Geriatric Nursing 35 (2014) S21eS26
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Feature Article
Proto Tai Chi: In search of a promising group exercise for the frail elderly Lan Yao, PhD, RN a, *, Kevin T. Foley, MD, FACP b, Ann M. Kolanowski, PhD, RN, FGSA, FAAN c, Barbara A. Smith, PhD, RN, FACSM, FAAN a a
College of Nursing, Michigan State University, USA Division of Geriatrics and Gerontology, College of Human Medicine, Michigan State University, USA c College of Nursing, Penn State University, USA b
a b s t r a c t Keywords: Tai Chi Exercise Older adults Physical activity Frailty
The purpose of this study was to conduct a pilot evaluation of a Proto Tai Chi exercise program for older adults and gain insight into the design of future trials involving those who are physically and cognitively frail. Proto Tai Chi (aka Wu Qin Xi) is a simple and intuitive Chinese exercise from which Tai Chi evolved. Twenty-four older adults (74.2 7.5 years, range 65e92) participated in a 5-day, 90-minute/day structured evaluation of a Proto Tai Chi exercise program. Mean completed exercise time by participants per protocol was 98.6%. Participants reported the program to be enjoyable and beneficial. Preliminary efficacy of the program was supported by improvement in measures of walking speed and range of motion at post-test. Results indicate that Proto Tai Chi is a well-accepted exercise option for older adults that may improve physical function and mobility. These preliminary findings merit further investigation in the frail elderly. Ó 2014 Mosby, Inc. All rights reserved.
Introduction
activity levels are associated with fewer declines in physical function and quality of life. As people age, they often suffer progressive deficits in health and function following a continuum that leads to frailty, disability, and death.4,7 Current literature considers frailty as a pathway from morbidity to disability4,7 that is not a direct result of chronic disease. Instead, it is associated with inactivity, the loss of physical reserves, and the decline of homeostatic capacities.11,12 The Punished Inefficiency Model of frailty views frailty as a dynamic process e a perpetuating, synergistic interaction e whereby individuals with loss of reserves also experience loss of efficiency in a manner that is detrimental to maintaining adequate activity.5 Stress strengthens this negative feedback on activity, leading to disuse and worsening of chronic disease states.5 Programs that improve exercise acceptance and adherence can potentially halt the cycle that leads to inactivity, frailty progression, and functional dependence. Evidence suggests that exercise interventions may potentially prevent, delay, or reverse the frailty process and therefore restore and/or maintain functional independence in older adults.2,4,11,12 The American College of Sports Medicine and American Heart Association recommends that sedentary older adults begin with balance, flexibility, and strength training to build endurance prior to participating in aerobic exercise.13 Tai Chi, a gentle and smooth neuromotor exercise, has drawn increasing attention within the rehabilitation community as a means to improve function and
Increased life expectancy creates a global challenge for a growing number of older adults living with co-morbidities. Proportionally, this will lead to an increase in the physically and cognitively frail adult population, who are at risk of poor health outcomes.1e3 Frailty is a clinical syndrome which predisposes older adults to extreme vulnerability, disability and death.1,4e7 Prevalence rates of frailty in community-dwelling elderly are reported between 4% and 59%.6,8 Those with frailty, even to a mild degree, have higher risk of admission to long-term care than non-frail individuals.6 Frailty level and rate of change are also associated with the trajectory of cognitive decline and incipient Alzheimer’s disease (AD).9,10 The rising population of older adults living with comorbidities and frailty has created a major health care burden for the United States in recent decades.1,3 The discovery of effective interventions to prevent and delay frailty and resultant disability in older persons is a public health priority.2 Inactivity is problematic for older individuals and particularly prevalent among those with co-morbidities. Higher
* Corresponding author. 1355 Bogue St., Room C248, East Lansing, MI 48824, USA. Tel.: þ1 517 353 4769; fax: þ1 517 355 5002. E-mail address: [email protected] (L. Yao). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.02.021
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reduce falls and disability.14 Moreover, Tai Chi’s fall-risk reduction effect has been verified and recognized as one of the most beneficial forms of fall prevention exercise recommended in Clinical Practice Guidelines.15e17 Evidence indicates that long- and short-term Tai Chi practice in the older population has additional benefits including: reduced fear of falling; decreased musculoskeletal pain; improved sleep; lowered stress levels; improved emotional health, psychosocial status and immune function; increased self-efficacy; and improved executive and cognitive function.18e20 Tai Chi has also been shown to positively influence functional limitations among frail older adults, however the effect is modified by type of Tai Chi protocol used, variable outcome measurements, and inconsistent subject participation and protocol adherence. Recent studies of the effectiveness of Tai Chi report inconclusive results in frail elderly and adults with a high fall risk.21e23 A 24week modified Sun Tai Chi intervention was not superior to a control seated flexibility and stretching activity in at-risk community dwelling older persons.23 However, the average number of Tai Chi and control exercise sessions subjects attended was approximately half the number scheduled. Additionally, withdrawal rates were high: 32% of the Tai Chi group versus 25% of controls.23 Posthoc analysis of another trial suggested that the high participant withdrawal and low adherence rates accounted for the lack of positive effects on falling and physical performance in the participants.24 Poor exercise motivation and engagement remain as significant methodological barriers in trials of Tai Chi effectiveness in the frail elderly. Proto Tai Chi (aka Wu Qin Xi) is the ancient Chinese exercise from which Tai Chi evolved.25e28 It is one of the National Fitness Programs recommended by the Chinese Health Qigong Association, Center of General Administration of Sport.29 Hua Tuo, a Chinese physician in the Han Dynasty (25e220 AD), developed the exercise through studying natural movements and fun postures of five animals25,26: tiger, deer, monkey, bear, and crane. The movements of each animal are distinctive and provide the basis for the exercise that is performed through imitative posturing and stance. When practicing an animal movement, one is encouraged through mental imagery to “be the animal,” and to be expressive with movement to make it more enjoyable (for instance, visualization of one’s self as a witty deer or playful monkey28,29). These intuitive movements are simple to imitate and perceived to be more enjoyable to practice due to human’s ingrained familiarity and societal bonding with animals.26,30 These features make Proto Tai Chi a pleasurable and promising activity option for older adults. Although this exercise was introduced to the United States in the 1990s,27 the literature is devoid of published studies of its utility and effectiveness in older American participants. Our long-term goal is to investigate the effectiveness of Proto Tai Chi exercise for maintaining or enhancing physical and cognitive performance in frail older Americans, including those with cognitive impairment and dementia. The primary objectives of this pilot project were to assess acceptability and safety of our exercise protocol, and evaluate participants’ feedback and preferences regarding the Proto Tai Chi exercise program. We hypothesized that participants in a Proto Tai Chi program would rate the activity as enjoyable and maintain high levels of participation over five consecutive days of scheduled exercise. Based upon previous studies of a week-long Tai Chi workshop that improved balance performance of the participants and specifically, in adults with Parkinson’s disease,31,32 the secondary objective was to assess preliminary efficacy of the program using simple parameters of physical function. Our hypothesis was that program participants would demonstrate improvements in measures of gait and range of motion.
