapted yoga and older adults 2020-2-21 search.
2.3 Data Synthesis and Analysis
Determining the study type and which Bloom’s learning domains (psychomotor, cognitive and affective) were measured by each study’s outcome measures was part of the review process. Oxford’s Level of Evidence was used to numerically code study design type: “1” for randomized control trials (RCT), “2” for cohort and quasi-experimental, “3” for case-control and “4” for case/case-series and qualitative . The authors extracted study details of each to populate the tables. Table 1 lists study title, journal, author and country. Subsequent tables are organized according to study type and level of evidence. Table 2 consists of large RCTs, operationally defined as studies with greater than 50 participants. Table 3 consists of medium and small RCTs, defined as those with >20 and <50 and ≤ 20 participants, respectively. Table 4 lists quasi-experimental and cohort studies, and Table 5 includes qualitative and case-series studies; both tables are further categorized using the operational definitions for study size. Data extracted from each article included first author and year, study purpose, participants, diagnoses, sample size, setting, group allocation, methods, outcome measures, results, discussion and effect. Also included in each table was classification of the outcome measures using Bloom’s taxonomy of affective, psychomotor and/or cognitive domains.
The search yielded 3147 titles, Covidence removed 140 duplications. An additional 2730 articles were removed via screening of the titles and abstracts, leaving 277 full text articles for consideration. Upon further investigation 66 quantitative and 9 qualitative studies met the inclusion criteria. Frequency counts of summary statements are provided for the data columns in Tables 2-5. Of the 75 studies, 26 were published in complementary therapy/yoga journals, 20 in geriatric journals, 13 in physical therapy journals, three in cancer journals, two in orthopedic/pain journals and 11 in general journals, including two dissertations. This review included 32 RCTs, 13 large, 14 medium and five small. There were three large, five medium and three small quasi-experimental, six medium and 15 small cohort studies. There were three large, two medium and four small qualitative studies and 2 case-series studies.
There were 2964 participants among the 75 studies. The median sample size was 25.5 (range 3-131); the mean sample size was 40. One study had three participants who were not grouped together , 28 studies had one group with chair/adapted yoga as the intervention [22,23,24,32,63,70,72,73,75,76,77,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,96], 38 studies had two groups [25,27,28,30,31,32,34,36,37,38,40,41,42,43,44,45,46,48,49,50,51,52,53,54,56,57,58,59,60,61,62,64,66,67,71,78,90] and 8 studies had three groups [29,35,39,47,55,65,69,94,97]. If a study had two groups, the second group served as a control, typically either waitlist or education [25,27,28,30,31,32,34,36,37,38,40,41,42,43,44,45,46,48,49,50,51,52,53,54,56,57,58,59,60,61,62,64,66,67,71,78,90]. If there were three groups, a second intervention was compared to chair yoga; interventions included Reiki, chair exercise, resistance training or tai chi [29,35,39,47,55,65,69,94,97] One study categorized the three groups according to pain site and type, with all of the participants receiving the same intervention . The majority of the studies (n = 46) included participant sex as part of the demographic profile; 29 studies did not. Fifteen studies included only females [28,36,39,46,48,49,52,55,61,62,71,83,84,90,94] and one study included only males . Ten studies had 1-24% males [25,27,28,39,51,64,65,73,89,92], another 10 had 25-49% males [25,34,38,58,69,73,74,92,95,97] and 10 studies had greater than 50% males as participants [27,29,32,53,54,60,76,89,92,93]. All of the study participants were older adults, 11 studies did not report additional age information [37,46,52,57,68,86,88,90,91,97,99]. Six studies provided an age range [28,35,41,77,94,95], seven studies included participants with a mean age 50-59 years [36,51,66,67,69,80,83], 19 studies with a mean age of 60-69 [25,40,42,43,48,50,56,59,63,70,71,73,81,84,85,87,93], 21 studies with a mean age of 70-79 [22,27,29,30,32,33,34,38,39,46,53,54,55,58,60,72,75,76,79,82,96] and 10 studies included participants with a mean age greater than 80 years [44,47,49,61,62,64,65,74,78,92]. The majority of these studies, 22 [29,33,35,38,41,44,45,50,51,52,59,62,64,71,73,75,76,78,79,80,84,90] of 75, were focused on community dwelling older adults, 11 of which were healthy. Orthopaedic diagnoses (n = 16), and cognitive impairment (n = 9) [37,39,47,60,68,88,92,96,97] accounted for the next largest diagnostic categories. The orthopaedic diagnoses were lower extremity osteoarthritis (n = 13) [22,25,27,28,30,31,32,34,46,53,65,66,95], vertebral impairments (n = 2) [55,72] and osteopenia (n = 1) . The remaining diagnostic categories include cardiopulmonary disorders (n = 5) [42,43,57,93,98], neurologic disorders (n = 7) [40,56,80,82,85,87,89], cancer (n = 8) [36,63,67,70,81,83,86], institutionalized [49,61,77,94] and chronic pain (n = 2) [69,74]. The remaining three studies included participants with a history of falls, insomnia or veterans [54,58,91].
