# Exercise as it relates to Disease/The effects of a Hatha Yoga program on a small group of Alzheimer's patients

This wikibook page is a critique of the journal article "Effects of Hatha-Yoga Program on a Small Group with Alzheimer’s Disease" by Quintero Gallego, Eliana Alexey, Rodríguez Ma.Clara, Guzman Lina, Alex Reyes and Dra. Olga LLanos
This critque was written for the Health, Disease and Exercise unit at the University of Canberra.

## What is the background to this research?

Alzheimer's disease (AD) is a degenerative neuropsychological disease that causes the continuous accelerative loss of nervous cells. The lost nervous cells affect varying cognitive processes including language, memory and motor function. Cognitive decline as a result of Alzheimer's disease can result in frontal reflexes liberation, smell disorders, graphesthesia, walking disorders, shaking, extrapyramidal signs, cerebellum disorders and convulsions. People affected by AD quality of life are severely inhibited. The ability to be able to carry out everyday activities, and maintain an independent life is difficult after a couple of months of AD. In 2020 it’s estimated world wide that over 50 million people live with AD, and every 3 seconds someone develops AD.
This article explores the possible benefits of Hatha yoga on peoples with AD. Hatha yoga involves movement of physical poses and breathing exercises, focussing on balance, equilibrium and inclination. This increases blood flow and flexibility in its participants. Hatha yoga participants have found that it can reduce stress, improve self efficacy and improve functionality and quality of life. While it is known that there is no cure for AD, there are several interventions that are able to delay deterioration, with physical activity being the only non-pharmacological intervention. With the best intervention ideally being a combination of physical activity and pharmacological interventions. The desired outcome from these inteverventions would be a delayed deterioration of the brains neurons and pathways. Preventing the loss of language, memory and motor function and preserving these functions for as long as possible.

## Where is the research from?

The research was conducted by the following analysts and their institutions:
* Neuropsychologist. Instituto Ortopédico Infantil Roosevelt- Bogotá Colombia
* Universidad El Bosque. - Bogotá Colombia
* Psychologist. - Bogotá Colombia
Neuropsychologists Quintero Gallego & Eliana Alexey from the Instituto Ortopédico Infantil Roosevelt are credited in many peer reviewed journals. Majority of their research is to do with children, challenges to their learning and effects of tumours and cancers of the brain. Psychologist Lina Guzman from Bogotá Colombia, Lina Guzman is a developmental psychologist of children, credited in many peer reviewed journals relating to defining and testing positive indicators for cognitive development.

## What kind of research was this?

This type of research was a ‘pre-experimental’ design of one group consisting of a pre test and post test after the Hatha Yoga intervention. Using a Wilcoxon signed rank test to analyse the data. The sample group consisted of eight volunteer patients diagnosed with moderate AD, seven women and a man, all over 60 years old, median age of 75 years and range of 65 to 83.
All volunteers had to pass inclusion criterion including, scoring 5 at the Global Deteriorate, taking medication, being covered by the health care system and accompanied by their caregivers. All participants were assessed by the neuropsychologist of the research team, procedural memory and imitation skills were preserved in the individuals, meaning they could take part in the Hatha yoga program following simple and short instructions.

## What did the research involve?

The procedure involved assessing the participants in 7 yoga positions, guided with short and repetitive directions. Instructions of mirroring the instructor, without abstract or lateral references. The program lasted for 14 weeks, with the participants attending two sessions that were an hour long. The instructor was repetitively re-emphasizing the focus on breath and self awareness in the space.
There were eight instruments used to measure the effectiveness of the program including:
* Quality of life in patients diagnosed with Alzheimer Disease (ADRQL).
* Hamilton scales for measuring anxiety and depression.
* Working memory and processing speed indexes.
* Tinetti Scale.
* Sit and Reach modified test.
* Barthel Scale.
* Lawton and Brody Scale.
* Qualitative questionnaire.