Methods Design A pre-test and post-test within-subjects design was used. Sample & recruitment Eligible participants in the pilot study were English speaking, community-dwelling adults age 65 years and older, diagnosed with at least one chronic health condition. They were also required to have transportation to attend the exercise classes that were held in a community center in mid-Michigan. Fliers and exercise class announcements were distributed through local geriatrics clinics, community centers and by word-ofmouth to invite potential participants. Two trained research assistants made initial telephone contact with those who responded to the project announcement, screened potential participants to determine their interest and eligibility for the study, and scheduled the informed consent and baseline assessment visits. Individuals with suspected cognitive impairment as assessed by the Six Item Screener33 were deemed ineligible and excluded. The Six-Item Screener is an efficient and accurate screening tool for studies that rely on subjects’ cognitive ability to participate in a complex intervention and/or provide self-reports.33 Individuals with contraindications to standing physical exercise (e.g., severe lumbar spine, or hip arthritis) were also excluded. A ten dollar gift card was provided to those who underwent pre- and post-evaluation as a token of appreciation for their time devoted to the project data collection. The study was approved by the Michigan State University Institutional Review Board. Movement description The core program consisted of five animal exercise forms, developed on the basis of the animal exercise movements illustrated by the Traditional Chinese Culture Institute International LLC28 and those compiled by the Chinese Health Qigong Association.26 The five animal exercises imitate the powerfulness of the tiger, the serenity and ease of the deer, the composure of the bear, the agility of the monkey, and the litheness of the crane.26,28 These techniques incorporate the essential features of the traditional Chinese Tai Chi that emphasize body alignment, stance balance, and the coordination of arms, legs, eyes, breathing and mind. As described by the Chinese Health Qigong Association, the tiger, deer, bear, monkey, and crane movements express their respective characteristics. For example, “the moving course of arms and corresponding changes of fingers in Deer Wrestling, as well as the forward stride of legs, the fistclenching and wrist-locking hand moves, the back-and-forth movement of the gravity center, the bouncing foot changes, and the flexible and smooth motions in Deer Running all reflect the characteristics of the Deer Exercise. Its characteristics are also reflected in its artistic conception, verve, and changes of breath” (A simple Analysis of the Meaning of Health Qigong-Wu Qin Xi, May 22, 2009).30 The intensity of each animal posture and stance was modified in the protocol to simplify participants’ understanding of exercise instructions as follows: The Tiger Climbs the Mountain; The Deer Nods Its Head; The Monkey Gazes at the Horizon; The Bear Rotates Its Shoulders; and The Crane Spreads Its Wings. The exercise routine emphasized the practice of single forms with multiple repetitions.
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Intervention procedure The Chinese Health Qigong Association26 suggests that an amount of exercise that makes the individual feel comfortable and pleasant is ideal. Consistent with this general practice recommendation, participants were reminded to enjoy the power of animals and be in control of the height to which their limbs were raised, range of movement of their body and limbs, and the intensity of physical exertion. Group exercise classes were taught by two professional trainers (a physical therapist and certified Tai Chi & Qigong instructor and a Master Tai Chi & Qigong trainer) using a 5day, 90-minute/day schedule. Each group class included approximately 70 min blocks of guided exercise practice per day, including warm-up and cool-down similar to the conventional Tai Chi opening and closing stance.26 Two 10 min breaks were offered to allow time for interactions between peers and the instructor or resting.
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shortness of breath, fatigue, sensations of weakness, complaints of sensory changes, light-headedness or dizziness, and sweating were recorded with the intervention or treatment rendered. Research staff completed the form during group classes based on their observations and subject reports. Data analysis Descriptive statistics were used to summarize participants’ individual characteristics and feedback. T-test, chi-squared or Fisher’s exact test were applied to compare differences in participants’ characteristics, and in pre-test and post-test performance. A twotailed test of significance was applied for all comparisons to reflect the pilot nature of the study. Analyses were performed using SPSS version 19. Results
Measurements
Profiles of the participants
Participant characteristics and status: Demographics (gender, age, ethnicity, marital status, living conditions) and mobility level were reported by subjects at baseline. Two trained research assistants conducted a health assessment (height, weight, blood pressure), collected health history (chronic illnesses and medication use), and administered the pain survey using the 0e10 Numeric Rating Scale.34 Physical performance measures were assessed using fall riskrelevant functional mobility tools35 and range of motion performance. The Timed Up and Go test (TUG); Unipedal Stance Time (UST), a one legged stance duration time; and fast and comfortable walking speed,36,37 are established, robust tests of balance, gait and fall risk. Walking speed was tested on a 6-meter course, at both fast and normal pace. TUG, UST, and fast and comfortable walking speed were timed with a stopwatch and were averaged over three trials. Range of motion performance, specifically, shoulder flexion, knee extension, and cervical rotation, were measured by goniometry by a trained research assistant. The research assistant also conducted baseline and endpoint physical performance assessments with the participants. Baseline data were collected within one week of the start of the intervention. End-of-intervention data were collected within one week after the last exercise class. Exercise adherence: Adherence was assessed by measuring both exercise time and level of engagement of each participant using a treatment receipt checklist developed for this study. Exercise time (minutes) was measured by stopwatch. Engagement was graded as good, fair, or poor, based on whether active participation was >90%, 80e90%, and 90% of the time observed). Exercise time and engagement level were not associated with participant baseline characteristics and status, such as demographics and health history. Adverse events No falls, injuries or other significant events occurred as indicted in the adverse event tracking form. Five participants reported fatigue or weakness that resolved in each case after 5 min of rest.
