O R I G I NA L A R T I C L E

The Effects of Tai Chi Exercise on Elders with Osteoarthritis: A Longitudinal Study Ching-Huey Chen1, Miaofen Yen1*, Susan Fetzer2, Li-Hua Lo3, Paul Lam4 1

Associate Professor, Department of Nursing & Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan 2 Associate Professor, Department of Nursing, College of Health and Human Services, University of New Hampshire, New Hampshire, USA 3 Associate Professor, Department of Nursing, Oriental Institute of Technology, Taipei, Taiwan 4 Lecturer of University of New South Wales and Family Physician, Sydney, Australia

Purpose Tai Chi exercise has been proven to be beneficial among elders with osteoarthritis (OA). The long-term effects of this exercise remain unclear. The purpose of this study was to evaluate the effects of the Tai Chi exercise for Arthritis (TCEA) program on the physical status and quality of life of OA elders. Methods This was a time series study with one group design. Subjects diagnosed with OA of the lower extremities, aged 60 years or over, were recruited from an outpatient clinic at a community teaching hospital. Thirteen participants joined a TCEA exercise class three times per week for 2 years. Physical status including body mass index (BMI), lean body mass, hand grasp strength, flexibility, and equilibrium were measured four times—at baseline, 3 months, 1 year, and 2 years of the TCEA exercise class. Quality of life was also measured at these time points. Results Lean body mass was significantly decreased within the study period (p < .05). Participants experienced significant improvements in physical functioning, role limitations, and social functioning on the dimensions of quality of life (SF-36) (p < .05). Conclusions Elderly people with OA should be encouraged to exercise using Tai Chi for maintaining physical function and improving quality of life. [Asian Nursing Research 2008;2(4):235–241] Key Words

osteoarthritis, quality of life, Tai Chi

BACKGROUND Tai Chi exercise, a traditional Chinese martial art, has been shown to have a positive impact on both physical and psychological function, and on the prevention of falls among the elderly (Verhagen, Immink, van der Meulen, & Bierma-Zeinstra, 2004; Wang, Collet, & Lau, 2004; Wolf et al., 2003). While Chen, Yang, Sun and Wu are the most popular styles of Tai Chi,

each with its own unique set of circular movements, all styles share the same essential principles of the practice (Li, Hong, & Chan, 2001). When practicing Tai Chi exercise, concentration of the mind and relaxation of the body are emphasized (Lam, 2006). Tai Chi exercise consists of fluid, gentle and slow circular movements with a semi-squat posture that requires precise joint movements, stability, and balance (Verhagen et al.).

*Correspondence to: Miaofen Yen, Department of Nursing & Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, No. 1, University Rd., Tainan, Taiwan (701). E-mail: [email protected] Received: September 5, 2008

Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4

Revised: September 12, 2008

Accepted: November 24, 2008

235

C.H. Chen et al.

Tai Chi has been helpful in alleviating joint pain, increasing muscle strength, flexibility and balance without further deterioration to the joints in older patients with osteoarthritis (OA) (Lumsden, Baccala, & Martire, 1998). For example, after 10 weeks with a minimum 1 hour of daily Tai Chi exercise, eight elders with arthritis showed significant reduction in pain (Adler, Good, Roberts, & Snyder, 2000). Hartman et al. (2000) found that two 1-hour Tai Chi classes per week for 10 weeks enhanced functional mobility and quality of life (QOL) in OA elders. Song and colleagues (Song, Lee, Lam, & Bae, 2003) studied 43 elderly women with OA; the study results showed that Tai Chi exercise reduced the severity of arthritis symptoms and improved balance and physical functioning after 12 weeks. A recent randomized controlled trial study on 41 elderly people with OA also supported the idea that 12 weeks of Tai Chi exercise program, three times per week for 40 minutes each time, can significantly improve participants’ perception of knee pain, physical function and stiffness (Brismée et al., 2007). The short-term benefits of Tai Chi exercise training, mostly 8–16 weeks, among elders with OA have been well documented (Adler et al., 2000; Song et al., 2003). Once elders have stopped practicing Tai Chi exercise, the positive effects are lost (Brismée et al., 2007). As OA is a chronic life-long disease, it seems appropriate to recommend continuation of Tai Chi exercise.Tai Chi exercise is a low to moderate intensity exercise and the effects of this exercise may be revealed through long term practice (Lan, Lai, & Chen, 2002). The long-term effects of Tai Chi exercise remain unclear. The purpose of the current study was to evaluate the effect of the Tai Chi exercise for Arthritis (TCEA) (Lam & Horstman, 2002) program practiced over 2 years on the general physical status and QOL of elders with OA.

