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The Effects of Tai Chi on Balance in Healthy Older Adults Byrne, Colleen; Fraser, Fairlie; Horswill, Brian; Trimble, Lindsay; Wang, Yakun 2008

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Colleen A. Byrne, Fairlie K. Fraser, Brian J. Horswill, Lindsay V. Trimble, Yakun WangThe Effects of Tai Chi on Balance in Healthy Older AdultsColleen A. Byrne, FairlieK. Fraser, Brian J. Horswill, Lindsay V. Trimble, YakunWangObjectives??Summarize current research on the effects of tai chi on balance in a healthy older adult population??Explore cross-cultural possibilities in research??Compare the effects of tai chi to other exercise interventions or no exercise??Discuss possible relationships between an increase in balance outcome measures and a decrease in falls risk in an older populationDefinitions??Tai Chi??Traditional or adapted slow forms of tai chi??Low impact, low velocity??Older Adult??Greater than 55 years of age??Healthy??No cardiopulmonary, neurological, musculoskeletal or chronic conditions that adversely effect mobility or balanceDefinitions??Balance??The ability to maintain center of gravity within base of support and limits of stability??Involves integration of visual, vestibular, somatosensory systems as well as motor control systems to coordinate muscular contractions??Postural Stability??The ability to use motor control systems to maintain balance in response to or in advance of perturbationsWhat is Tai Chi?What is tai chi???style of martial art that originated in China??over 300 years old??involves control over the displacement of body mass over one?s base of support, postural orientation, range of motion and emphasis on abdominal and lower-extremity muscle function??There are different styles of tai chi, Chen, Yang, Wu and Sun.  Each style has unique features.Mind-Body Approach??relaxation??slow movements??breathing??concentrationTai Chi and Physiotherapy??Lack of current research on effects of tai chi??Relatively new in North America as a exercise for elderly population??Balance and Falls a major issue in older adult population ??Need for exercise and community programs that physiotherapists can prescribe to the older population.Research Questions:Primary Research Question: ??What are the effects of tai chi on balance in the healthy older adult population?Secondary Research Questions:??How do long term tai chi practitioners compare to non-practitioners???How do long term tai chi practitioners compare to those participating in shorter interventions???How does the findings of research done on tai chi in China compare to research done in North America?Methods??Conducted initial database search in April 2007??Conducted Chinese database search in August 2007??Set up automatic updates and repeated searches periodically ??Final search of all databases conducted in June 2008??Initial search yielded 8 articles, final search in June yielded one further articleSearch StrategyTitles ReviewedTitles ChosenSelected for Full Text ReviewSelected for InclusionAbstracts ReviewedDuplicates RemovedBalance, Postural Stability, Dynamic Equ120Cinahl49221Medline197633113535PEDro47263EMBASE22EMB Reviews67Sport Discus32255170Chinese DatabaORElderly, Older adult, AgedANDTai Chi, T'ai Chi, Tai ji, Tai Chi ChuaKey Words??Tai chi/ t?ai chi / tai ji / tai chi chuan??Postural stability/ posture / postural equilibrium??Balance/ dynamic equilibrium??Elderly/ aging / aged / older adultChinese Literature Search??Heilongjiang Provincial Library, Harbin, China??Chinese Journal Full Text Database (1996-present)Chinese Literature Search??In Chinese language??Same key words as used for the English database??170 titles reviewed??55 abstracts were chosen??22 full text articles were selected??3 articles were included Search Strategy??Titles reviewed by 2 independent reviewers??Required one reviewer to accept to be included to next stage??Abstract reviewed by 2 independent reviewers??Required both reviewers to accept to be included, or one reviewer plus 3rd reviewer to settle disputes??Full Text review completed by 2 independent reviewers??Both reviewers applied inclusion and exclusion criteria and completed PEDro scale??Inconsistencies were resolved by 3rd reviewerInclusion Criteria??Healthy older adults??