LETTERS TO THE EDITOR RESEARCH EFFECTS OF TAI CHI BALL ON BALANCE AND PHYSICAL FUNCTION IN OLDER ADULTS WITH TYPE 2 DIABETES MELLITUS To the Editor: The increasing prevalence of type 2 diabetes mellitus (DM) in older adults is a major health concern, because the risk of injurious falls and physical disability is two to three times as great in older adults with diabetes mellitus as in those without.1 This greater risk is presumably because individuals with DM have chronically high blood glucose levels, which can affect the sensorimotor receptors in the lower extremities, compromising an important mechanism for balance control.2 Long-term practice of tai chi ball combined with music training can significantly improve the physical function of individuals with DM and improve their glucose and lipid parameters.3 The purpose of this study was to investigate whether tai chi ball exercise may be an appropriate treatment strategy to improve balance control and decrease the risk of falling in this population.
METHODS Thirty-two older adults with DM (mean age 65.5) were randomized into two groups: 16 to the tai chi ball team and 16 to a control group. The tai chi ball group played tai chi ball for 3 months in three 1- to 2-hour sessions per week, and the control group underwent no intervention. Static and dynamic balance (Berg Balance Scale), dynamic balance (Timed Up-and-Go), and fitness (arm
curls, 30-second chair stand, back scratch, chair sit-andreach, 8-foot Timed Up-and-Go, 6-minute walk test) were measured in each subject at baseline and 3 months later.
RESULTS After 3 months, Berg Balance Scale (P = .008), arm curls (P = .03), 30-second chair stand (P = .04), r-BS (P = .046), right chair sit-and-reach (P = .008), left chair sit-and-reach (P = .009), 6-minute walk test (P = .04), Timed Up-and-Go (P = .02), glycosylated hemoglobin (P = .04) improved in tai chi ball participants. Control group performance remained at the pretest level (Table 1).
DISCUSSION This study evaluated the effects of the tai chi ball training on the balance and fitness of older adults with DM and confirmed the hypothesis that the balance and fitness of individuals with diabetes mellitus can be improved using a 3-month tai chi ball training intervention (Table 1). A previous study showed that long-term tai chi ball training can significantly enhance the physical function of individuals with DM and improve glucose and lipid parameters.3 The movement of tai chi ball improves central nervous system function in individuals with Parkinson’s disease with mild central nervous system dysfunction and has beneficial effects on physical rehabilitation.4 Tai chi ball has been reported to be a safe, enjoyable form of exercise that could improve balance in community-dwelling elderly adults, decrease the risk of falls, and increase bone mineral
Table 1. Performance on Two Repeated Tests for the Two Groups Control Group Before Intervention
After Intervention
Before Intervention
After Intervention
Mean Standard Deviation
Test
Arm curls in 30 seconds, right arm, n Arm curls in 30 seconds, left arm, n 30-second chair stand Back scratch right, cm Back scratch left, cm Chair sit-and-reach right, cm Chair sit-and-reach left, cm Timed Up-and-Go, seconds 6-minute walk test, meters Berg Balance Scale Glycosylated hemoglobin
Tai Chi Ball Group
21.5 22.4 11.6 21.8 27.3 6.7 6.8 7.8 414.3 42.4 7.0
4.6 4.5 2.9 16.7 9.6 9.9 11.3 0.8 93.2 8.1 1.6
21.9 22.3 11.7 21.5 27.8 6.2 6.9 7.8 416.3 43.6 7.0
6.1 5.3 4.3 15.2 12.7 7.6 4.8 3.1 89.1 11.8 1.4
21.7 22.0 11.7 21.6 27.5 6.2 6.5 7.8 412.8 42.4 7.0
3.7 4.5 3.6 14.2 15.9 8.3 8.0 2.6 126.8 9.5 1.8
26.9 23.2 14.4 18.8 26.3 1.0 2.5 6.8 462.6 51.9 6.6
4.4a,c 4.4 4.8a,c 12.9a,c 14.3 5.3b,d 5.0b,d 2.2a,c 123.3a,c 4.4b,d 1.5a,c
Data are not transformed. P < a.05, b.01 compared with baseline. P < c.05, d.01 tai chi ball compared with control after 3 months.