METHODS This study was a longitudinal, repeated, one group design to examine the effects of TCEA on general physical status and QOL in elders with OA. 236

Sample The participants were recruited from outpatient clinics in a community teaching hospital in southern Taiwan. The inclusion criteria included a diagnosis of lower extremity OA, being aged 60 years or older, no medical or physical contraindications to low intensity physical exercise and a willingness to attend a TCEA exercise group three times a week. A previous study indicated elders’ preference for a group of 20–30 participants (Chen, Chen, Wang, & Huang, 2005). Using the G power 3 program (Faul, Erdfelder, Lang, & Buchner, 2007; Institut Für Experimentelle Psychologie, 2008.), for one group pre- and post-test with parameters of effect size = 0.5, alpha = .05, and a power value of .80, a total of 27 subjects were required for the study. The effect size was based on Song’s study (Song et al., 2003) for improving physical functioning. Therefore, 30 elders with OA were invited to participate in the study. Tai Chi Exercise for Arthritis (TCEA) TCEA, originally developed by Lam, consisted of 12 forms of exercise modified from Sun-style Tai Chi. The reasons for choosing 12 Sun-style forms for TCEA were that: (a) it included agile steps with many forward and backward movements to improve flexibility; (b) its higher stance position made these exercises easier for older people to learn and practice; and (c) it contained many Qi-enhancing exercises to improve the circulation of body energy and to facilitate healing. Participants may, therefore, enjoy a sense of achievement from learning the movements, which may in turn enhance their adherence to the regimen. The TCEA was also designed to be especially safe for people with arthritis. High risk movements were excluded and adaptation for different disabilities was built in (Lam & Horstman, 2002). The TCEA program included warm up, 12 forms of TCEA and cool down sections. The sequence of every class was (a) warm-up stretching exercise (5 minutes), (b) 12 forms TCA (8 sets), (c) stretching exercise (5 minutes), (d) 12 forms TCA (8 sets), and (e) cool-down stretching exercise or activity (5 minutes). Each class lasted approximately 50 minutes. Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4

Tai Chi Exercise

Procedures The hospital administration granted permission to carry out the study, as there was no Institutional Review Board. The participants signed written consent forms before the study. The consent form included details about the benefits of joining the program, potential risks with prevention maneuvers, and the nature of voluntary participation. Primary physicians referred patients to the study based on the inclusion criteria for the study. The hospital offered a space which allowed 30 people to perform TCEA together. Two TCEA leaders were trained to ensure that the TCEA was carried out consistently and followed the standards established by Lam. Two TCEA leaders were trained through Tai Chi workshops were led by Lam so that they could become proficient enough to lead the Tai Chi group as certified Tai Chi for arthritis program instructors. Each leader received a TCEA instructor certificate from Dr. Lam. The two leaders led the class together for 1 month to ensure the consistency of the intervention. These two leaders took turns leading TCEA exercise classes three times per week. The first 4 weeks of TCEA classes were dedicated to helping participants, step-by-step, to become familiar with the 12 forms of TCEA. During this month, the leaders examined each participant individually to ensure the accuracy in performing TCEA every time they attended the class. An examination of performance accuracy was then implemented every 3 months. All participants attended the TCEA exercise classes three times per week. Patient attendance was recorded. The adherence rate was calculated based on the number of times a participant was present. In order to increase adherence, the leaders provided health related information at the end of each class and spent time with the participants after class to understand the difficulties in performing Tai Chi. Private tutoring was held at the end of each class when needed. A pre-test was conducted for each participant to form the pre-test data during the first month of the study. Follow-up measures were completed after 3 months, 1 year and 2 years. Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4