3.2 Dosing and Intervention
The duration of each intervention session ranged from 15-120 minutes, with 10 having sessions 30 minutes or less [36,37,43,47,50,66,67,77,92,94], 15 with 45-minute sessions [22,27,30,31,33,34,35,39,54,64,65,86,88,89,96], 25 with 50- 60-minute sessions [25,28,41,45,46,48,49,51,52,53,55,57,59,60,68,69,71,73,74,75,76,84,85,87,93], and 16 with > 60-minute sessions [29,31,38,42,44,52,56,62,70,78,79,80,81,83,90,95] and another 9 were unspecified [40,58,61,63,82,91,97,98]. Forty of the studies held intervention sessions twice weekly [22,27,30,32,33,35,37,39,40,41,47,49,51,52,53,57,61,62,63,64,65,68,70,73,75,77,78,79,80,81,82,83,84,85,88,90,92,93,94,95], two met 2-3 times a week [49,91], 19 studies met once per week [29,31,35,38,42,43,44,46,50,55,56,57,66,69,74,76,86,87,89], most of which were supplemented with a home program, 11 met three times per week [25,28,36,48,54,59,60,67,71,72,84], and three were unspecified [63,96,98]. Study intervention durations ranged from six weeks to 18 months; the most common duration was eight weeks (n = 31) [22,25,27,30,32,33,34,36,40,42,44,45,46,50,52,53,63,64,65,67,68,73,76,78,80,81,82,86,87,89,90], followed by 12 weeks (n = 19) [31,37,38,39,43,48,51,54,57,58,60,62,66,79,83,85,88,93,96] and 10 weeks (n = 6) [41,55,69,74,77,92]. Chair yoga interventions were described as including breathwork, meditation and yoga with the participant seated in a chair; some interventions identified specific yoga styles, with hatha as the most common. Ten study interventions encouraged/included a home exercise program as part of the protocol [29,44,45,46,56,57,67,76,81,90].
Fifty-six studies were conducted in the United States [22,27,28,29,30,32,33,34,35,40,41,42,43,44,45,46,51,52,53,54,57,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,95,96,97,98], two studies in the countries of Germany [36,50], Portugal [49,61], Australia [47,56], Sweden [55,93], Taiwan [60,62] and Thailand [48,71]. One study was conducted in the countries of the Czech Republic , Japan , the United Kingdom  New Zealand , Indonesia , Greece , and Israel . Studies were primarily conducted across community centers (n = 21) [27,30,31,32,34,35,38,39,41,49,50,53,56,57,61,62,64,65,66,79,95], hospital facilities (n = 25) [37,42,43,44,47,58,60,63,67,68,69,70,73,74,76,77,78,81,86,89,91,92,93,94] and universities (n = 23) [22,25,29,36,40,45,46,48,51,52,54,59,71,72,75,80,82,83,84,85,87,90,97], two university community facilities [28,55], one community hospital , one academic hospital  and two settings were unspecified [33,88].
3.4 Bloom’s Learning Domains
Seventy of the 75 studies included some measure of psychomotor function. Types of measures were highly varied among studies spanning from physiologic and impairment to functional to fitness performance measures. There was no single outcome measure common among studies. The most common impairment measured was balance via the Berg Balance Scale, followed by the Functional Reach and Single Limb Balance Tests. Gait was the most common functional activity measured using the Timed Up and Go Test, 6 Minute Walk Test and other gait assessments for speed and endurance. Self-reported measures were used for pain, fatigue and dyspnea, sleep, fragility and arthritis symptoms. The Western Ontario and McMaster University Osteoarthritis Index was the most prevalently used measure for osteoarthritis.