>55 years of age ???satisfactory health???Balance outcome measures were used ??Tai chi as the primary intervention ??Control groups participated in comparable exercise program, balance training, or no interventionExclusion Criteria??Pedro scores of 4/11 or lower ??Studies published in only English or ChineseData Extraction & Analysis??Standardized data extraction form ??Information extracted includes:??Patient populations??Interventions??Controls??Methodological procedures??Outcome measuresSubject Characteristics??1310 Participants??Mean age 72.3 years??Healthy older adults with no pathologies??Community dwelling & independent livingTai Chi Interventions??Modified Tai Chi group class ??Yang, Ng, Sun-style or mixed styles of tai chi??Style of Tai Chi not specified in the Chinese studies??Independent practice ranging from 3 months -18 years??Length of intervention in English studies:??8 weeksto 12 months??1 hour /week to 6, 1 hour sessions / weekControl Groups??Varied in both the amountand typeof prescribed activity??Exercise class??No exercise??Education ??Computerized balance training??Resistance exercise program??Self-determined level of physical activityOutcomes Measured??All outcome measures reported by each study were included in the data extraction process, however only outcome measures pertaining to balance were analyzed for comparisonBalance Outcome Measures1. Dynamic Computerized Posturography (ChattecxTMor SMARTTMfrom NeuroCom International) A force plate measures force in several different axes (anterior/posterior and lateral COM displacement)SMART balance systemBalance Outcome Measures2.Sensory Organization Test (SOT) ??EquiTest computerized dynamic posturography system (ChattecxTMor SMARTTMfrom NeuroCom International)??Consists of force platform and visual surround (stationary or sway-referenced) ??Assesses an individual?s ability to use information received by the somatosensory, visual and vestibular systems by systematically altering visual information and movement of the platform.  Sensory Organization Test (SOT)1.normal vision, fixed platform 2.eyes closed, fixed platform 3.vision sway-referenced, fixed platform 4.normal vision, sway referenced platform 5.eyes closed, sway referenced platform6.both vision and platform sway-referenced. Somatosensory Organization Test (SOT)The information obtained from SOT includes:Equilibrium Score-quantifies postural stability under each of the three trials of the six sensory conditions. Sensory Analysis?analyses the ability to use input from the each sensory system to maintain balance. ??The somatosensory ratio is condition2/condition1??The visual ratio score is condition4/condition1??The vestibular ratio score is the ratio of condition5/condition1Strategy Analysis-quantifies ankle strategy & hip strategyCenter of Gravity (COG) Alignment-the patient's COG position relative to the center of the BOS at the start of each trial. Balance Outcome Measures3. SwayMetermeasures displacements of the body at the level of the waist.  A 40cm long rod with a mounted pen at the end, attached to the subject posteriorly using a firm belt measures displacement.  The subject tries to stand as still as possible for 30 seconds under the 4 test conditions ??on floor with eyes open ??on floor with eyes closed ??on foam rubber mat with eyes open ??on foam rubber mat with eyes closedBalance Outcome Measures4. Maximal Balance Range and CoordinatedStability Tests??Require subjects to adjust their balance in a controlled manner when near limits of BOS??Assessed by measuring maximal lateral sway with feet placed in a near tandem position and eyes open.Balance Outcome Measures5. Choice Stepping Reaction Time. ??Consists of a low platform with six plates ??Two base plates on which the participant stands and four stepping plates that can be illuminated in a random order.  ??Participants are instructed to step onto a plate as quickly as possible when it becomes illuminated, Each panel contains a pressure switch to determine the time of foot contact. Figure from Lord et al. (2001)Balance Outcome Measures6. Limits of Stability Test (LOS test)??LOS measures a subject?s ability to voluntarily weight shift within their BOS, and briefly maintain stability over time. ??System consists of dual force plates and a video screen on which the subject's current normalized COP is displayed.  ??Eight target positions are on the screen: front, right front, right, right back, back, left back, left, and left front. ??The LOS system has three outcome measures: reaction time, maximum excursion, and directional control. Balance Outcome Measures7.Fear of Falling Questionnaires8. Heel to toe Walking?involves heel to toe walking Assesses lateral foot displacement during gait over 10feet walked9. Timed Up and Go (TUG) test?assesses several functional manoeuvres such as standing up, walking over 3m, turning and sitting down. 10. Modified Wolfson Test-uses a belt to apply a recorded amount of force in order to pull the subject off balance Summary of Results ?Wolf et al. (1997)RCT??Interventions:??TC2x/wk1 hour15 weeks??ED1x/wk1 hour15 weeks??CBT1x/wk1 hour15 weeks??Outcomes Measured??Chattex Balance System??Fear of Falling Questionaire??Results -Improvement in Postural