Joint Mobility

Yordanka Aleksandrova, Anya Doncheva, Lyudmila Chervenkova, National Sports Academy 'Vasil Levski', Sofia, Studentski Grad, Department of Kinesitherapy and Rehabilitation

Summary

The purpose of the research is to investigate the effect of a three-month yoga program on joint mobility of old people with non-active lifestyle living in a retirement home.

Methods

Thirteen people aged 69 to 89 years have been investigated. They have been asked to do some exercises of the Pawanmuktasana series 1 (anti-rheumatic group) for 3 months, 3 times per week, 30 minutes per every class. We checked the mobility of the cervical part of the spine (by centimetres) and also the following joints: shoulder, elbow, wrist, ankle and knee (by angularity).

Results

We found statistically significant improvements in the unfolding of the cervical spine and the folding in the left elbow joint. There is a tendency of improvement of four other indicators. We consider that a prolongation of the exercise yoga period would lead to improvement in larger number of the researched indicators. Key words: yoga, joint mobility, old people.

Preface

The absolute and the relative number of old people (as part of the whole population) in all of Europe is growing. Bulgaria is one of the countries where this fact can be seen very clearly. At the moment statistic data shows that the Republic of Bulgaria is a country with predominantly ageing people [5]. A progressive decline of physical activity can be seen in old people's lifestyle. The lack of physical activity is one of the reasons for reduction of natural joint mobility. Non-activity is an additional reason for further consequences of ageing [12]. This leads to bad quality of life for elderly people. Simple yogasanas can gradually rehabilitate and keep the volume of movement in the joints.

The word 'yoga' is derived from the Sanskrit root 'yuj'. It means 'integration, union, association' [6]. Yoga is a way of living aimed at achieving perfect control over mind, senses and body. Maharshi Patanjali firstsystematizedit in the ancient text Yoga Sutra. He talks about raja yoga mainly as a means of purifying, educating, and disciplining the mind to direct its powerful energy to enlightenment of consciousness and using the potential and creative energy of human nature [16].

The person who lives according to yoga principles, adheres to the law of moderation at all times. It is imperative that asanas are performed on an empty stomach only. That's why three hours after a meal is a good time for doing yoga [6].

Hatha yoga is one of the most popular yogas among modern people. This yoga is mainly associated with physical body exercises asana. Sage Patanjali said that in raja yoga, ÔÇťAsana is a stable, non-tensioning and pleasant way of sitting. Asana is a body posture or slow and moderate movement combined with proper breathing and relaxation. Practising asana leads to a beneficialeffect for the whole body. The effect of asanas is increased when it is done together with yogic breathing pranayama [1, 2].

Nowadays many people are predisposed to immobilization by their lifestyle. For thousands of years, people have been active throughout their lives. The reason for many of their movements was survival. They moved to get food, escape predators and migrate to more favourable places and lands. Long days spent working on farms, long walking on the way to the city for school or purchasing products, and other factors in the daily lives of our ancestors, show that they had very little time to rest without movement.

During the middle of 20th century due to technologies, the greater number of people using cars and the work in offices began gradually to reduce the level of physical activity. Despite the technological advances of humankind, people's bodies still need a lot of movement. Today, when there is a great choice in almost every aspect of life, many people choose to spend their time and day immobile. The World Health Organization (WHO) estimates that the lack of physical activity is associated with 3.2 million deaths per year. The most frequent consequences of inadequate physical activity are cardiovascular disease, diabetes, reduced blood circulation, confused thinking (lack of concentration), loss of muscle strength and bone strength [4].

Definitely, yoga is one of the most effective ways to help increase the activity for the elderly people. Practising appropriate asanas leads to movement of the joints and muscles and elimination of stiffness of the body. Thirty-minute practices for improving the volume of joint movement performed on a daily basis can greatly increase joint mobility and flexibility. Regular physical activity can also be anti-stress and leads to loss of anxiety, as well as reduce depressive symptoms [7]. Physical activity is one of the most important things that can be done to keep the joints healthy. Older people who have not a physically active lifestyle, put themselves at risk to decrease their muscle mass by 40% and joint mobility by 10—40% in different parts of the body [12]. Yoga has the right asanas even for people who already have arthrosis or other chronic diseases of the locomotor system. The reduction in bone density is a significanthealth and social problem in the late age. A study, using a 12-minute daily program with 12 selected yoga poses for 2 years, reports an improvement in bone density in the spine and femur area of practitioners who already have mild osteoporosis or osteopenia [11].

We would like to focus on the ability of the elderly with their personal efforts to improve their lifestyle, as well as their health, self-esteem and overall personal attitude towards life according to and/or despite the conditions in which they live.

Purpose of the study

To see what will be the effect of a three-month yogic exercise program on joint mobility in elderly people with an inactive lifestyle.

Hypothesis

We suppose that the three-month practice of yoga exercises described in this report will alleviate existing pain and increase the level of freedom and movement of the examined joints.