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Dizziness occurred in one participant and resolved completely once seated. All participants returned to exercise after these brief symptoms improved. Exit feedback All participants rated their overall experience with the program as helpful in the de-identified exit feedback form. Twenty-two rated the program as “helped a great deal” and two rated it as “somewhat helpful.” Having an experienced exercise instructor, performing exercise movements associated with animals, and practice in a group setting were rated by the participants as the top three factors which contributed to the overall program success (see Table 2). Participants described several benefits of the animal movements in their exit feedback form such as: it was fun, easy to learn and remember; and improved balance, strength, endurance and pain. The majority of the participants (n ¼ 19) indicated that they would continue to practice all five animal exercises after the program ended, and the remainder indicated that they would continue practicing three to four of the animal movements. The percentages of each of the five animal movements that were selected as “would continue” were tiger 91.7% (22/24), bear 87.5% (21/24), deer 87.5% (21/24), crane 87.5% (21/24), and monkey 83.3% (20/24), respectively, with monkey being the least selected by four participants. Tiger and bear were the most fun to practice among all five animal movements; deer was the easiest and monkey was the least easy to perform. Changes in physical performance Table 3 listed means and standard deviations of physical performance at pre-test and post-test. At the end of the 5-day program, improvements were observed in the Timed Up and Go test (p < .05), comfortable gait speed (p < .01), fast gait speed (p < .05), knee extension (p < .01) and cervical rotation (p < .01). Discussion Participants in this pilot study had chronic illness. Our data showed that Proto Tai Chi was well-received by all participants despite their varying health conditions. Participants completed 98.6% of scheduled exercise time and reported high satisfaction with the program. In addition, they expressed their intent to Table 1 Sample demographic characteristics (n ¼ 24). Mean SD or % Mean age (years) Female Caucasian Formal education (years) Marital status Married Single/divorced/widowed Type of living arrangement With family at home Alone at own home Activity level (self-report) Active Not enough Body mass index (kg/m2) Normal Over weight Obese Number of prescription medications Use of walking aids Pain (0e10)
74.2 7.5 22 (91.7%) 22 (91.7%) 17.6 2.4 11 (45.8%) 13 (54.2%) 11 (45.8%) 13 (54.2%) 16 (66.7%) 8 (33.3%) 28.0 4.9 8 (33.3%) 9 (37.5%) 7 (29.2%) 3.6 2.9 2 (8.3%) 2.1 2.0
continue practicing the animal exercise movements after the project ended. None of the participants experienced falls or other significant injury related to the intervention. As is seen in Table 2, benefits associated with animal exercise movements and practicing in a group were both rated among the top three motivating factors that prevented attrition from the exercise program. The findings suggest that Proto Tai Chi can be an enjoyable and feasible group exercise option for the elderly with chronic illnesses. Enjoyment associated with the exercise and willingness to exercise are important factors that influence adherence among older adults.38 A Cochrane review reported that intervention programs focused on physical and cognitive performance, while at the same time promoting psychological well-being and social interaction, are most likely to have positive rehabilitation effects in the elderly.39 Although it is imperative to increase the activity levels of older individuals with potentially function-limiting conditions such as cognitive impairment and high fall risk, exercise intervention recommendations are largely challenged by insufficient evidence of exercise modalities that are effective and encourage uptake and adherence.24,35 Tai Chi is an intervention with multi-faceted therapeutic features40,41 that incorporate physical, motivational, and behavioral elements.41 Tai Chi appears safe and feasible in elders with stroke,42 patients with Parkinson’s disease,31,43 and those with Alzheimer’s dementia,35,44 especially when positive emotional motivators are provided along with the Tai Chi exercise.43,44 However, current Tai Chi exercise interventions for frail older individuals are associated with variable or inconclusive outcomes21e23 and program adaptation is necessary to maintain adherence and achieve its expected results. Protocol modifications are essential to increase the adherence to and reduce the withdrawal rate from the program prior to conducting a large efficacy trial.24 Benefits of practicing Proto Tai Chi as indicated by the Chinese Health Qigong Association include: reduced waistline/waist to buttocks ratio in female practitioners, improved cardiovascular and respiratory function, and reinforced grip strength.26 Benefits have also been reported for mood, spiritual vitality and psychological confidence.26 Proto Tai Chi is described as fun, suitable for children, and more intuitive to perform.28,29 However, sparse research has been conducted on its utility and effectiveness in the United States. Many factors affect physical activity in older adults45 and are likely to vary according to a range of personal, social, and environmental conditions. Therefore, it is an important first step to investigate whether Proto Tai Chi is associated with enjoyment in American older adults, whose past experiences with this exercise form and perceived benefits are likely to be different from those previously studied in China. Although the study was exploratory in nature and limited in its scope, the outcomes showed preliminary evidence of efficacy and benefits for the participants. Improvements in the Timed-Up-and Go test, gait speed, and range of motion in the knee and cervical spine were observed after the 5-day Proto Tai Chi training program (p < .05); improvement trends in Unipedal Stance Time and shoulder range of motion were also observed (p > .05). Similar improvement was shown in previous studies brief Tai Chi interventions.31,32 One study showed that at the end of a 5-day Tai Chi program, improvements were observed from pre-test for three physical-performance measures (i.e., 50-ft speed-walk, Timed-Upand Go, and functional-reach tests, p < .05) in 17 subjects with Parkinson’s disease (mean age 71.5 years).31 Another study involving experienced Tai Chi practitioners (n ¼ 33, mean age 55 years) indicated that a 6-day intensive Tai Chi workshop resulted in improved balance performance as measured by computerized dynamic posturography.32 The improvement in physical performance observed in this pilot study occurred for uncertain reasons, but may have due to
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Table 2 Frequency and mean score of program factors which facilitated motivation and continued participation in the exercises reported by participants (n ¼ 24). Factors
Frequencies of factors selected
①
②
Experienced exercise instructor Exercise movements associated with animals Participation in a group setting Structured schedule Space used for exercise/activity
Factor means
③
④
⑤
2 4 6 9
23 20 18 15 12
1
1
2 2 2 3
4.88 4.75 4.66 4.50 4.50
Subjects were instructed to circle a number between 1 and 5 for each factor, with 5 representing the highest level of perceived benefit.
reductions in subjective experience of pain reported by the participants. Pain in older adults with chronic illnesses negatively impacts muscle strength, range of motion, and mobility, and results in further loss of physical function and increased pain.46 Pain reduction and reduced joint stiffness in cognitively impaired older adults with knee osteoarthritis are likely an effect of certain Tai Chi components.46 The strengths of this study include the use of professional trainers e who had extensive experience in teaching Tai Chi and Tai Chi-like exercises e in the intervention protocol development and the employment of standardized project-specific adherence, engagement, and adverse events tracking forms for monitoring the acceptability, exercise adherence, and safety of the Proto Tai Chi exercise program. The participants were a highly educated group of older individuals (formal education completed 17.6 2.4 years) who all provided valuable intellectual insights into the program via written comments on their exit feedback forms. Limitations Several limitations of this pilot work need to be recognized. First, the small convenience sample and the very brief duration of the intervention in this study limit the clinical significance of the study findings. The sample consisted of a group of motivated volunteers who may have had high expectations with respect to their personal outcomes resulting in biased program evaluations. Second, the effect of the treatment cannot be determined in the absence of a control group. A large-scale clinical trial should be undertaken to determine whether an intensive training protocol over a longer study period would result in improved performance outcomes and preservation of physical functioning. Despite these limitations, our preliminary findings demonstrate that Proto Tai Chi is an enjoyable, safe, and potentially effective approach to improve physical activity participation and adherence, mobility, and functional performance in the elderly.