Stability???TC NO improvements??CBTSome improvementsYang et al. (2007)RCT??Interventions:??TC3x/week1 hour6 months??CGmaintained normal activity level??Outcomes Measured??Sensory Organization Test (SOT)??BOS & Stance Width (Foot trace measurements)??Results -TC vs Control group???SOT Vestibular score was 47% greater in TC??BOSIncrease in quiet stance in TCVoukelatos et al. (2007)RCT??Interventions:??TCcommunity 1 hour/week16 weeks??CGinstructed not to do TC for 24 weeks??Outcomes Measured??Number of falls (self reported)??Static balance measured using sway meter??Results -TC vs Control group on sway meter???Better on 5/6 measurements on sway meter??NO improvements in max leaning balanceWoo et al. (2007)RCT??Interventions:??TC3x/week 12 months??RTEresistance band exercises 3x/week for 12 months??CGNo exercise for 12 months??Outcomes Measured??SMART Balance Master??Stance time in: semi-tandem, tandem and single stance??Bend reach performance test??Other: BMD, muscle strength, grip strength & gait velocity??Results -Changes in TC vs RTE or CG???NO changes in balance, flexibility or number of fallsTsang et al. (2004)CCT??Interventions:??TC6x/week1.5 hours8 weeks??EDmorning walk & gentle stretching, similar contact time??Outcomes Measured??Sensory Organization Test (SOT)??Limits of Stability Test (LOS)??Results -Improvements in static balance???SOTTC had better vestibular ratio??LOSTC had better directional control of their leaning trajectoryLi et al. (2007)CCT??Interventions:??TC1x/week 1 hour12 months??CGmaintained normal physical activity levels??Outcomes Measured??Timed single leg stance (static balance)??Line walking test (dynamic balance)??Other: Finger choice reaction time test, Muscle strength & Ankle  flexibility??Results -Improvements in TC vs CG???TCImprovements in static balance NO difference between groups at 12 months for any outcome measureXiao et al. (2006)CS??Interventions:??TC3x/week 1 hour> 24 months??CGOther exercise and house work??Outcomes Measured??Dynamic Balance:Tandem walking Stepping on spot with eyes closed??Static Balance:Rhomberg test One leg stand with eyes closed??Sensory Organization Test (SOT)??TUG??Other: Step length & Wolfson testXiao et al (2006)CS??Results -Improvements in TC vs CG???Static Balance?Improvements in single leg stance & Rhomberg test in TC??Dynamic Balance?Greater improvements in TC??SOT?Improvements in 3 of 6 conditions (eyes closed)??TUG & Others?NO differenceYan et al. (2005)CS??Interventions:??TC3x/week 30 minutes > 3 months??EG3x/week 30 minutes > 3 months??CGNo regular exercise??Outcomes Measured??Balance performance monitor:Gait AnalysisCOM??Static Balance:RhombergModified Rhomberg??TUG??Results -Improvements in TC vs EG and CG???Improvements in ALL outcome measuresWang et al. (2003)CS??Interventions:??TCLong term practice??CGHealthy older adults with similar education and lifestyle??Outcomes Measured??Static balance (force plate measures)??Other: gait analysis, ROM and Biodex isokinetic dynamometer (LE strength)??Results -Improvements in TC vs CG???Improvements in force plate measures in eyes open conditions??No difference in eyes closed conditionsWang et al  (2003)(2007)Yang et al  (2007)5/115/115/114/115/115/118/118/119/11TC had better vestibular ratio (SOT), better directional control of leaning trajectory (LOS).2BTC scored better in force plate measures in eyes open conditions, but no difference in eyes closed.3CTC showed improvements in static balance measured by single leg stance and Rhombergtest.  Also improvements in dynamic balance.No difference in TUG.3CTC showed improvements in Rhombergand Modified Rhombergtests, completed the TUG faster & improvements in static balance using force plate measures.3CTC improvements in static balance measured by timed one leg stance, BUT no difference at 12 months.4CTC did not improve postural stability measured by force plate after 15 weeks.1BTC was better on 5/6 variables measured on sway meter.  No improvement in max leaning balance.1BTC vestibular ratio score was 47% greater at 6 months, and had an increase in quiet stance BOS.1BTC showed no changes in musclestrength, balance, flexibility or number of falls.1BDiscussion: Quality of Studies??PEDro ratings for all studies had an average of 6/11??RCTs, CCTs and Cross-sectional studies??Methodological quality could be improved by:??Blinding of assessors??Randomization of intervention and control groups??Standardization of interventions??Addition of intention to treat analysisDiscussion: Outcome Measures??Studies used many different outcome measures related to balance??Outcome measures can be generalized intoclinical or non-clinical??We used a combination of previous literature validating outcome measures and our own judgment on what outcome