JAGS 63:176–208, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
0002-8614/15/$15.00
JAGS
JANUARY 2015–VOL. 63, NO. 1
density.5,6 In the present investigation, data analysis indicated that static and dynamic balance Berg Balance Scale scores were significantly greater in the tai chi ball group than in the control group (P = .02) after three 3-month intervention (Table 1). The tai chi ball group significantly decreased the time required to complete the 8-foot up-andgo test (P = .02; Table 1). It is not surprising that greater improvement in static and dynamic balance performance (Berg Balance Scale, Timed Up-and-Go) was found in tai chi ball group than in the control group, because tai chi ball training includes a series of graceful movements, constant weight shifting with rotational and multisegmental circular movements, and changes in the base of support from double- to single-leg standing and is known for its benefit in balance. Intervention programs including resistance, endurance, balance, and flexibility training have traditionally been used to decrease the fall risk of older adults with and without diabetes mellitus.7,8 In the present investigation, the tai chi ball group demonstrated significantly greater improvement in right upper body flexibility (P = .046), right arm strength (P = .03), lower body muscle strength and endurance (P = .04), right (P = .008) and left (P = .009) lower body flexibility, and aerobic endurance (P = .04) than the control group after a 3-month intervention (Table 1). The result is consistent with findings that the long practice of tai chi ball has a positive effect on muscle strength, endurance, and muscle reaction time, which was likely to have contributed to the improvement in the walking speed.9,10 The results of this study indicate that tai chi ball exercise may improve balance, flexibility, muscle strength, and aerobic endurance strength, thereby ultimately reducing the risk of falls. These findings can contribute to the future planning of community-based exercise programs for older adults with DM. Chun-Mei Xiao, Msc Department of Health Promotion and Physical Education, Beijing Institute of Graphic Communication, Beijing, China Yong-Chang Zhuang, Msc Department of Wushu, Beijing Sport University, Beijing, China
ACKNOWLEDGMENTS The authors thank the subjects for participating in the study. Conflict of Interest: The authors have no conflict of interest. No funding was received for this study. Author Contributions: Xiao: study concept and design, performing the experiments, acquisition of subjects and data, analysis and interpretation of data, preparation of first draft and final manuscript. Zhuang: performing the experiments, acquisition of subjects and data. Sponsor’s Role: No sponsor for this study.
REFERENCES 1. Wallace C, Reiber GE, LeMaster J et al. Incidence of falls, risk factors for falls, and fall-related fractures in individuals with diabetes and a prior foot ulcer. Diabetes Care 2002;25:1983–1986.
LETTERS TO THE EDITOR
177
2. McKeon PO, Hertel J. Diminished plantar cutaneous sensation and postural control. Percept Mot Skills 2007;104:56–66. 3. Wei D-l. Influence of Taiji ball on health physical fitness of patients with type 2 diabetes. J Nanjing Institute of Physical Educ 2012;1:8–11. 4. Yong Z. The influences of Taiji softball exercise with drug therapy in mild Parkinson’s patients on the rehabilitation. Fu Jian Sports Sci Technol 2009;28:15–20. 5. Wang J. Influences of Taiji softball to postmenopausal women’s bone mineral density and bone metabolism index. J Beijing Sport University 2007;9:1226–1228. 6. Yao Y. Influence of 6 months Taiji ball exercise on static balance of older people. Chin J Sports Med 2008;27:612–613. 7. Brandon JL, Gaasch DA, Boyette LW et al. Effects of long-term resistive training on mobility and strength in older adults with diabetes. J Gerontol A Biol Sci Med Sci 2003;88A:740–745. 8. Sigal RJ, Kenny GP, Wasserman DH et al. Physical activity/exercise and type 2 diabetes. Diabetes Care 2004;27:2518–2539. 9. Lai X-H. Influence of taiji ball on health physical fitness and biochemical indexes of old people. J China Sport Sci Technol 2010;46:122–124. 10. Liu Z-F. Birth of Taiji softball game and its effect. J Nanjing Institute of Phys Educ 2007;6:53–55.
PHYSICAL FITNESS AND SOCIOCOGNITIVE ENGAGEMENT ARE ASSOCIATED WITH DIFFERENT ASPECTS OF COGNITION IN OLDER ADULTS To the Editor: Alzheimer’s disease (AD) is characterized by progressive neural decline resulting in severe memory loss that interferes with daily life. One in nine Americans aged 65 and older has AD, and the incidence is projected to increase rapidly as the population ages.1 There is no cure for dementia, and thus there is urgent need to identify interventions that will help older adults maintain cognitive abilities for longer into their life span. Exercise has shown promise in alleviating aspects of age-related cognitive decline,2 but more work is needed to understand how exercise may reduce the risk of dementia and more specifically which aspects of cognition exercise targets. Physical fitness may be mitigating memory loss to delay AD diagnosis, but little is known about the link between physical fitness and memory function in healthy older adults; the main aim of the present study was to examine that relationship. Studies examining the relationship between exercise and memory in healthy older adults have yielded mixed results. In one study, older adults with higher levels of aerobic fitness had better spatial working memory for material tested after a 3-second delay,3 but this is too short a delay to examine long-term memory, which is affected by AD. Improvements in memory for material retained over longer delays have been observed after low-intensity exercise training but not moderate-intensity training,4 suggesting that aerobic fitness benefits resulting from an exercise program may not underlie the memory benefits. Furthermore, one study found no association between selfreported physical activity and episodic memory in older adults; however, participants who reported watching more television had poorer episodic memory,5 suggesting that disengagement from sociocognitive activities may be particularly detrimental for memory in aging. Engaging in socially and cognitively stimulating activities has been shown to mitigate cognitive decline in aging and reduce the risk of AD.6
METHODS Thirty-two older adults with DM (mean age 65.5) were randomized into two groups: 16 to the tai chi ball team and 16 to a control group. The tai chi ball group played tai chi ball for 3 months in three 1- to 2-hour sessions per week, and the control group underwent no intervention. Static and dynamic balance (Berg Balance Scale), dynamic balance (Timed Up-and-Go), and fitness (arm
curls, 30-second chair stand, back scratch, chair sit-andreach, 8-foot Timed Up-and-Go, 6-minute walk test) were measured in each subject at baseline and 3 months later.