Measurements Physical status The indicators for physical status included body composition, balance, muscle strength and flexibility. Body composition was evaluated by InBody 3.0® (Inbody 3.0, Biospace Co., Korea) (1999) which was based on the bioelectrical impedance analysis (BIA) method to estimate body weight, body mass index (BMI), lean body mass (LMB), and body fat.The validity and reliability of BIA have been well established in studies with healthy adults and diabetic patients undergoing hemodialysis (Kushner, Gudivaka, & Schoeller, 1996). The InBody was calibrated before the study. Balance was evaluated by how long (in seconds) the participants could stand on a single foot with eyes closed. Muscle strength was evaluated by handgrip strength (in pounds) of the dominant hand using a Jamar® (Jamar 5030J1, Nexgen Ergonomics, USA) hydraulic hand dynamometer (1997). Flexibility was assessed by the length (in cm) between the tip of middle finger and the feet when the participants were in a sitting position with both feet straight out on the floor and bending the waist and stretching both hands toward the feet without bending the knees. Quality of life QOL was measured with the Chinese version of the 36-item short form of the Medical Outcomes Study questionnaire (SF-36, version I) (Ware, 1997). The Chinese version has been developed and tested (Lu, Tseng, & Tsai, 2003) and permission to use the instrument was granted. The SF-36 includes 36 self-assessed items, consisting of eight dimensions: physical functioning (PF); role limitations due to physical problems (RP); bodily pain (BP); social functioning (SF); general health perception (GH); role limitations due to emotional problems (RE); vitality (VT); and mental health (MH). Each dimension was scored from 0–100, with higher scores indicating better QOL. The reliability and validity of the SF-36 have been verified and documented in many studies representing different populations (Coons, Rao, Keininger, & Hays, 2000). 237

C.H. Chen et al.

Data Analysis SPSS (14.0) for Windows was used for data analysis. Demographic data were analyzed by descriptive statistics. To examine the differences in outcome indicators among measurements, repeated measure analysis of variance (ANOVA) was applied if the normality assumption was fulfilled for the data of measured indicators. Normality for each variable was tested by Kolmogorov-Smirnor test. If the normality assumption was violated, a Friedman test was used to test the difference among the four measures. A p value less than .05 was considered statistically significant.

RESULTS Demographics Thirty participants completed the pre-test measurements, 6 people dropped out within 3 months (20%), another 10 people stopped practicing before the sixth month (33%), and 1 person left after 1 year of practicing. The attrition rate was 53% within 6 months. The reasons for withdrawing from the program included lack of interest (n = 10), physical illnesses (n = 3), moving to another place (n = 1), lack of time (n = 1), car accident (n = 1), and death (n = 1). Pre-test data of elders completing the study and those who failed to complete the 2-year TCEA program were compared. There was no difference in any demographic variable, physical status measurement or QOL variable between the groups. For those who completed the program (n = 13), the attendance rate was at least 80%. The average age was 68.5 years (SD = 3.69; age range 60–74 years). Seven participants were male and six were female. Only one participant reported having no formal education. The majority of participants were married (92%) and none of them lived alone. The demographic characteristics of the participants are shown in Table 1. Effectiveness of TCEA on physical status The effectiveness of TCEA on physical status is listed in Table 2. Among the indicators of physical status, LBM was significantly decreased within the study period (p < .05). Handgrip strength and balance 238

Table 1 Demographic Characteristics of Participants (N = 13) Variable

N

Percentage (%)

Age 60–65 66–70 71–75

3 5 5

23.1 38.5 38.5

Gender Male Female

7 6

53.8 46.2

Education level None Elementary school Junior high school Senior high school College and above

1 3 3 5 1

8.0 23.1 23.1 38.5 8.0

Marital status Married Widower or widow

12 1

92.3 7.7

6 3 4

46.2 23.1 30.8

Living condition With significant other With children With all above

increased gradually over the 2 years, although these increases were not statistically significant. The flexibility assessment revealed a fluctuation in result within four sets of measurements. The data on flexibility at year 2 of follow up was higher than at pre-test.