measures are most appropriate for the study populationDiscussion: Outcome Measures??What are the best outcome measures for balance???Which ones are validated in the literature???Why is this important???What are the best outcome measures for theolder adult population???What makes them good for an older adult population???Which ones are validated in the literature???Why is this important?Correlation to Falls Risk??It is important to have balance outcome measures that correlate to falls risk because it makes them more relevant in the older adult population??The ability to predict falls risk and also measure our ability to reduce it can affect clinical outcomes??Difficult to measure falls because must rely on self reporting by subjects??Rogers et al. and Lord et al. described a positive correlation between an improvement in balance outcomes and risk of falls . ??Rogers et al. described that many physical parameters including reduced postural stability, decreased dynamic balance and decreased mobility are associated with an increase in fall risk in the older population.  Discussion: East vs. West Research CulturesWestern Research Culture ??Emphasis on standardization of procedures??Methodological details are included??Different disciplines are able to understand methods and interpret findingsDiscussion: East vs. West Research CultureEastern Research Culture ??Use the study design most appropriate for the subject being studied??Methodological details are omitted??Generally written for use by researchers within the same disciplineDifference between included Eastern and Western studiesWesternStudies ??RCT and CCT??Mainly non-clinical balance outcome measures??Smaller sample sizeEastern Studies??Cross sectional studies??Both clinical and non-clinical balance measures??Larger sample sizeDiscussion: Tai Chi Interventions??Tai chi interventions in this study used a number of different forms of tai chi??Chinese articles did not specify the tai chi being done??Frequency, Intensity Time and Type varied between studies making comparison difficult??Variation in type to tai chi increases generalizability to a realistic community settingLimitations??Small sample sizes??decreased power of results??May have missed some of the effects of tai chi on balance??Difficult to blind tai chi intervention??Difficult to measure the holistic nature of tai chi??research outcome measures may miss some important aspects of tai chiLimitations??Difficult to summarize the ideal tai chi program for improving balance??each study used different tai chi interventions??Subjects that were considered unhealthy were not included??Possible effects of tai chi on this population were therefore missed??Only one member of the research group spoke Chinese??used second reviewer with experience in Chinese medical research tomaintainrigorSummary??Effects of tai chi on balance related outcome measures??Improved ability to utilize vestibular and somatosensory information??Decreased sway??Increased lateral stability??Use of increased BOS??Decreased reaction times??Decreased fear of falling/increased confidence in balance abilitiesFuture Research Questions1. What is the appropriate length of intervention in order to adequately determine the effects of tai chi? 2. Is the westernized version of tai chi used in research a valid example of traditional tai chi used in the east?3. Does western research overlook important aspects of tai chi that are not measurable by current scientific outcome measures?4. What is the relationship between balance outcome measures and fall risk?Future Research Questions5. What are the best FITT (Frequency, Intensity, Type, Time) parameters for tai chi for improvements in balance, and what are the best FITT parameters to maintain these improvements?6. What balance outcome measures are best suited, as well as valid and reliable for use in the older adult population?7. Do different styles of tai chi have different effects on balance?8. What is the effect of tai chi on balance in an unhealthy population?Research implications??Technology enables easier access and sharing of information??global PT knowledge translation??It is possible to study topics across cultures??broader understanding of the topic??larger audience for findingsClinical Implications??No adverse effects??safe??High compliance??interest??No equipment/special facility required??cost efficientClinical implications??Older population specific benefits??Social??Physical activity??Body awareness??Increased confidence in balance ability??Decreased fear of falling/anxietyClinical implications??Tai chi may not be any more beneficial for balance than RTE or BT??Tai chi is another option PTs can use to encourage/facilitate physical activity??Interest-adherence / cost-feasibility??Communication is key to finding the best fit for individualizedPA recommendationsSo????Tai chi is a safe, cheap, social, relaxing, andenjoyable way to participate in physical activity and potentially improve balance, which makes it suitable foran older population.Acknowledgements??Dr. Elizabeth Dean??Dr. Susan Harris??Charlotte Beck??Dr. Angela Bush??Jiao Fang MeiQuestions?References1.Scott, V. The Evolution of Senior?s Falls Prevention in British Columbia. BC Injury Research and Prevention Unit. [cited 2008 Jul15 ]. www.injuryresearch.bc.ca/categorypages.aspx?catid=1&subcatid=7&catname=&subcatname=Falls%20Prevention. 