Table 3 Physical performance outcomes at pre-test and post-test (n ¼ 24). Measures Timed Up and Go (seconds)a Unipedal Stance Time (seconds)b Comfortable gait speed (meters/ second)b Fast gait speed (meters/second)b Shoulder flexion (L) (degrees)b Shoulder flexion (R) (degrees)b Knee extension (L) (degrees)a Knee extension (R) (degrees)a Cervical rotation (L) (degrees)b Cervical rotation (R) (degree)b *p < .05; **p < .01. a Lower values indicate improvement. b Higher values indicate improvement.
Pre-test
Post-test
8.88 2.09 12.48 9.50 1.11 .21 1.58 145.04 150.21 4.79 4.92 55.42 57.71
With the goal of enriching the enjoyment of a Tai Chi like exercise program, this study collected participants’ feedback and experience to provide a preliminary evaluation of the Proto Tai Chi program and gain insight for the design of future studies using this intervention with other groups older adults, including those who are frail and cognitively impaired. Given the positive preliminary outcomes of the study, it is reasonable to extend the Proto Tai Chi program to a larger cohort of frail elders. Frailty research has recently focused on identification of vulnerable older adults with frailty and means to delay its adverse consequences through exercise participation. Conducting intervention research with frail older individuals remains a challenge. Guidelines for large-scale trials of interventions aimed at preventing or delaying disability in older persons have not yet been established.1,2 The findings from this pilot work provide a foundation to begin the development of a rigorous Proto Tai Chi exercise intervention for frail older adults. Although this study was conducted at a large community center and utilized certified trainers, a successful Proto Tai Chi program requires no equipment and little space and can easily be adopted and taught by facility staff as a low-cost group exercise option in long-term care settings. As the number of older adults living with co-morbidities and frailty continues to increase, this study provides important insight into group exercise options that can be adopted to improve physical activity participation and engagement in frail older adults. Acknowledgment The study was funded by the Pearl J. Aldrich Endowment in Aging Research Award. We thank Christina Praedel, RN; Nathan Urban, RN; and Julie King, LPTA, for their assistance with participant screening, data collection and testing. We especially thank Jann Nestell, PT, certified Tai Chi & Qigong Teacher; Dan Jones, Master Tai Chi & Qigong Trainer for their assistance in the intervention protocol development and service in Proto Tai Chi tutoring. References
p
8.26 1.74 .019* 14.22 10.34 .139 1.20 .20 .003**
.23 1.66 .29 35.38 146.17 21.54 20.01 152.00 15.90 5.21 1.67 2.82 4.68 3.25 4.71 12.85 57.42 10.66 10.21 65.08 9.17
Implications
.041* .860 .372 .004** .185 .396 .004**
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7. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med. 2011;27(1):17e26. 8. Sternberg SA, Wershof Schwartz A, Karunananthan S, Bergman H, Mark Clarfield A. The identification of frailty: a systematic literature review. J Am Geriatr Soc. 2011;59(11):2129e2138. 9. Buchman AS, Schneider JA, Leurgans S, Bennett DA. Physical frailty in older persons is associated with Alzheimer disease pathology. Neurology. 2008;71(7):499e504. 10. Boyle PA, Buchman AS, Wilson RS, Leurgans SE, Bennett DA. Physical frailty is associated with incident mild cognitive impairment in community-based older persons. J Am Geriatr Soc. 2010;58(2):248e255. 11. Peterson MJ, Giuliani C, Morey MC, et al, Health, Aging and Body Composition Study Research Group. Physical activity as a preventative factor for frailty: the health, aging, and body composition study. J Gerontol A Biol Sci Med Sci. 2009;64(1):61e68. 12. Landi F, Abbatecola AM, Provinciali M, et al. Moving against frailty: does physical activity matter? Biogerontology. 2010;11(5):537e545. 13. Rogers CE, Larkey LK, Keller C. A review of clinical trials of Tai Chi and qigong in older adults. West J Nurs Res. 2009;31(2):245e279. 14. Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and injuries: cooperative studies of intervention techniques. J Am Geriatr Soc. 1996;44(5):489e497. 15. CDC. Falls Among Older Adults: An Overview. http://www.cdc.gov/ HomeandRecreationalSafety/Falls/adultfalls.html; Accessed 03.01.13. 16. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148e157. 17. Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull. 2011;22(3e4):78e83. 18. Wu G. Evaluation of the effectiveness of Tai Chi for improving balance and preventing falls in the older population e a review. J Am Geriatr Soc. 2002;50(4):746e754. 19. Taylor-Piliae RE, Haskell WL, Waters CM, Froelicher ES. Change in perceived psychosocial status following a 12-week Tai Chi exercise programme. J Adv Nurs. 2006;54(3):313e329. 20. Taylor-Piliae RE, Newell KA, Cherin R, Lee MJ, King AC, Haskell WL. Effects of Tai Chi and Western exercise on physical and cognitive functioning in healthy community-dwelling older adults. J Aging Phys Act. 2010;18(3):261e279. 21. Faber MJ, Bosscher RJ, Chin A, Paw MJ, van Wieringen PC. Effects of exercise programs on falls and mobility in frail and pre-frail older adults: a multicenter randomized controlled trial. Arch Phys Med Rehabil. 2006;87(7):885e896. 22. Logghe IH, Zeeuwe PE, Verhagen AP, et al. Lack of effect of Tai Chi Chuan in preventing falls in elderly people living at home: a randomized clinical trial. J Am Geriatr Soc. 2009;57(1):70e75. 23. Day L, Hill KD, Jolley D, Cicuttini F, Flicker L, Segal L. Impact of tai chi on impairment, functional limitation, and disability among preclinically disabled older people: a randomized controlled trial. Arch Phys Med Rehabil. 2012;93(8): 1400e1407. 24. Logghe IH, Verhagen AP, Rademaker AC, et al. Explaining the ineffectiveness of a Tai Chi fall prevention training for community-living older people: a process evaluation alongside a randomized clinical trial (RCT). Arch Gerontol Geriatr. 2011;52(3):357e362.