Persons investigated

The study includes 13 elderly people (12 women and 1 man) aged 69 to 89 years (average age 79.8 years, standard deviation = 6.44), living in the retirement home 'Longevity', Sofa, Bulgaria, who have not practised yoga until the present study. Criteria for including people in the study: they have to live in this home, have a desire for participation in yoga classes, be able to understand instructions of the yoga teacher and have no acute or chronic illnesses that make the participation in the survey contra-indicated (confirmedby a doctor from the retirement home 'Longevity'). Regarding the need to use a walking aid,

the people surveyed are classifiedas follows: 4 people with independent gait, 6 people using a walking stick and 3 people moving independently with a walker-construction.

The investigated persons have several different diseases, which were treated according to the current medical practice and are listed in Table 1:

TABLE 1 - Diseases of investigated persons
Disease Number of persons
Arthrosis (gonarthrosis and / or coxarthrosis, spondyloarthrosis, etc.) 9
Hypertension 7
Diabetes 3
Ankylosis 1
Chronic arterial insufficiency of the limbs 1
Ischemic heart disease 1
Stomach ulcer 1
Lumbar radiculitis 1
Gout 1

Organization of the survey

The study was conducted on the territory of the retirement home 'Longevity' starting on 15th January and ending on 15th April 2017 (three months). Three times weekly (on Mondays, Wednesdays and Fridays) thirty-minute group yoga classes appropriate for this age group were held during this period. Altogether 39 classes were conducted, with 11 of the participants attending 100% and the other two attending 95% of the classes. There were no dropouts during the study.

Immediately before and after this three-month intervention, some tests were performed to investigate the volume of motion and movement pain.

Characteristics of applied yoga exercises

The series of exercises performed by the participants in the study was appropriate to their physical and mental capabilities, the illnesses they had and the basic requirements for conducting a group procedure with this contingent. The participants were motivated to be regular and they were. Precise, complete and comprehensible explanations about the exercises were given. The exercises were arranged starting with the easier and were gradually followed by the more difficultones. The individual approach was always respected. The research is based on practices from the firstgroup of the Pawanmuktasanaseries, the anti-rheumatic group [6]. All exercises are performed from the initial pose, sitting on a chair. During a class movements are made up to 5 times for each type of movement for each joint. The tendency for each participant was to perform the movement in the largest, painless and possible volume of movement for each joint.

Typically, the exercises were performed with very slow speed. The speed of movement is such as to fold and unfold the fingersfor 15 seconds. This slow speed is according to the yoga philosophy of moving problematic joints and also requires more awareness and better control over the performance. Exercises included in the study are described in Appendix 1.

Instrumentarium of the study

We checked the volume of movement by measuring the following parameters that have been measured at the end of the maximum possible movement of each joint:

  1. Volume of movement in the cervical portion of the spine (centimetry chin-sternum and ear-acromion);
  2. Volume of movement in the joints of the upper limb: shoulder joint (unfolding and folding), elbow and wrist joints (flexion and extension), wrist joint (ulnar and radial outlet) measured in degrees by the methodology SFTR;
  3. Volume of movement in lower limb joints: ankle and knee joints (folding), measured in degrees by SFTR.

The pain during movement in all tested joints was detected with a visual digital scale (Fig. 1).

FIGURE 1 — Visual digital scale

Statistical processing

The statistical processing of the results was carried out with a specialized statistical program: SPSS.19. ConfidenceInterval (CI) was determined to be 95%. The normality of the distribution of the primary data from the firstand second tests was determined by the Kolmogorov-Smirnov test. The distribution of the data for the volume of movement for almost all variables was normal in both studies. In this case, we used the t-test to compare the dependent samples. Only the primary data on folding and unfolding of the left shoulder joint as well as all the pain data were not with normal distribution, so we used a non-parametric test, Wilcoxon's test, for the comparison of dependent samples.

Results

Statistical results of the examined cervical spine mobility parameters are presented in Table 2. They show a statistically significantincrease in beard-sternum distance when moving the head back, which is an average of 0.75 cm greater after the experiment. This indicates that the volume of movement in the cervical spine in the backward direction has increased after the applied yoga program. The second result, which has a statistically significantimprovement, is folding in the left elbow joint (increased on average by 4.18 degrees). We have no data on whether this mean improvement in flexionof the elbow joint is a clinically significantdifference in this contingent.

TABLE 2 — Statistical results on the surveyed indicators for cervical spine mobility (centimetry)
  n I test II test a
Mean SD Mean SD
Beard-sternum distance (forward head bend) 13 3.54 1.9 3.0 1.87 0.065
Beard-sternum distance (head backward) 13 14.15 2.7 14.9 2.23 0.006
Distance ear-acromion (to the side to the right) 13 6.92 2.9 6.0 1.73 0.459
Distance ear-acromion (to the side to the left) 13 6.54 3.23 6.1 1.5 0.577

Decrease in average values shows improvement. Compare t-test to dependent samples.

All other results on volume of movement indicators have no statistically significantchange. But four of them have a strong tendency to change, namely: distance beard-sternum at head forward inclination, unfolding right wrist, radial movement in the right wrist, unfolding in the right ankle joint. We may assume that extending the program or day-to-day work with the same exercises would result with statistically significant changes in indicators that have a strong tendency to change in the direction of improvement.