2006 BCIRPU. Retrieved July 2008.2.Health Canada -Division of Aging and Seniors. A Best Practices Guide for the Prevention of Falls Among Seniors Living in the Community. www.hc-sc.gc.ca/seniors-aines/. Minister of Public Works and Government Services Canada, 2001.Retrieved July 2008.3.Piirtola M, Era P. Force platform measurements as predictors of falls among older people -a review. Gerontology. 2006; 52:1-16.4.Fisher K, Harmer J, Li PF. TC: Improving Functional Balance and Predicting Subsequent Falls in Older Persons. Med Sci Sports Exerc. 2004;36:2046-2052.5.Henderson, NK, White CP, Eisman JA. The roles of exercise and fall risk reduction in the prevention of osteoporosis. Endocrinol Metab Clin North Am. 1998;27(2):369-87. 6.Lin MR, Hwang HF, Wang YW, Chang SH, and Wolf SL. Community-based Tai Chi and its effect on injurious falls, balance, gait, and fear of falling in older people. Phys Ther. 2006 Sep;86(9):1189-201. 7.Lui PP, Qin L, Chan KM. Tai Chi Chuan exercises in enhancing bone mineral density in active seniors. Clin Sports Med. 2008;27:75-86.8.Verhagen AP, Immink M, Van der Meuelen A,  Bierma-Zeinstra SM. The efficacy of Tai Chi Chuan in older adults: a systematic review. Fam Pract. 2004;21:107-113.9.Busing, KJ. Determining the Effects of Tai Chi on Dynamic Balance and Fear of Falling in an Elderly Population. Activities Adapt Aging. 2005. 30, 2, 49-6410.Yim-Chiplis P, Talbot L. Defining and measuring balance in adults. Biol Res Nurs. 2000;1(4):321-331.11.Langley FA, MackIntosh SFH. Functional Balance Assessment of Older Community Dwelling Adults: A systematic review of the Literature. The Internet Journal of Allied Health Sciences and Practice. University of South Australia, Adelaide. 2007(5)4:1-11References12.Pajala S, Era P, Koskenvuo M, Kaprio J, T?rm?kangas T, Rantanen T. Force platform balance measures as predictors of indoor and outdoor falls in community-dwelling women aged 63-76 years. J Gerontol A Biol Sci Med Sci. 2008;63:171-178.13.Buatois S, Gueguen R, Gauchard GC, Benetos A, Perrin PP. Posturography and risk of recurrent falls in healthy non-institutionalized persons aged over 65. Gerontology. 2006; 52:345-352.14.Hutchinson K. Changes in the mean center of balance during balance testing in young adults. Phys Ther. 1995;75(8):699-706.15.Tsang W, Hui-Chan C. Effect of 4 and 8 week intensive tai chi training on balance control in the elderly. Med Sci Sports Exerc. 2004;36(4):648-657.16.Voukelatos A, Cumming R, Lord S, Rissel C. A randomized controlled trial of tai chi for the prevention of falls: the central Sydney TC trial. J Am Geriatr Soc. 2007; 55(8):1185-1191.17.Li Y, Cheri N, Van Oteghen D, Van Oteghen S. Effects of extended tai chi intervention on balance and selected motor functions of the elderly. Am J Chin Med. 2007;35(3):383-391.18.Wolf S, Barnhart H, Ellison G, Coogler C, Atlanta FICSIT group. The effect of tai chi quan and computerized balance training on postural stability in older subjects. Phys Ther. 1997;77(4):371-384.19.Yan T, Xie R, Guo Y, Jin D, Cao Y. Comparison of the effects of shadowboxing on equilibrium function of healthy elderly women. Chinese Journal of Clinical Rehabilitation 2005;9:159-161.20.Wang W, Liu Q.  The research on how tai chi influences the lowerextremity function in elderly. Journal of Guangzhou Institute of Physical Education 2003;23:36-38.21.Woo J. A randomised controlled trial of tai chi and resistance exercise on bone health, muscle strength and balance in community-living elderly people. Age Ageing. 2007;36:262-268.22.Yang Y, Verkuilen J, Rosengren K, Grubisich S, Michael R, Hsiao-Wecksler E. Effect of combined taiji and qigone training on balance mechanisms: a randomized controlled trial of older adults. Med Sci Monit. 2007;13(8):339-348.23.Xiao C, Wang T, Jiang G. Research on impacts of Taijiquan on the balance ability of the aged people. Journal of Beijing Sports University 2006;29:489-490.24.Rogers M, Rogers N, Takeshima N, Mohammod I. Methods to assess and improve the physical parameters associated with fall risk in older adults. Prev Med. 2003;36:255-264.

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