RESULTS After 3 months, Berg Balance Scale (P = .008), arm curls (P = .03), 30-second chair stand (P = .04), r-BS (P = .046), right chair sit-and-reach (P = .008), left chair sit-and-reach (P = .009), 6-minute walk test (P = .04), Timed Up-and-Go (P = .02), glycosylated hemoglobin (P = .04) improved in tai chi ball participants. Control group performance remained at the pretest level (Table 1).
DISCUSSION This study evaluated the effects of the tai chi ball training on the balance and fitness of older adults with DM and confirmed the hypothesis that the balance and fitness of individuals with diabetes mellitus can be improved using a 3-month tai chi ball training intervention (Table 1). A previous study showed that long-term tai chi ball training can significantly enhance the physical function of individuals with DM and improve glucose and lipid parameters.3 The movement of tai chi ball improves central nervous system function in individuals with Parkinson’s disease with mild central nervous system dysfunction and has beneficial effects on physical rehabilitation.4 Tai chi ball has been reported to be a safe, enjoyable form of exercise that could improve balance in community-dwelling elderly adults, decrease the risk of falls, and increase bone mineral
Table 1. Performance on Two Repeated Tests for the Two Groups Control Group Before Intervention
After Intervention
Before Intervention
After Intervention
Mean Standard Deviation
Test
Arm curls in 30 seconds, right arm, n Arm curls in 30 seconds, left arm, n 30-second chair stand Back scratch right, cm Back scratch left, cm Chair sit-and-reach right, cm Chair sit-and-reach left, cm Timed Up-and-Go, seconds 6-minute walk test, meters Berg Balance Scale Glycosylated hemoglobin
Tai Chi Ball Group
21.5 22.4 11.6 21.8 27.3 6.7 6.8 7.8 414.3 42.4 7.0
4.6 4.5 2.9 16.7 9.6 9.9 11.3 0.8 93.2 8.1 1.6
21.9 22.3 11.7 21.5 27.8 6.2 6.9 7.8 416.3 43.6 7.0
6.1 5.3 4.3 15.2 12.7 7.6 4.8 3.1 89.1 11.8 1.4
21.7 22.0 11.7 21.6 27.5 6.2 6.5 7.8 412.8 42.4 7.0
3.7 4.5 3.6 14.2 15.9 8.3 8.0 2.6 126.8 9.5 1.8
26.9 23.2 14.4 18.8 26.3 1.0 2.5 6.8 462.6 51.9 6.6
4.4a,c 4.4 4.8a,c 12.9a,c 14.3 5.3b,d 5.0b,d 2.2a,c 123.3a,c 4.4b,d 1.5a,c
Data are not transformed. P < a.05, b.01 compared with baseline. P < c.05, d.01 tai chi ball compared with control after 3 months.