Measures of affect were reported in 57 of the 75 studies. Measurement included the qualities of anxiety, stress, mood, fatigue, life satisfaction, morale, well-being, self-compassion, self-esteem, self-efficacy, depression, anger, personality and quality of life. These measures were self-report. Some measures were quality-specific, but also were varied amongst the studies. Moss conducted a RCT to examine the feasibility and effectiveness of a mindfulness-based stress reduction program on 39 elders in a continuing care community. The chair yoga group practiced for 120 minutes once per week, supplemented with 25-30 minutes of daily exercise for eight weeks. The intervention group showed significant improvement in acceptance and psychological flexibility and in role limitations due to physical health and verbally reported increased awareness, less judgement, and greater self-compassion compared to the control group . Toise also conducted an RCT to examine the feasibility and effectiveness of a chair yoga program for patients with implantable cardiac defibrillators. Total shock anxiety and anxiety significantly decreased for the yoga group, but increased for the control group. Compared to the control, the yoga group had greater overall self-compassion and greater mindfulness. Exploratory analyses utilizing a linear model (R2 = 0.98) of observed device-treated ventricular (DTV) events revealed that the expected number of DTV events in the yoga group was significantly lower than in the control. AY had a 32% lower risk of experiencing device-related firings at the end of follow-up compared to the control group .
3.5 Affective, Cognitive and Psychomotor Learning Domains
There was one study in which all three learning domains were addressed by the outcome measures. Oken conducted a study to determine the effect of yoga on cognitive function, fatigue, mood, and QoL in seniors. There were no effects on cognitive and alertness measures, but adapted yoga improved physical and QoL measures compared to exercise and control .
3.6 Affective and Psychomotor Learning Domains
Of the 51 studies with both affective and psychomotor outcome measures, large studies included nine RCTs [27,29,31,32,33,34,36,37,38], two quasi-experimental [58,60] and two qualitative studies [90,91]; these studies were predominantly conducted with patient populations of community dwelling older adults with lower extremity osteoarthritis and determined that chair yoga can reduce pain, improve mood but had no impact on frailty measures [27,32,33,36] Several of these studies were conducted in community-based facilities, senior housing, university and medical centers. One of the qualitative studies found that delivering adapted yoga to a wide range of patients within a healthcare setting appears to be feasible and acceptable. These results were the same for either delivery mode, in-person or telehealth, with participants reporting high levels of satisfaction and improvement in multiple problem areas .
Studies of moderate size included 11 RCTs [39,40,41,43,45,46,47,49,50,51,52], five quasi-experimental [61,62,63,64,65,66], four cohort [69,70,73,74] and two qualitative studies [92,93] Populations included sedentary older adults and community dwellers, COPD, knee osteoarthritis, chronic stroke and frail adults with impaired cognition. Study sites included community centers, universities and outpatient clinics/hospitals.
Three RCTs [55,56,57], one quasi-experimental , eight cohort [77,80,83,84,86,87,88,89] four qualitative [94,95,96,97] and two case series studies [22,98] were small. Sites included universities, community and cancer centers. Study populations included lower extremity cancer, osteoarthritis, community dwellers, Alzheimer’s, pulmonary hypertension and COPD, neurologic disorders and impaired cognition.
3.7 Cognitive and Psychomotor Learning Domains
Of the 75 studies, there were nine that specifically targeted older adults with dementia/Alzheimer’s [37,39,47,60,68,88,92,95,96] Only two studies reported using a cognitive measure [39,95], and another measured dementia quality of life  One study reported both psychomotor and cognitive measures . In this RCT of 49 women with mild cognitive impairment, it was determined that the resistance group had better results than the chair yoga group and that the chair yoga group had better results than the control group. The interventions were provided twice weekly for 12 weeks. The authors suggest a longer study duration in future research.
3.8 Psychomotor-only Learning Domain
Seventeen studies used only psychomotor outcome measures. There were three large [25,28,30], one medium  and two small RCTs [53,54], one large  and two small quasi-experimental [66,68] and eight small cohort studies [71,72,75,76,78,79,82] McCaffrey, 2019 compared chair yoga with chair exercise in a small RCT of 18. Both groups had significant increases in the TUG and WOMAC, with no differences between groups .
3.9 Affective-only Learning Domain
There were five studies reporting outcome measures pertaining to the affective learning domain; study types included one large and two medium RCTs, one small cohort and one large qualitative study. Bonura conducted a large RCT to assess the effect of chair yoga on the psychological health of older adults. Chair yoga improved more than the other two groups in anger, anxiety, depression, well-being, self-efficacy and self-efficacy for daily living . Similar results were found with the other studies with community dwelling, implantable cardiac defibrillator, and veterans [42,44,63,81].
The results of this scoping review support the use of chair/adapted yoga as an intervention for older adults; the majority of the studies had positive, if not significant results. Studies investigating chair/adapted yoga as an intervention for older adults consist of fairly robust study design, with RCTs and cohort studies predominating. That said, most of these studies compared chair/adapted yoga to a control group rather than another intervention and ten included follow-up data collection [27,30,32,34,35,37,42,45,46,64] Of the 75 studies included in this review, 15 reported follow-up. [27,30,32,34,35,37,42,45,46,64,68,74,80,83,95].
