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Clinical applications of yoga for the pediatric population: a systematic review |
Birdee GS, Yeh G Y, Wayne PM, Phillips RS, Davis RB, Gardiner P |
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CRD summary This review found some evidence to support beneficial effects of yoga in paediatric populations, but the limited quantity and quality of the evidence precluded definitive conclusions. The findings appeared to reflect the quality and disparity of the presented evidence, but given the significant risk of language and potential for publication bias, the conclusions may not be reliable. Authors' objectives To assess the effects of clinical applications of yoga in children. Searching MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PsycINFO were searched up to December 2008 for studies written in English. Search terms were reported. Reference lists of retrieved articles were searched for further studies. Dissertations and abstracts were excluded from the review. Study selection Randomised controlled trials (RCTs) and non-randomised controlled trials that assessed yoga or yoga-based interventions in participants aged up to 21 years were eligible for inclusion in the review. Interventions that included non-yoga activities such as games, massage, interactive discourse and general relaxation techniques were also eligible for inclusion. Studies were excluded if they assessed meditation without specifically including yoga or assessed mindfulness-based stress reduction, transcendental meditation or relaxation response.
Included studies assessed a variety of different yoga techniques, most were common techniques such as postures (79%), breathing (67%) and/or meditation (59%). Nearly one third of interventions also included other yoga techniques including locks (bandhas), cleansing exercises (kriyas), hand gestures (mudras), yoga diets, philosophy and devotional songs. Clinical applications for yoga included physical fitness, cardiorespiratory effects, motor skills/strength, mental health and psychological disorders, behaviour and development, irritable bowel syndrome and birth outcomes following prenatal yoga. Duration of interventions varied, with an average length of nine weeks (range one day to one year). Interventions were commonly compared with regular exercise, activity or school; other control groups included no intervention and waiting list controls. The most commonly investigated populations were healthy children and young adults; other populations included children with various conditions such as attention-deficit/hyperactivity disorder, domestic/social problems and educational problems. The largest group of studies was carried out in adolescents (12 to 18 years) or older children (five to 11 years). No studies were conducted in younger children (two to five years) and only one was conducted in neonates (up to one month). Most studies were conducted in India; the rest were carried out in USA, Australia, Canada and Germany. The outcomes assessed varied between studies (further details were presented in the review).
The authors did not state how many reviewers performed the selection. Assessment of study quality One reviewer assessed the quality of the included RCTs using the Jadad scale (randomisation, blinding and follow-up). Each study was awarded a score between 0 (weak) and 5 (strong). More detailed information was collected about methods of randomisation, blinding of outcome assessors, reporting of withdrawals/dropouts, calculation of sample size, use of intention-to-treat data, description of the intervention, justification of the control group and training of the yoga instructor's qualifications. A second reviewer assessed 20% of the studies to check for agreement; the authors reported a kappa score of r=1.0 (excellent reliability). The quality of non-RCTs was not assessed. Data extraction Data were extracted independently by two reviewers. The main findings for each outcome and the statistical significance of the findings were reported, where available. Methods of synthesis Studies were grouped according to application and synthesised using narrative techniques with accompanying summary tables of data. Results of the review Nineteen RCTs (n=1,081) and 15 non-randomised controlled trials (n=1,341) were included in the review. Many of the studies were of low methodological quality: 13 studies scored only 1 on the Jadad scale; four studies scored 2; and two studies scored 3. Methodological problems included randomisation methods, withdrawals and dropouts, and poor reporting of yoga interventions. Eleven of the 19 RCTs failed to carry out an appropriate analysis of data.
Studies assessed physical health (three RCTs), cardiorespiratory fitness (five RCTs), motor skills/strength (two RCTs and three non-RCTs), psychological health (one RCT and two non-RCTs), body image/eating disorders (three RCTs and three non-RCTs), behaviour and development (one RCT and three non-RCTs), visual perception (three RCTs), cognitive function (one RCT and two non-RCTs), mental retardation (one RCT), gastrointestinal disease (one RCT), prenatal outcomes (one non-RCT), oxidative stress (one non-RCT) and traditional yoga outcomes (one RCT).
Most interventions were associated with at least one positive outcome effect. No adverse events were reported in any of the studies. Authors' conclusions Although there was some suggestion of beneficial effects, the limited quantity and quality of the evidence prevented any conclusions being drawn as to the effectiveness of clinical applications of yoga in paediatric populations. CRD commentary This review assessed a clearly defined research question. Searches were carried out in a wide range of databases for eligible studies; however, relevant data may have been missed through the lack of any specific searches for unpublished data, which suggesting a risk of publication bias. More importantly, 19 studies were excluded from the review as they were not written in English. Given the topic area and the fact that most studies were carried out in India, this limitation suggested that the review was at significant risk of language bias. Some attempts were made to reduce the risk of reviewer error and bias through use of more than one reviewer to extract the study data; it was unclear whether similar precautions were taken during study selection and only a proportion of the studies (RCTs only) were assessed for study quality by more than one reviewer. Given the differences between studies with regard to interventions, populations and outcomes, use of narrative synthesis methods appeared appropriate. The methodological problems identified in most studies suggested that data may not be reliable. Overall, the findings of the review appeared to reflect the quality and disparity of the presented evidence, but given the significant risk of language and potential for publication bias, the conclusions may not be reliable. Implications of the review for practice and research Practice: The authors did not state any implications for practice.
Research: The authors stated that further good-quality research that followed published guidelines and methods was required to identify potential clinical applications of yoga for children and to assess its effects. In particular, use of yoga for disorders of behaviour and development, including attention-deficit/hyperactivity disorder needed to be investigated further. Bibliographic details Birdee GS, Yeh G Y, Wayne PM, Phillips RS, Davis RB, Gardiner P. Clinical applications of yoga for the pediatric population: a systematic review. Academic Pediatrics 2009; 9(4): 212-220.e9 Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Cardiovascular Diseases /therapy; Child; Child Behavior Disorders /therapy; Complementary Therapies /methods; Developmental Disabilities /therapy; Female; Humans; Irritable Bowel Syndrome /therapy; Male; Pediatrics; Prognosis; Randomized Controlled Trials as Topic; Treatment Outcome; Yoga AccessionNumber 12009107562 Date bibliographic record published 21/10/2009 Date abstract record published 24/03/2010 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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