Effectiveness of TECA on Quality of Life The effectiveness of TECA on eight dimensions of self-assessed QOL (SF-36) is shown in Table 3. Participants experienced significant improvements in PF, RP, and SF on the dimensions of QOL over 2 years follow up (p < .05). Specifically, PF and RP demonstrated a steady improvement during 2 years of practicing TECA. SF reached 100 points at the first year and declined at the second year of measurements. Despite this, the SF score at the second year was higher than the pre-test score. Although not statistically significant, the RE score showed the same fluctuation as the SF score. There was a non-statistically Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4

Tai Chi Exercise

Table 2 The Effectiveness of TCEA on Physical Status (N = 13)

BMI (kg/m2) LBM (kg) Fat weight (kg) Strength (lb) Flexibility (cm) Balance (sec)

Pre-test

3 months

1 year

2 years

F value/ Chi-square

24.7 (2.7) 44.9 (7.0) 18.2 (5.2) 31.0 (10.1) 31.0 (11.3) 8.2 (8.6)

24.6 (2.5) 45.3 (6.9) 17.8 (4.8) 32.0 (10.1) 32.8 (11.2) 7.2 (6.6)

24.5 (2.4) 44.8 (6.7) 17.8 (4.5) 32.9 (11.3) 31.3 (11.3) 8.2 (2.4)

24.7 (2.4) 44.2 (6.9) 18.4 (4.8) 38.0 (16.5) 32.3 (12.3) 9.3 (6.4)

0.330 5.591* 0.674 2.367 4.968† 2.951†

Post hoc test (y = year) Pre-test > 2y

Note. *p < .05; †denotes the Friedman test was applied. The others were tested by repeated measurement analysis of variance (ANOVA). BMI = body mass index; LBM = lean body mass.

significant tendency to improvement in BP and VT and a decline in MH.

DISCUSSION The results of this study should be interpreted with caution. The use of a one group design to evaluate Tai Chi exercise is not powerful enough to predict the long term effects. The addition of a control group to a longitudinal study could provide additional support for the intervention. However, no longitudinal studies evaluating the effect of Tai Chi exercise that continued for over 2 years could be identified in the literature. The drop-out rate of this study was similar to previous reports (Ettinger et al., 1997), and this also limits the study findings. Although other Tai Chi studies have reported a drop-out rate from 3–34%, the duration of the exercise for the majority of these studies was less than 6 months according to a systematic review (Verhagen et al., 2004). Lack of interest was the most commonly listed reason (n = 10) for withdrawing from the program. Lack of interest was also the leading reason for older people not engaging in physical activity during leisure time (Satariano, Haight, & Tager, 2000). While most of the elderly in Taiwan were familiar with the term, they did not have any experience in performing Tai Chi. Rosengren’s study (2003) suggested that it Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4

took at least 4 months for individuals to achieve a moderate level of Tai Chi skills. Inspiring elderly people’s interest during this long period of learning is a challenge for Tai Chi instructors. Usually, people need a period of 3–6 months to get used to Tai Chi (Lam, 2006). Even though the attrition rate of this study was above 50%, no participants dropped out after 1 year of practicing. Strategies to inspire elders’ interest beyond the 3-month period require further investigation. The change in physical condition after 2 years of TCEA was disappointing. The decline in LBM during the study period may be due to aging. Low intensity exercise such as TCEA may not be effective in overcoming the effects of aging and chronic illness. Physical indicators specific to knee strength and flexibility may be more indicative of the therapeutic effects of TCEA. Participants experienced significant QOL improvements, specifically in their perception of physical functioning, social functioning and physical role limitations. As expected, when compared with the general elder population, pre-intervention QOL dimension scores were lower (Tsai, Chi, Lee, & Chou, 2004). This result was similar to that of the study by Jakobsson and Hallberg (2002). They suggested that older people with arthritis, either rheumatoid arthritis or osteoarthritis, generally had low QOL measures. After 2 years of practicing TCEA, the elders’ scores (PF and RP) equaled or exceeded those 239

240

Note. *p < .05; †denotes the Fredman test was applied. The others were tested by repeated measurement analysis of variance (ANOVA).