## What were the basic results?

The results indicate that the hatha yoga program helped to maintain and improve scores on mental cognition and functionality, however, was not as effective in improving the mental health of the participants with regards to both the anxiety and depression scores. The results showed no trends in younger age or gender preference in better results when compared. However, noting that participant eight was the oldest of the participants and had lower scores comparatively to the rest of the sample.
The results that reflected the best outcome were for functionality. The physical health characteristics in both flexibility and equilibrium were almost 100% effective, seven of the participants showed development in both flexibility and equilibrium, with the last participant maintaining these characteristics. Instrumental functionality also displayed improvements with seven of the eight participants preserving functionality and the remaining improved their initial score. The results that reflected minor improvements were related to mood and mental health. Mental health scales proved poor, the depression scale reflected that six participants maintained the same levels of depression in pre and post test. The remaining two participants had lower depression symptoms than prior to the intervention. The anxiety results displayed only two participants showed improved anxiety, the remaining participants were evenly split between retaining anxiety symptoms and gaining higher results.
Table 1a
| Variable | Measure | Sub 1 | Sub 2 | Sub 3 | Sub 4 | Sub 5 | Sub 6 | Sub 7 | Sub 8 |
| Working Memory | Pre-test | 90 | 95 | 95 | 96 | 98 | 97 | 93 | 90 |
| Working Memory | Post-test | 90 | 95 | 95 | 95 | 93 | 96 | 96 | 95 |
| Processing Speed | Pre-test | 64 | 62 | 62 | 62 | 79 | 62 | 62 | 62 |
| Processing Speed | Post-test | 62 | 62 | 62 | 62 | 74 | 62 | 62 | 62 |
| Anxiety | Pre-test | 13 | 12 | 2 | 9 | 15 | 4 | 10 | 20 |
| Anxiety | Post-test | 7 | 20 | 6 | 5 | 10 | 8 | 16 | 28 |
| Depression | Pre-test | 3 | 8 | 1 | 16 | 12 | 9 | 12 | 23 |
| Depression | Post-test | 7 | 12 | 6 | 7 | 18 | 7 | 18 | 21 |
| Quality of Life | Pre-test | 39 | 41 | 46 | 32 | 25 | 36 | 32 | 32 |
| Quality of Life | Post-test | 38 | 38 | 44 | 33 | 17 | 43 | 35 | 16 |
| Equilibrium | Pre-test | 26 | 25 | 16 | 25 | 15 | 21 | 15 | N/A |
| Equilibrium | Post-test | 27 | 28 | 20 | 27 | 27 | 25 | 28 | N/A |
| Flexibility | Pre-test | 24 | 15 | 11 | 11.5 | 14 | 11 | 14 | 5 |
| Flexibility | Post-test | 29 | 19 | 15 | 21 | 17 | 24 | 15 | 5 |
| Basic Functionality | Pre-test | 100 | 90 | 100 | 100 | 90 | 100 | 100 | 45 |
| Basic Functionality | Post-test | 100 | 85 | 90 | 100 | 100 | 100 | 100 | 20 |
| Instrumental Functionality | Pre-test | 6 | 4 | 4 | 3 | 2 | 4 | 3 | 1 |
| Instrumental Functionality | Post-test | 5 | 4 | 4 | 3 | 3 | 3 | 3 | 1 |

## What conclusions can we take from this research?

The program showed improvements in cognition as well as confidence and self-efficacy among the patients. Repetition was extremely important in instruction, coaching the patients in addition to having the volunteers focus on their breath as a way to calm and focus themselves on the session. Their breath being the one thing, they can control and always bring themselves back to. From this research we can conclude that completing a Hatha yoga session, frequently, can have a benefit to patients suffering from AD. This study had improved the stability and equilibrium of the patients, both from the data perspective and an observational perspective of the care-takers. Improving the motor of control of the patients, as a primary symptom of AD is loss of motor control, shaking and convulsions.

## Practical advice

Doing any physical activity when suffering from AD is beneficial for mental and physical health. Particularly it may be more appropriate to practice a discipline like yoga or pilates, as they both specifically focus on equilibrium and stability, while being low intensity and impact. Physical activity such as yoga, pilates and even stretching both static and dynamic, would be beneficial for general populations, improving both flexibility and strength. Specifically, introducing yoga as a form of early intervention for any mild cognitive impairment disease could prove helpful. As yoga does provide the body exercises for strength, stability, balance and equilibrium. Acting as a buffer against the diseases, preventing advanced deterioration of the brain and the associated cells affected.

## Further information/resources

* Information Alzheimer's Disease: https://www.cdc.gov/aging/aginginfo/alzheimers.htm
* Information on Hatha Yoga: https://www.ekhartyoga.com/articles/philosophy/what-is-hatha-yoga
* Information on the Wilcoxon Scale: https://www.sciencedirect.com/topics/medicine-and-dentistry/wilcoxon-signed-ranks-test
* Other fundings related to Yoga interventions on AD: https://www.cambridge.org/core/journals/international-psychogeriatrics/article/randomized-controlled-trial-of-kundalini-yoga-in-mild-cognitive-impairment/138A3EB97520CE72B01D17059B7AA286

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Gallego Q, Alexey E, Ma.Clara R, Lina G. Effects of Hatha-Yoga Program on a Small Group with Alzheimer’s Disease. Journal of Yoga & Physical Therapy. 2011;01(03).
* ↑ ADI - Dementia statistics [Internet]. Alzheimer’s Disease International. Available from: https://www.alzint.org/about/dementia-facts-figures/dementia-statistics/
* 1 2 Sivakumar P, Varambally S, Thirthalli J, Varghese M, Basavaraddi I, Gangadhar B, et al. Randomized clinical trial of yoga-based intervention in residents from elderly homes: Effects on cognitive function. Indian Journal of Psychiatry [Internet]. 2013;55(7):357. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3768212/
* 1 2 3 Brenes GA, Sohl S, Wells RE, Befus D, Campos CL, Danhauer SC. The Effects of Yoga on Patients with Mild Cognitive Impairment and Dementia: A Scoping Review. The American Journal of Geriatric Psychiatry. 2019 Feb;27(2):188–97.