JAGS 63:176–208, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
0002-8614/15/$15.00
JAGS
JANUARY 2015–VOL. 63, NO. 1
density.5,6 In the present investigation, data analysis indicated that static and dynamic balance Berg Balance Scale scores were significantly greater in the tai chi ball group than in the control group (P = .02) after three 3-month intervention (Table 1). The tai chi ball group significantly decreased the time required to complete the 8-foot up-andgo test (P = .02; Table 1). It is not surprising that greater improvement in static and dynamic balance performance (Berg Balance Scale, Timed Up-and-Go) was found in tai chi ball group than in the control group, because tai chi ball training includes a series of graceful movements, constant weight shifting with rotational and multisegmental circular movements, and changes in the base of support from double- to single-leg standing and is known for its benefit in balance. Intervention programs including resistance, endurance, balance, and flexibility training have traditionally been used to decrease the fall risk of older adults with and without diabetes mellitus.7,8 In the present investigation, the tai chi ball group demonstrated significantly greater improvement in right upper body flexibility (P = .046), right arm strength (P = .03), lower body muscle strength and endurance (P = .04), right (P = .008) and left (P = .009) lower body flexibility, and aerobic endurance (P = .04) than the control group after a 3-month intervention (Table 1). The result is consistent with findings that the long practice of tai chi ball has a positive effect on muscle strength, endurance, and muscle reaction time, which was likely to have contributed to the improvement in the walking speed.9,10 The results of this study indicate that tai chi ball exercise may improve balance, flexibility, muscle strength, and aerobic endurance strength, thereby ultimately reducing the risk of falls. These findings can contribute to the future planning of community-based exercise programs for older adults with DM. Chun-Mei Xiao, Msc Department of Health Promotion and Physical Education, Beijing Institute of Graphic Communication, Beijing, China Yong-Chang Zhuang, Msc Department of Wushu, Beijing Sport University, Beijing, China
ACKNOWLEDGMENTS The authors thank the subjects for participating in the study. Conflict of Interest: The authors have no conflict of interest. No funding was received for this study. Author Contributions: Xiao: study concept and design, performing the experiments, acquisition of subjects and data, analysis and interpretation of data, preparation of first draft and final manuscript. Zhuang: performing the experiments, acquisition of subjects and data. Sponsor’s Role: No sponsor for this study.
REFERENCES 1. Wallace C, Reiber GE, LeMaster J et al. Incidence of falls, risk factors for falls, and fall-related fractures in individuals with diabetes and a prior foot ulcer. Diabetes Care 2002;25:1983–1986.
LETTERS TO THE EDITOR
177
2. McKeon PO, Hertel J. Diminished plantar cutaneous sensation and postural control. Percept Mot Skills 2007;104:56–66. 3. Wei D-l. Influence of Taiji ball on health physical fitness of patients with type 2 diabetes. J Nanjing Institute of Physical Educ 2012;1:8–11. 4. Yong Z. The influences of Taiji softball exercise with drug therapy in mild Parkinson’s patients on the rehabilitation. Fu Jian Sports Sci Technol 2009;28:15–20. 5. Wang J. Influences of Taiji softball to postmenopausal women’s bone mineral density and bone metabolism index. J Beijing Sport University 2007;9:1226–1228. 6. Yao Y. Influence of 6 months Taiji ball exercise on static balance of older people. Chin J Sports Med 2008;27:612–613. 7. Brandon JL, Gaasch DA, Boyette LW et al. Effects of long-term resistive training on mobility and strength in older adults with diabetes. J Gerontol A Biol Sci Med Sci 2003;88A:740–745. 8. Sigal RJ, Kenny GP, Wasserman DH et al. Physical activity/exercise and type 2 diabetes. Diabetes Care 2004;27:2518–2539. 9. Lai X-H. Influence of taiji ball on health physical fitness and biochemical indexes of old people. J China Sport Sci Technol 2010;46:122–124. 10. Liu Z-F. Birth of Taiji softball game and its effect. J Nanjing Institute of Phys Educ 2007;6:53–55.
PHYSICAL FITNESS AND SOCIOCOGNITIVE ENGAGEMENT ARE ASSOCIATED WITH DIFFERENT ASPECTS OF COGNITION IN OLDER ADULTS To the Editor: Alzheimer’s disease (AD) is characterized by progressive neural decline resulting in severe memory loss that interferes with daily life. One in nine Americans aged 65 and older has AD, and the incidence is projected to increase rapidly as the population ages.1 There is no cure for dementia, and thus there is urgent need to identify interventions that will help older adults maintain cognitive abilities for longer into their life span. Exercise has shown promise in alleviating aspects of age-related cognitive decline,2 but more work is needed to understand how exercise may reduce the risk of dementia and more specifically which aspects of cognition exercise targets. Physical fitness may be mitigating memory loss to delay AD diagnosis, but little is known about the link between physical fitness and memory function in healthy older adults; the main aim of the present study was to examine that relationship. Studies examining the relationship between exercise and memory in healthy older adults have yielded mixed results. In one study, older adults with higher levels of aerobic fitness had better spatial working memory for material tested after a 3-second delay,3 but this is too short a delay to examine long-term memory, which is affected by AD. Improvements in memory for material retained over longer delays have been observed after low-intensity exercise training but not moderate-intensity training,4 suggesting that aerobic fitness benefits resulting from an exercise program may not underlie the memory benefits. Furthermore, one study found no association between selfreported physical activity and episodic memory in older adults; however, participants who reported watching more television had poorer episodic memory,5 suggesting that disengagement from sociocognitive activities may be particularly detrimental for memory in aging. Engaging in socially and cognitively stimulating activities has been shown to mitigate cognitive decline in aging and reduce the risk of AD.6