Pre-test < 1y; 3m < 1y; 1y > 2y

Pre-test < 1y, 2y; 3m < 1y, 2y Pre-test < 1y, 2y

12.421*† 4.152† 2.126 4.321 1.420 4.356† 3.261* 1.215* 88.9 (10.8) 86.5 (28.2) 81.2 (18.6) 66.7 (19.2) 75.0 (13.2) 87.5 (16.9) 82.1 (35.0) 76.6 (13.5) 88.5 (16.3) 82.7 (29.6) 75.4 (16.6) 72.9 (18.0) 71.5 (14.2) 100.0 (0.0) 89.7 (25.0) 77.9 (8.6) 75.0 (24.6) 63.5 (46.3) 71.2 (22.9) 73.5 (12.8) 68.1 (13.0) 88.5 (10.8) 79.5 (29.0) 78.5 (15.7) Physical functioning (PF) Role limitations-physical (RP) Bodily pain (BP) General health (GH) Vitality/energy (VT) Social functioning (SF) Role limitations-emotional (RE) Mental health (MH)

71.5 (21.9) 48.1 (40.1) 66.0 (20.9) 65.0 (15.0) 67.3 (14.2) 83.7 (16.4) 66.7 (40.8) 78.5 (15.8)

F value/Chi-square 2 years 1 year 3 months Pre-test

The Effectiveness of TCEA on Quality of Life (N = 13)

Table 3

Post hoc test (y = year)

C.H. Chen et al.

of the normative data except in the area of MH (Tsai, Chi, Lee, & Chou). MH and VT scores declined over time even though the statistical tests were non-significant. It seems that practicing TCEA was not sufficient to overcome the progressive loss of vitality and energy caused by aging. Medications and life events might be confounding factors that need to be considered in future studies. Other than that, the benefits of TCEA program in health-related QOL were promising. The improvements, particularly in PF and RP, accumulated even into the second year.

Implications for Future Research The results support the idea that elderly patients with OA of the lower extremities may benefit from practicing TCEA. Some of these benefits may increase continuously over 2 years of regular practicing. The adherence rate is favorable, especially after the first 6 months. It is important to design an exercise program that fits with individuals’ interests to enhance adherence and to incorporate relapse prevention in the program as suggested by Chao, Foy, and Farmer (2000). For a longitudinal study, leaders must be aware of the difficulties and obstacles of practicing Tai Chi for each member during the first 3 months of the program. Strategies such as promoting the relationships between leaders and each member, and increasing group member interactions should be considered in order to provide opportunities for each participant to share their difficulties and experiences in overcoming the obstacles. Specific physical indicators measuring knee strength should be included in future studies. In practice, information on Tai Chi training classes can be provided to people with OA. Additional research is needed with larger sample sizes and comparison groups to determine the long term effects of TCEA.

ACKNOWLEDGMENTS Source of support: This study was funded by the National Science Council (NSC-90-2314-B-006117), Taiwan. Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4