Seniors of all ages from 50 to 80+ participated in chair yoga programs. The most common dose was 2x/week for 8 weeks for 50-60 minutes. The majority of the interventions were performed in community, university and hospital settings. The body of literature represents participants from the continents of North America, Europe, Asia, and Australia. Generally speaking, the findings of this study are consistent with previous reviews and meta-analyses; yoga can have a positive impact on psychomotor, affective and cognitive domains. Of these reviews, five were exclusive to yoga [16,17,99,100,101], while the others included other mind-body, breathing and exercise interventions for adults and children [1,2,3,5,6,18] The review by McCall involved older adults with acute and chronic health conditions, the review by Sivaramakrishnan involved older adults and Sieczkowska’s review was focused on those with rheumatic arthritis. Both meta-analyses demonstrated support for yoga as an intervention with large effects for emotional, social, health and physical function; neutral support for mental health, pain and vitality [16,17,101]. While none of these reviews were exclusive to chair/adapted yoga, some of the studies in this current review were included in those previous [25,35,39,46,47,49,51,56,65,66,72].
The affective and psychomotor domains of learning are well represented among the outcome measures across these studies. It has been demonstrated that the intervention of chair/adapted yoga has the capacity to improve physical impairments, functional mobility and capacity, affective characteristics such as mood, sleep and stress as well as social aspects including quality of life and life satisfaction. Though not extensively studied, there exists no support that yoga has the capacity to improve cognitive function However, chair/adapted yoga can improve the physical and affective aspects of someone with impaired cognitive function [37,47,60]. The findings suggest that yoga can be used to complement traditional medical and therapy interventions and, in many cases, has already done so [32,37,47,68,96]. With the rising costs of healthcare and the reduction in traditional therapy services, chair/adapted yoga has been demonstrated to be a feasible and acceptable form of treatment for the older adult population. Physical and occupational therapists should continue to partner with yoga instructors to bring chair/adapted yoga to community-based settings. Chair/adapted yoga can be performed both by patients and their caregivers alike, thereby offering an activity that both can experience together.
The literature included in this review spans more than ten years and sufficiently provides evidence of its use with a variety of diagnoses, as well as community dwelling well-elders. Further study should explore additional patient diagnoses including neurologic, orthopedic, and cardiopulmonary. While knee osteoarthritis has been extensively studied, disorders of the shoulder have not. The neurologic diagnosis of stroke, Parkinson’s disease and dementia/Alzheimer’s have received some attention from chair/adapted yoga, while other diagnoses such as multiple sclerosis, spinal cord injury and traumatic brain injury have not. Future research should consider introducing a second intervention to better understand the comparison of yoga with other exercise forms or therapy interventions to determine if it could sufficiently be substituted or used as an adjunct. Standardizing chair/adapted yoga interventions as per diagnostic population may also be of interest to future researchers/practitioners. This would include research to determine the best frequency, intensity and time (FIT) prescription. Given the ramifications of the current pandemic, work to explore delivery modes should also continue; two studies included in this review have investigated use of telehealth  and digital video disc . Studies with more follow-up are also recommended.
This scoping review was limited to chair/adapted yoga for older adults. There may be other types of yoga interventions used with older adults, not included in this review. Meditation, yoga nidra, Ayurveda are other yoga practices that were omitted from this review that could potentially benefit this population. This review excluded literature pertaining to traditional yoga practice. Furthermore, this review was intentionally limited by date to reflect current literature of the past 10 years. It is possible that there is additional evidence to support chair/adapted yoga preceding this time frame. This study did not include those that were not peer-reviewed or in the English language. A meta-analysis to statistically determine the effects of chair/adapted yoga to enhance physical and/or affective function was not performed, but could be done in the future.
The quality of literature supporting chair/adapted yoga is fairly substantial as evidenced by RCTs, quasi-experimental and cohort study types. The evidence to support chair/adapted yoga as an intervention for older adults is relatively also substantial, both community dwelling and those with certain physical and psychological diagnoses. It is recommended that this intervention continue to be utilized and studied with this population.
The author would like to acknowledge Geoffrey Staysniak, the reference librarian consulted on the search technique used for this review.
Dr. Veneri, primary researcher, is responsible for the study design, search and review of the literature, data extraction and analysis, and is the primary author. Dr. Gannotti, second researcher, is responsible for search and review of the literature, data extraction and analysis.
The authors have declared that no competing interests exist.
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