Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial

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Disability & Rehabilitation, 2013; 35(17): 1429–1435© 2013 Informa UK, Ltd.ISSN 0963-8288 print/ISSN 1464-5165 onlineDOI: 10.3109/09638288.2012.737084

Purpose: To compare the effectiveness of supervised Tai Chi exercises versus the conventional physical therapy exercises in a personalized rehabilitation program in terms of the incidence and severity of falls in a frail older population. Method: The participants were frail older adults living in the community, admitted to the day hospital program in Sherbrooke, Quebec, Canada (n = 152). They were randomized to receive a 15-week intervention, either by supervised Tai Chi exercises (n = 76) or conventional physical therapy (n = 76). Fall incidence and severity were assessed using both the calendar technique and phone interviews once a month during 12 months following the end of the intervention. Other variables were collected at baseline to compare the two groups: age, comorbidity, balance, sensory interaction on balance, and self-rated health. Results: Both interventions demonstrated a protective effect on falls but Tai Chi showed a greater one (RR = 0.74; 95% CI = 0.56–0.98) as compared to conventional physical therapy exercises. Conclusions: Supervised Tai Chi exercises as part of a rehabilitation program seem to be a more effective alternative to the conventional physical therapy exercises for this specific population.

Keywords: Accidental falls, elderly, Tai Chi

Introduction

Accidental falls are one of the most serious problems for seniors in western countries [1–4]. In the general population, 35–40% of people over 65 fall at least once a year [5]. Ten to 25% of these falls result in significant physical injuries [5–7]. Moreover, seniors who have fallen have a 50% chance of fall-ing again during the following year [8,9]. Quality of life is also compromised, leading older people to reduce their outings and thus decrease their social activities [1].

Given the prevalence of this health problem, great efforts have been made to prevent or decrease the incidence of falls, especially in the last decade. Different intervention programs have been developed to decrease the rate of falls and risk of falling [10,11]. Several types of interventions have been examined: exercise program, pharmaceutical intervention, and environmental intervention [10]. According to this meta-analysis based on several randomized clinical trials (Cochrane Review), there is no doubt that an exercise pro-gram that included multiple components as strengthening, balance, and flexibility can be effective [10].

Tai Chi is an innovative way of performing balance exercises, using movements and body displacement in a way to improve balance and prevent falls [12]. Indeed, recent systematic reviews have shown that Tai Chi exercises are useful in reducing the risk of falls [13–15] and improving balance [16] in healthy older adults. The theoretical background of using Tai Chi on balance retraining relies on

ReseaRch PaPeR

Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial

Michel Tousignant, hélène corriveau, Pierre-Michel Roy, Johanne Desrosiers, Nicole Dubuc & Réjean hébert

Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada

Correspondence: Michel Tousignant, PT, Ph.D., Research Centre on Aging, Sherbrooke Geriatric University Institute, 1036 Belvédère Sud, Sherbrooke, Québec, J1H 4C4, Canada. Tel: 819-780-2220. Ext: 45351. Fax: 819-829-7141. E-mail: [email protected]

Disability & Rehabilitation

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10.3109/09638288.2012.737084

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Tai Chi exercises in fall prevention

02October2012

• Seniors who have fallen have a 50% chance of fall-ing again during the following year, leading them to reduce their outings and thus decrease their social activities.

• Frail older people could benefit more from an individ-ualized intervention than the regular group program generally used in a Tai Chi intervention.

• Tai Chi exercises seems to be a good alternative to regular physiotherapy exercises as a part of a multidis-ciplinary intervention in preventing a subsequent fall over a 12-month period.

Implications for Rehabilitation

(Accepted October 2012)

M. Tousignant et al.

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three principles of motor learning. Firstly, the movements facilitate sensorimotor integration with the preparation and execution of tasks during perturbation-based balance training which is used to help reverse specific age-related impairments in balance-recovery reactions [17]. More specifically, balance benefits from Tai Chi are attributable to numerous changes from single leg to double leg stances, movements that involve various stabilizers by body movement changes and constant coordination of the lower extremity with upper extremity [18]. Secondly, the cognitive demand of Tai Chi in executing a task helps learning, and finally, repetition, promotes learning. Moreover, it is recognized that exercise programs developed in accordance with well-established principles of motor learning, such as individualization, specificity, overload, adaptation-progression and variability is better than group exercises. Another aspect in favor of the use of Tai chi exercise is the good compliance to the exercise programs by elders at risk for falls [19], elders with chronic stroke [20], nursing home residents [21–23], and older adults who are transitionally frail [24,25].