Tai Chi Exercise

REFERENCES Adler, P., Good, M., Roberts, B., & Snyder, S. (2000). The effects of Tai Chi on older adults with chronic arthritis pain. Journal of Nursing Scholarship, 32, 377. Brismée, J. M., Paige, R. L., Chyu, M. C., Boatright, J. D., Hagar, J. M., & McCaleb, J. A. (2007). Group and home-based tai chi in elderly subjects with knee osteoarthritis: A randomized controlled trial. Clinical Rehabilitation, 21, 99–111. Chao, D., Foy, C. G., & Farmer, D. (2000). Exercise adherence among older adults: Challenges and strategies. Control Clinical Trials, 21, S212–S217. Chen, K. M., Chen, W. T., Wang, J. J., & Huang, M. F. (2005). Frail elders’ views of Tai Chi. Journal of Nursing Research, 13, 11–20. Coons, S. J., Rao, S., Keininger, D. L., & Hays, R. D. (2000). A comparative review of generic quality-oflife instruments. Pharmacoeconomics, 17, 13–35. Ettinger, W. H., Burns, R., Meesier, S. P., Applegate, W., Rejeski, W. J., & Morgan, T. (1997). A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: the fitness arthritis and seniors trial (FAST). Journal of American Medical Society, 277, 25–31. Faul, F., Erdfelder, E., Lang, A. G. & Buchner, A. (2007). G*power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175–191. Hartman, C. A., Manos, T. M., Winter, C., Hartman, D. M., Li, B., & Smith, J. C. (2000). Effects of Tai Chi training on function and quality of life indicators in older adults with osteoarthritis. Journal of the American Geriatrics Society, 48, 1553–1559. Institut Für Experimentelle Psychologie. (2008). Retrieved October 23, 2008, from http://www.psycho.uniduesseldorf.de/abteilungen/aap/gpower3/ Jakobbson, U., & Hallberg, I. R. (2002). Pain and quality of life among older people with rheumatoid arthritis and/or osteoarthritis: A literature review. Journal of Clinical Nursing, 11, 430–443. Kushner, R. F., Gudivaka, R., & Schoeller, D. A. (1996). Clinical characteristics influencing bioelectrical impedance analysis measurements. American Journal of Clinical Nutrition, 64 (Suppl), S423–S427. Lam, P. (2006). Teaching Tai Chi effectively. Sydney: Tai Chi Productions.

Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4

Lam, P., & Horstman, J. (2002). Overcoming Arthritis. New York: DK Publishing, Inc. Lan, C., Lai, J. S., & Chen, S. Y. (2002). Tai Chi Chuan: An ancient wisdom on exercise and health promotion. Sports Medicine, 32, 217–224. Li, J. X., Hong, Y., & Chan, K. M. (2001). Tai Chi: Physiological characteristics and beneficial effects on health. British Journal of Sports & Medicine, 35, 148–156. Lu, J. F., Tseng, H. M., & Tsai, Y. J. (2003). Assessment of health-related quality of life in Taiwan (I): Development and psychometric testing of SF-36 Taiwan version. Taiwan Journal of Public Health, 22, 501–511. Lumsden, D. B., Baccala, A., & Martire, J. (1998). Tai Chi for osteoarthritis: An introduction for primary care physicians. Geriatrics, 53, 87–88. Rosengren, K. S. (2003). Quantification of Taiji learning in older adults. Journal of American Geriatric Society, 51, 1186. Satariano, W. A., Haight, T. J., & Tager, I. B. (2000). Reasons given by older people for limitation or avoidance of leisure time physical activity. Journal of American Geriatrics, 48(5): 505–512. Song, R., Lee, E. O., Lam, P., & Bae, S. C. (2003). Effects of Tai Chi exercise on pain, balance, muscle strength, and perceived difficulties in physical functioning in older women with osteoarthritis: A randomized clinical trails. Journal of Rheumatology, 30, 2039–2044. Tsai, S. Y., Chi, L. Y., Lee, L. S., & Chou, P. (2004). Healthrelated quality of life among urban, rural, and island community elderly in Taiwan. Journal of Formosa Medical Association, 103, 196–204. Verhagen, A. P., Immink, M., van der Meulen, A., & Bierma-Zeinstra, S. M. A. (2004). The efficacy of Tai Chi Chuan in older adults: A systematic review. Family Practice, 21, 107–113. Wang, C., Collet, J. P., & Lau, J. (2004). The effect of Tai Chi on health outcomes in patients with chronic conditions. Archive of Internal Medicine, 164, 493–501. Ware, J. E. J. (1997). SF-36 Physical & Mental Health Summary Scales: A user’s manual. Boston: Quality Metric. Wolf, S. L., Barnhart, H. X., Kutner, N. G., McNeely, E., Coogler, C., & Xu, T. (2003). Selected as the best paper in the 1990s: Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. Journal of the American Geriatrics Society, 51, 1794–1803.

241

The effects of tai chi exercise on elders with osteoarthritis: a longitudinal study.

Tai Chi exercise has been proven to be beneficial among elders with osteoarthritis (OA). The long-term effects of this exercise remain unclear. The pu...
200KB Sizes 0 Downloads 4 Views