25. Yang J-M. The Root of Chinese Qigong: Secrets of Health, Longevity, & Enlightenment. 2nd ed. Wolfeboro, NH: Ymaa Publication Center; 1997. 26. Wu Qin Xi: Five-animal Qigong Exercises. London, UK: Singing Dragon; 2008. 27. Garofalo MP. Five animal frolics (Wu Qin Xi) Qigong an ancient Chinese exercise regimen for nourishing life. http://www.egreenway.com/qigong/animalfrolics. htm. 28. The Traditional Chinese Culture Institute International. http://tccii.com/index. asp; Accessed 22.05.12. 29. A Simple Analysis of the Meaning of Health Qigong - Wu Qin Xi. http://jsqg. sport.org.cn/en/tips/wqx/2009-05-22/280254.html; Accessed 15.01.13. 30. Ballarini G. Pet therapy. Animals in human therapy. Acta Biomed. 2003;74(2): 97e100. 31. Li F, Harmer P, Fisher KJ, Xu J, Fitzgerald K, Vongjaturapat N. Tai Chi-based exercise for older adults with Parkinson’s disease: a pilot-program evaluation. J Aging Phys Act. 2007;15(2):139e151. 32. Li H, Waite GN, Moga MM, Lam P, Geib RW. Balance improvements after a week-long tai chi workshop as determined by dynamic posturography - biomed 2010. Biomed Sci Instrum. 2010;46:172e177. 33. Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40(9):771e781. 34. McCaffery M, Beebe A. Pain: Clinical Manual for Nursing Practice. Baltimore: V.V.: Mosby Company; 1993. 35. Yao L, Giordani BJ, Algase DL, You M, Alexander NB. Fall risk-relevant functional mobility outcomes in dementia following dyadic tai chi exercise. West J Nurs Res. 2013;35(3):281e296. 36. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. Oneleg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45(6):735e738. 37. van Iersel MB, Munneke M, Esselink RA, Benraad CE, Olde Rikkert MG. Gait velocity and the Timed-Up-and-Go test were sensitive to changes in mobility in frail elderly patients. J Clin Epidemiol. 2008;61(2):186e191. 38. Resnick B, Spellbring AM. Understanding what motivates older adults to exercise. J Gerontol Nurs. 2000;26(3):34e42. 39. Crocker T, Forster A, Young J, et al. Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013;2:CD004294. 40. Wayne PM, Manor B, Novak V, et al. A systems biology approach to studying Tai Chi, physiological complexity and healthy aging: design and rationale of a pragmatic randomized controlled trial. Contemp Clin Trials. 2013;34(1):21e34. 41. Wayne PM, Kaptchuk TJ. Challenges inherent to t’ai chi research: part I e t’ai chi as a complex multicomponent intervention. J Altern Complement Med. 2008;14(1):95e102. 42. Taylor-Piliae RE, Coull BM. Community-based Yang-style Tai Chi is safe and feasible in chronic stroke: a pilot study. Clin Rehabil. 2012;26(2):121e131. 43. Klein PJ. Tai Chi Chuan in the management of Parkinson’s disease and Alzheimer’s disease. Med Sport Sci. 2008;52:173e181. 44. Yao L, Giordani B, Alexander NB. Developing a positive emotion-motivated Tai Chi (PEM-TC) exercise program for older adults with dementia. Res Theory Nurs Pract. 2008;22(4):241e255. 45. Resnick B, D’Adamo C. Factors associated with exercise among older adults in a continuing care retirement community. Rehabil Nurs. 2011;36(2):47e53. 82. 46. Tsai PF, Chang JY, Beck C, Kuo YF, Keefe FJ. A pilot cluster-randomized trial of a 20-week Tai Chi program in elders with cognitive impairment and osteoarthritic knee: effects on pain and other health outcomes. J Pain Symptom Manage. 2013;45(4):660e669.
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Feature Article
Proto Tai Chi: In search of a promising group exercise for the frail elderly Lan Yao, PhD, RN a, *, Kevin T. Foley, MD, FACP b, Ann M. Kolanowski, PhD, RN, FGSA, FAAN c, Barbara A. Smith, PhD, RN, FACSM, FAAN a a
College of Nursing, Michigan State University, USA Division of Geriatrics and Gerontology, College of Human Medicine, Michigan State University, USA c College of Nursing, Penn State University, USA b
a b s t r a c t Keywords: Tai Chi Exercise Older adults Physical activity Frailty
The purpose of this study was to conduct a pilot evaluation of a Proto Tai Chi exercise program for older adults and gain insight into the design of future trials involving those who are physically and cognitively frail. Proto Tai Chi (aka Wu Qin Xi) is a simple and intuitive Chinese exercise from which Tai Chi evolved. Twenty-four older adults (74.2 7.5 years, range 65e92) participated in a 5-day, 90-minute/day structured evaluation of a Proto Tai Chi exercise program. Mean completed exercise time by participants per protocol was 98.6%. Participants reported the program to be enjoyable and beneficial. Preliminary efficacy of the program was supported by improvement in measures of walking speed and range of motion at post-test. Results indicate that Proto Tai Chi is a well-accepted exercise option for older adults that may improve physical function and mobility. These preliminary findings merit further investigation in the frail elderly. Ó 2014 Mosby, Inc. All rights reserved.