We compared the results of the study of motion pain in all tested joints using statistical methods, but there were no statistically significantchanges. Pain is a factor that depends on many indicators. Perhaps there is a necessity for a longer activity period (more than 3 months) and/or a greater number of classes.

Statistical results of the investigated indicators for the volume of movement of the upper limbs are presented in Table 3.

TABLE 3 — Statistical results on the surveyed indicators for the volume of movement of the upper limbs
  n I test II test a
Mean SD Mean SD
Shoulder joint unfolding (right) 13 133.54 18.04 134.62 21.55 0.446
Shoulder joint unfolding (left) 12 130.83 17.94 129.2 21.62 0.317*
Shoulder joint folding (right) 13 131.00 24.06 131.15 24.68 0.886
Shoulder joint folding (left) 12 127.92 22.51 127.1 21.89 0.458*
Elbow joint folding (right) 13 124.31 5.040 125.00 6.46 0.337
Elbow joint folding (left) 13 121.62 8.6 125.8 6.72 0.028
Wrist folding (right) 13 47.46 13.43 46.92 10.32 0.655
Wrist folding (left) 13 47.69 9.04 48.85 11.02 0.190
Wrist unfolding (right) 13 48.15 10.05 50.38 7.21 0.083
Wrist unfolding (left) 13 48.77 6.03 48.85 5.46 0.944
Wrist ulnaric unfolding (right) 13 21.54 6.17 21.46 6.02 0.944
Wrist ulnaric unfolding (left) 13 22.15 4.86 20.85 3.44 0.202
Wrist radial unfolding (right) 13 22.62 4.464 23.69 3.33 0.063
Wrist radial unfolding (left) 13 23.54 3.31 24.31 2.1 0.436

Compared with t-test for comparison of dependent samples; * Wilcoxon test for the comparison of dependent samples. Increasing average values shows improvement.

Statistical results of the investigated indicators for the volume of movement of the lower limbs are presented in Table 4.

TABLE 4 — Statistical results on the surveyed indicators for the volume of movement of the lower limbs
  n I test II test a
Mean SD Mean SD
Knee folding (right) 12 95.83 30.06 97.08 27.34 0.389
Knee folding (left) 13 90.77 38.56 91.54 38.21 0.337
Ankle folding (right) 13 23.38 11.44 23.54 10.78 0.798
Ankle folding (left) 13 22.38 8.69 23.92 9.04 0.104
Ankle unfolding (right) 13 12.23 5.85 13.38 6.13 0.082
Ankle unfolding (left) 13 13.85 2.76 15.77 3.24 0.054

Compare t-test for comparing of dependent samples. Increasing average values shows improvement.

Discussion

The type of yoga exercises described in this study and the peculiarities of the persons studied (age, illness, etc.) are such that the exercises applied by us can generally be referred to as kinesitherapy for the elderly [3]. As such, yoga can find its place in the overall treatment, restoration or at least alleviation of various disease symptoms in a natural way, by activating the body's own mechanisms of healing [3, 8].

With this study, we would also like to draw attention to the possibilities of yoga with regard to such accessible, grouped, inexpensive and individually adapted effects on the state of the elderly people.

In later years with the increase of age there is usually a progressive reduction in the volume of movement in the joints. Having this in mind, we do consider as a good result the improved mobility we have found in two of the tested indicators and the strong tendency for improvement in four more of them.

During the study, we also witnessed positive changes in the mental state of the investigated persons, which we have described extensively in another report. These results are a reason to believe that the development of application of yoga with regard to elderly people can be beneficialto practitioners in particular and to the whole of society in general.

Our opinion is confirmedby other studies conducted with a similar age group that reported positive changes in spine mobility. An increase in quality is achieved due to the performance of appropriate asanas. The period during which the practices are conducted is longer (20 weeks) compared to our research and other asanas are practised [8, 9, 15].

Other studies similar to ours using chairs for yoga practices in the elderly also show improvement in body functions and improvement in mental states when compared with control groups [13]. Similar to our results, some authors report that the application of an eight-week yoga exercise program on a chair shows improvement in body functions without affecting the pain level in elderly patients with arthrosis [14].

On the other hand, a review of published experimental studies on the treatment of patients with knee arthritis indicates that the use of 40 to 90 minute sessions with yoga exercises lasting at least 8 weeks show pain relief and improved function that can be detected after two weeks of intervention [10].

Conclusion

This three-month program of yoga exercises improved the cervical spine unfolding and left elbow folding of elderly people with a non-active lifestyle. Although the other measured movement volume indicators did not change significantly, four

of them showed a strong improvement trend. Perhaps the prolongation of the activities would lead to an improvement of more than the surveyed indicators.

We should keep in mind that at this age the usual tendency is to decrease the volume of movement and to increase pain. In this case even the results we achieved through yoga exercises that show the maintenance of the available volume of movement and its improvement in some of the examined joints can be considered a good result for a three-month program.