Introduction
activity levels are associated with fewer declines in physical function and quality of life. As people age, they often suffer progressive deficits in health and function following a continuum that leads to frailty, disability, and death.4,7 Current literature considers frailty as a pathway from morbidity to disability4,7 that is not a direct result of chronic disease. Instead, it is associated with inactivity, the loss of physical reserves, and the decline of homeostatic capacities.11,12 The Punished Inefficiency Model of frailty views frailty as a dynamic process e a perpetuating, synergistic interaction e whereby individuals with loss of reserves also experience loss of efficiency in a manner that is detrimental to maintaining adequate activity.5 Stress strengthens this negative feedback on activity, leading to disuse and worsening of chronic disease states.5 Programs that improve exercise acceptance and adherence can potentially halt the cycle that leads to inactivity, frailty progression, and functional dependence. Evidence suggests that exercise interventions may potentially prevent, delay, or reverse the frailty process and therefore restore and/or maintain functional independence in older adults.2,4,11,12 The American College of Sports Medicine and American Heart Association recommends that sedentary older adults begin with balance, flexibility, and strength training to build endurance prior to participating in aerobic exercise.13 Tai Chi, a gentle and smooth neuromotor exercise, has drawn increasing attention within the rehabilitation community as a means to improve function and
Increased life expectancy creates a global challenge for a growing number of older adults living with co-morbidities. Proportionally, this will lead to an increase in the physically and cognitively frail adult population, who are at risk of poor health outcomes.1e3 Frailty is a clinical syndrome which predisposes older adults to extreme vulnerability, disability and death.1,4e7 Prevalence rates of frailty in community-dwelling elderly are reported between 4% and 59%.6,8 Those with frailty, even to a mild degree, have higher risk of admission to long-term care than non-frail individuals.6 Frailty level and rate of change are also associated with the trajectory of cognitive decline and incipient Alzheimer’s disease (AD).9,10 The rising population of older adults living with comorbidities and frailty has created a major health care burden for the United States in recent decades.1,3 The discovery of effective interventions to prevent and delay frailty and resultant disability in older persons is a public health priority.2 Inactivity is problematic for older individuals and particularly prevalent among those with co-morbidities. Higher
* Corresponding author. 1355 Bogue St., Room C248, East Lansing, MI 48824, USA. Tel.: þ1 517 353 4769; fax: þ1 517 355 5002. E-mail address: [email protected] (L. Yao). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.02.021
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reduce falls and disability.14 Moreover, Tai Chi’s fall-risk reduction effect has been verified and recognized as one of the most beneficial forms of fall prevention exercise recommended in Clinical Practice Guidelines.15e17 Evidence indicates that long- and short-term Tai Chi practice in the older population has additional benefits including: reduced fear of falling; decreased musculoskeletal pain; improved sleep; lowered stress levels; improved emotional health, psychosocial status and immune function; increased self-efficacy; and improved executive and cognitive function.18e20 Tai Chi has also been shown to positively influence functional limitations among frail older adults, however the effect is modified by type of Tai Chi protocol used, variable outcome measurements, and inconsistent subject participation and protocol adherence. Recent studies of the effectiveness of Tai Chi report inconclusive results in frail elderly and adults with a high fall risk.21e23 A 24week modified Sun Tai Chi intervention was not superior to a control seated flexibility and stretching activity in at-risk community dwelling older persons.23 However, the average number of Tai Chi and control exercise sessions subjects attended was approximately half the number scheduled. Additionally, withdrawal rates were high: 32% of the Tai Chi group versus 25% of controls.23 Posthoc analysis of another trial suggested that the high participant withdrawal and low adherence rates accounted for the lack of positive effects on falling and physical performance in the participants.24 Poor exercise motivation and engagement remain as significant methodological barriers in trials of Tai Chi effectiveness in the frail elderly. Proto Tai Chi (aka Wu Qin Xi) is the ancient Chinese exercise from which Tai Chi evolved.25e28 It is one of the National Fitness Programs recommended by the Chinese Health Qigong Association, Center of General Administration of Sport.29 Hua Tuo, a Chinese physician in the Han Dynasty (25e220 AD), developed the exercise through studying natural movements and fun postures of five animals25,26: tiger, deer, monkey, bear, and crane. The movements of each animal are distinctive and provide the basis for the exercise that is performed through imitative posturing and stance. When practicing an animal movement, one is encouraged through mental imagery to “be the animal,” and to be expressive with movement to make it more enjoyable (for instance, visualization of one’s self as a witty deer or playful monkey28,29). These intuitive movements are simple to imitate and perceived to be more enjoyable to practice due to human’s ingrained familiarity and societal bonding with animals.26,30 These features make Proto Tai Chi a pleasurable and promising activity option for older adults. Although this exercise was introduced to the United States in the 1990s,27 the literature is devoid of published studies of its utility and effectiveness in older American participants. Our long-term goal is to investigate the effectiveness of Proto Tai Chi exercise for maintaining or enhancing physical and cognitive performance in frail older Americans, including those with cognitive impairment and dementia. The primary objectives of this pilot project were to assess acceptability and safety of our exercise protocol, and evaluate participants’ feedback and preferences regarding the Proto Tai Chi exercise program. We hypothesized that participants in a Proto Tai Chi program would rate the activity as enjoyable and maintain high levels of participation over five consecutive days of scheduled exercise. Based upon previous studies of a week-long Tai Chi workshop that improved balance performance of the participants and specifically, in adults with Parkinson’s disease,31,32 the secondary objective was to assess preliminary efficacy of the program using simple parameters of physical function. Our hypothesis was that program participants would demonstrate improvements in measures of gait and range of motion.
Methods Design A pre-test and post-test within-subjects design was used. Sample & recruitment Eligible participants in the pilot study were English speaking, community-dwelling adults age 65 years and older, diagnosed with at least one chronic health condition. They were also required to have transportation to attend the exercise classes that were held in a community center in mid-Michigan. Fliers and exercise class announcements were distributed through local geriatrics clinics, community centers and by word-ofmouth to invite potential participants. Two trained research assistants made initial telephone contact with those who responded to the project announcement, screened potential participants to determine their interest and eligibility for the study, and scheduled the informed consent and baseline assessment visits. Individuals with suspected cognitive impairment as assessed by the Six Item Screener33 were deemed ineligible and excluded. The Six-Item Screener is an efficient and accurate screening tool for studies that rely on subjects’ cognitive ability to participate in a complex intervention and/or provide self-reports.33 Individuals with contraindications to standing physical exercise (e.g., severe lumbar spine, or hip arthritis) were also excluded. A ten dollar gift card was provided to those who underwent pre- and post-evaluation as a token of appreciation for their time devoted to the project data collection. The study was approved by the Michigan State University Institutional Review Board. Movement description The core program consisted of five animal exercise forms, developed on the basis of the animal exercise movements illustrated by the Traditional Chinese Culture Institute International LLC28 and those compiled by the Chinese Health Qigong Association.26 The five animal exercises imitate the powerfulness of the tiger, the serenity and ease of the deer, the composure of the bear, the agility of the monkey, and the litheness of the crane.26,28 These techniques incorporate the essential features of the traditional Chinese Tai Chi that emphasize body alignment, stance balance, and the coordination of arms, legs, eyes, breathing and mind. As described by the Chinese Health Qigong Association, the tiger, deer, bear, monkey, and crane movements express their respective characteristics. For example, “the moving course of arms and corresponding changes of fingers in Deer Wrestling, as well as the forward stride of legs, the fistclenching and wrist-locking hand moves, the back-and-forth movement of the gravity center, the bouncing foot changes, and the flexible and smooth motions in Deer Running all reflect the characteristics of the Deer Exercise. Its characteristics are also reflected in its artistic conception, verve, and changes of breath” (A simple Analysis of the Meaning of Health Qigong-Wu Qin Xi, May 22, 2009).30 The intensity of each animal posture and stance was modified in the protocol to simplify participants’ understanding of exercise instructions as follows: The Tiger Climbs the Mountain; The Deer Nods Its Head; The Monkey Gazes at the Horizon; The Bear Rotates Its Shoulders; and The Crane Spreads Its Wings. The exercise routine emphasized the practice of single forms with multiple repetitions.
L. Yao et al. / Geriatric Nursing 35 (2014) S21eS26
Intervention procedure The Chinese Health Qigong Association26 suggests that an amount of exercise that makes the individual feel comfortable and pleasant is ideal. Consistent with this general practice recommendation, participants were reminded to enjoy the power of animals and be in control of the height to which their limbs were raised, range of movement of their body and limbs, and the intensity of physical exertion. Group exercise classes were taught by two professional trainers (a physical therapist and certified Tai Chi & Qigong instructor and a Master Tai Chi & Qigong trainer) using a 5day, 90-minute/day schedule. Each group class included approximately 70 min blocks of guided exercise practice per day, including warm-up and cool-down similar to the conventional Tai Chi opening and closing stance.26 Two 10 min breaks were offered to allow time for interactions between peers and the instructor or resting.
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shortness of breath, fatigue, sensations of weakness, complaints of sensory changes, light-headedness or dizziness, and sweating were recorded with the intervention or treatment rendered. Research staff completed the form during group classes based on their observations and subject reports. Data analysis Descriptive statistics were used to summarize participants’ individual characteristics and feedback. T-test, chi-squared or Fisher’s exact test were applied to compare differences in participants’ characteristics, and in pre-test and post-test performance. A twotailed test of significance was applied for all comparisons to reflect the pilot nature of the study. Analyses were performed using SPSS version 19. Results
Measurements
Profiles of the participants
Participant characteristics and status: Demographics (gender, age, ethnicity, marital status, living conditions) and mobility level were reported by subjects at baseline. Two trained research assistants conducted a health assessment (height, weight, blood pressure), collected health history (chronic illnesses and medication use), and administered the pain survey using the 0e10 Numeric Rating Scale.34 Physical performance measures were assessed using fall riskrelevant functional mobility tools35 and range of motion performance. The Timed Up and Go test (TUG); Unipedal Stance Time (UST), a one legged stance duration time; and fast and comfortable walking speed,36,37 are established, robust tests of balance, gait and fall risk. Walking speed was tested on a 6-meter course, at both fast and normal pace. TUG, UST, and fast and comfortable walking speed were timed with a stopwatch and were averaged over three trials. Range of motion performance, specifically, shoulder flexion, knee extension, and cervical rotation, were measured by goniometry by a trained research assistant. The research assistant also conducted baseline and endpoint physical performance assessments with the participants. Baseline data were collected within one week of the start of the intervention. End-of-intervention data were collected within one week after the last exercise class. Exercise adherence: Adherence was assessed by measuring both exercise time and level of engagement of each participant using a treatment receipt checklist developed for this study. Exercise time (minutes) was measured by stopwatch. Engagement was graded as good, fair, or poor, based on whether active participation was >90%, 80e90%, and 90% of the time observed). Exercise time and engagement level were not associated with participant baseline characteristics and status, such as demographics and health history. Adverse events No falls, injuries or other significant events occurred as indicted in the adverse event tracking form. Five participants reported fatigue or weakness that resolved in each case after 5 min of rest.
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Dizziness occurred in one participant and resolved completely once seated. All participants returned to exercise after these brief symptoms improved. Exit feedback All participants rated their overall experience with the program as helpful in the de-identified exit feedback form. Twenty-two rated the program as “helped a great deal” and two rated it as “somewhat helpful.” Having an experienced exercise instructor, performing exercise movements associated with animals, and practice in a group setting were rated by the participants as the top three factors which contributed to the overall program success (see Table 2). Participants described several benefits of the animal movements in their exit feedback form such as: it was fun, easy to learn and remember; and improved balance, strength, endurance and pain. The majority of the participants (n ¼ 19) indicated that they would continue to practice all five animal exercises after the program ended, and the remainder indicated that they would continue practicing three to four of the animal movements. The percentages of each of the five animal movements that were selected as “would continue” were tiger 91.7% (22/24), bear 87.5% (21/24), deer 87.5% (21/24), crane 87.5% (21/24), and monkey 83.3% (20/24), respectively, with monkey being the least selected by four participants. Tiger and bear were the most fun to practice among all five animal movements; deer was the easiest and monkey was the least easy to perform. Changes in physical performance Table 3 listed means and standard deviations of physical performance at pre-test and post-test. At the end of the 5-day program, improvements were observed in the Timed Up and Go test (p < .05), comfortable gait speed (p < .01), fast gait speed (p < .05), knee extension (p < .01) and cervical rotation (p < .01). Discussion Participants in this pilot study had chronic illness. Our data showed that Proto Tai Chi was well-received by all participants despite their varying health conditions. Participants completed 98.6% of scheduled exercise time and reported high satisfaction with the program. In addition, they expressed their intent to Table 1 Sample demographic characteristics (n ¼ 24). Mean SD or % Mean age (years) Female Caucasian Formal education (years) Marital status Married Single/divorced/widowed Type of living arrangement With family at home Alone at own home Activity level (self-report) Active Not enough Body mass index (kg/m2) Normal Over weight Obese Number of prescription medications Use of walking aids Pain (0e10)
74.2 7.5 22 (91.7%) 22 (91.7%) 17.6 2.4 11 (45.8%) 13 (54.2%) 11 (45.8%) 13 (54.2%) 16 (66.7%) 8 (33.3%) 28.0 4.9 8 (33.3%) 9 (37.5%) 7 (29.2%) 3.6 2.9 2 (8.3%) 2.1 2.0
continue practicing the animal exercise movements after the project ended. None of the participants experienced falls or other significant injury related to the intervention. As is seen in Table 2, benefits associated with animal exercise movements and practicing in a group were both rated among the top three motivating factors that prevented attrition from the exercise program. The findings suggest that Proto Tai Chi can be an enjoyable and feasible group exercise option for the elderly with chronic illnesses. Enjoyment associated with the exercise and willingness to exercise are important factors that influence adherence among older adults.38 A Cochrane review reported that intervention programs focused on physical and cognitive performance, while at the same time promoting psychological well-being and social interaction, are most likely to have positive rehabilitation effects in the elderly.39 Although it is imperative to increase the activity levels of older individuals with potentially function-limiting conditions such as cognitive impairment and high fall risk, exercise intervention recommendations are largely challenged by insufficient evidence of exercise modalities that are effective and encourage uptake and adherence.24,35 Tai Chi is an intervention with multi-faceted therapeutic features40,41 that incorporate physical, motivational, and behavioral elements.41 Tai Chi appears safe and feasible in elders with stroke,42 patients with Parkinson’s disease,31,43 and those with Alzheimer’s dementia,35,44 especially when positive emotional motivators are provided along with the Tai Chi exercise.43,44 However, current Tai Chi exercise interventions for frail older individuals are associated with variable or inconclusive outcomes21e23 and program adaptation is necessary to maintain adherence and achieve its expected results. Protocol modifications are essential to increase the adherence to and reduce the withdrawal rate from the program prior to conducting a large efficacy trial.24 Benefits of practicing Proto Tai Chi as indicated by the Chinese Health Qigong Association include: reduced waistline/waist to buttocks ratio in female practitioners, improved cardiovascular and respiratory function, and reinforced grip strength.26 Benefits have also been reported for mood, spiritual vitality and psychological confidence.26 Proto Tai Chi is described as fun, suitable for children, and more intuitive to perform.28,29 However, sparse research has been conducted on its utility and effectiveness in the United States. Many factors affect physical activity in older adults45 and are likely to vary according to a range of personal, social, and environmental conditions. Therefore, it is an important first step to investigate whether Proto Tai Chi is associated with enjoyment in American older adults, whose past experiences with this exercise form and perceived benefits are likely to be different from those previously studied in China. Although the study was exploratory in nature and limited in its scope, the outcomes showed preliminary evidence of efficacy and benefits for the participants. Improvements in the Timed-Up-and Go test, gait speed, and range of motion in the knee and cervical spine were observed after the 5-day Proto Tai Chi training program (p < .05); improvement trends in Unipedal Stance Time and shoulder range of motion were also observed (p > .05). Similar improvement was shown in previous studies brief Tai Chi interventions.31,32 One study showed that at the end of a 5-day Tai Chi program, improvements were observed from pre-test for three physical-performance measures (i.e., 50-ft speed-walk, Timed-Upand Go, and functional-reach tests, p < .05) in 17 subjects with Parkinson’s disease (mean age 71.5 years).31 Another study involving experienced Tai Chi practitioners (n ¼ 33, mean age 55 years) indicated that a 6-day intensive Tai Chi workshop resulted in improved balance performance as measured by computerized dynamic posturography.32 The improvement in physical performance observed in this pilot study occurred for uncertain reasons, but may have due to
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S25
Table 2 Frequency and mean score of program factors which facilitated motivation and continued participation in the exercises reported by participants (n ¼ 24). Factors
Frequencies of factors selected
①
②
Experienced exercise instructor Exercise movements associated with animals Participation in a group setting Structured schedule Space used for exercise/activity
Factor means
③
④
⑤
2 4 6 9
23 20 18 15 12
1
1
2 2 2 3
4.88 4.75 4.66 4.50 4.50
Subjects were instructed to circle a number between 1 and 5 for each factor, with 5 representing the highest level of perceived benefit.
reductions in subjective experience of pain reported by the participants. Pain in older adults with chronic illnesses negatively impacts muscle strength, range of motion, and mobility, and results in further loss of physical function and increased pain.46 Pain reduction and reduced joint stiffness in cognitively impaired older adults with knee osteoarthritis are likely an effect of certain Tai Chi components.46 The strengths of this study include the use of professional trainers e who had extensive experience in teaching Tai Chi and Tai Chi-like exercises e in the intervention protocol development and the employment of standardized project-specific adherence, engagement, and adverse events tracking forms for monitoring the acceptability, exercise adherence, and safety of the Proto Tai Chi exercise program. The participants were a highly educated group of older individuals (formal education completed 17.6 2.4 years) who all provided valuable intellectual insights into the program via written comments on their exit feedback forms. Limitations Several limitations of this pilot work need to be recognized. First, the small convenience sample and the very brief duration of the intervention in this study limit the clinical significance of the study findings. The sample consisted of a group of motivated volunteers who may have had high expectations with respect to their personal outcomes resulting in biased program evaluations. Second, the effect of the treatment cannot be determined in the absence of a control group. A large-scale clinical trial should be undertaken to determine whether an intensive training protocol over a longer study period would result in improved performance outcomes and preservation of physical functioning. Despite these limitations, our preliminary findings demonstrate that Proto Tai Chi is an enjoyable, safe, and potentially effective approach to improve physical activity participation and adherence, mobility, and functional performance in the elderly.
Table 3 Physical performance outcomes at pre-test and post-test (n ¼ 24). Measures Timed Up and Go (seconds)a Unipedal Stance Time (seconds)b Comfortable gait speed (meters/ second)b Fast gait speed (meters/second)b Shoulder flexion (L) (degrees)b Shoulder flexion (R) (degrees)b Knee extension (L) (degrees)a Knee extension (R) (degrees)a Cervical rotation (L) (degrees)b Cervical rotation (R) (degree)b *p < .05; **p < .01. a Lower values indicate improvement. b Higher values indicate improvement.
Pre-test
Post-test
8.88 2.09 12.48 9.50 1.11 .21 1.58 145.04 150.21 4.79 4.92 55.42 57.71
With the goal of enriching the enjoyment of a Tai Chi like exercise program, this study collected participants’ feedback and experience to provide a preliminary evaluation of the Proto Tai Chi program and gain insight for the design of future studies using this intervention with other groups older adults, including those who are frail and cognitively impaired. Given the positive preliminary outcomes of the study, it is reasonable to extend the Proto Tai Chi program to a larger cohort of frail elders. Frailty research has recently focused on identification of vulnerable older adults with frailty and means to delay its adverse consequences through exercise participation. Conducting intervention research with frail older individuals remains a challenge. Guidelines for large-scale trials of interventions aimed at preventing or delaying disability in older persons have not yet been established.1,2 The findings from this pilot work provide a foundation to begin the development of a rigorous Proto Tai Chi exercise intervention for frail older adults. Although this study was conducted at a large community center and utilized certified trainers, a successful Proto Tai Chi program requires no equipment and little space and can easily be adopted and taught by facility staff as a low-cost group exercise option in long-term care settings. As the number of older adults living with co-morbidities and frailty continues to increase, this study provides important insight into group exercise options that can be adopted to improve physical activity participation and engagement in frail older adults. Acknowledgment The study was funded by the Pearl J. Aldrich Endowment in Aging Research Award. We thank Christina Praedel, RN; Nathan Urban, RN; and Julie King, LPTA, for their assistance with participant screening, data collection and testing. We especially thank Jann Nestell, PT, certified Tai Chi & Qigong Teacher; Dan Jones, Master Tai Chi & Qigong Trainer for their assistance in the intervention protocol development and service in Proto Tai Chi tutoring. References
p
8.26 1.74 .019* 14.22 10.34 .139 1.20 .20 .003**
.23 1.66 .29 35.38 146.17 21.54 20.01 152.00 15.90 5.21 1.67 2.82 4.68 3.25 4.71 12.85 57.42 10.66 10.21 65.08 9.17
Implications
.041* .860 .372 .004** .185 .396 .004**
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