Despite the fact that researches on Tai Chi encompass wide variations in the target population, type, frequency and duration of Tai Chi exercises [26], Tai Chi exercise programs have not been used as part of rehabilitation programs with frail older adults living in the community. Much of this popu-lation who is referred to rehabilitation specifically for a fall problem presents multisystem diseases that can affect the abil-ity to maintain balance. It is suggested that this frail popula-tion could benefit more from an individualized intervention than the regular group program generally used in a Tai Chi intervention [15]. In this context, the present study compared the effectiveness of a Tai Chi intervention with conventional physical therapy in a personalized rehabilitation exercise pro-gram to reduce the incidence and severity of subsequent falls in a frail older population.

Method

DesignThe study used a randomized blind controlled trial design to document the efficacy of supervised Tai Chi exercises in fall prevention versus the conventional physical therapy exercises for frail older adults living in the community and presenting multiple disabilities. Fall incidence in both groups was mea-sured in the 12 months following the end of the interventions.

ParticipantsThe participants were frail older adults admitted to a day hos-pital program (DHP) at the University Institute of Geriatrics of Sherbrooke in Québec, Canada. In the context of our study, frail elderly referred to people who have multiple comor-bidities and present important problems leading to a loss of functional autonomy requiring a minimum of three services (i.e. occupational therapy, physiotherapy, neuropsychology, nursing, or physician). Types of diagnoses varied from stroke/neurological diseases, musculoskeletal and gait disorders [27]. From these categories of patients, those who were referred spe-cifically for a recent fall problem were eligible for this research

project. Inclusion criteria were to: (i) be referred for a fall problem; (ii) be identified as being at high risk for a fall on the initial medical assessment (Berg Balance Scale score ≤49/56 and at least one accidental fall in the previous 6 months); and (iii) be mentally able to take part in an exercise program as assessed with the Modified Mini-Mental State (3MS) (score of 3MS >65) [28]. This test is widely used in screening for demen-tia. The lower the score, the greater the cognitive impairments. Exclusion criteria were to: (i) be declared unfit for physical activities following a medical assessment; and (ii) present a mental or physical condition incompatible with physical activ-ities. A score of 49/56 on the Berg scale was established on the basis of the higher sensitivity (77%) and specificity (86%) of this score to detect fallers in an older population [29]. Thus, our choice seems to fulfill our goal to recruit frail older adults.

Recruitment and samplingAll referrals to the DHP for a fall problem were screened by a medical team. Upon the first visit, each patient was assessed with the 3MS by a physician and the Berg Balance Scale (BBS) [30] was administered by a physiotherapist during the same visit. Thereafter, inclusion and exclusion criteria were verified by the physician. All participants who met the criteria were then contacted by a research assistant and the project was explained to them. During this first contact, the research assistant, who was trained with the specific protocol, also did a brief history of falls and verified the occurrence of at least one fall during the last 6 months. Those who met this particular fall criterion and who agreed to participate were included in the study. All participants gave informed consent prior to data collection and the study protocol was approved by the ethics board of the Research Centre on Aging, Health and Social Services Centre-University Institute of Geriatrics of Sherbrooke.

RandomizationTaking into account that the participants had fallen recently, the sample was stratified on balance disabilities according to the BBS score with a cut-off score of 36/56, resulting in two groups for the two types of intervention: (i) high balance disabilities: score under 36; (ii) low balance disabilities: score between 36 and 49. Assignment to either one of the intervention groups (supervised Tai Chi or conventional physiotherapy) was done by a random number generator using SPSS package. The process used was a block randomization of two participants to ensure equal num-ber in each group. Two sets of sealed envelopes were created for each BBS stratum. The coordinator of the recruitment opened the envelope when the participant was assigned to one of the two BBS stratum. All other research assistants involved in the assessment were blinded to the group assignment.

Independent variable: balance programAll rehabilitation treatments received by the participants took place at the day hospital. Each participant received a multi-disciplinary intervention including physician assessment, review of medication, nutrition and occupational therapy. For the balance program (supervised Tai Chi exercises or conven-tional physical therapy), treatment intensity was the same for both experimental and comparison groups. Each session was

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planned to last 60 min twice a week for 15 weeks. Each partici-pant had a total of 30 h of therapy.

Conventional physical therapyIn this study, the conventional physical therapy was based on a balance program which consisted of weight transfer, strengthening, and walking exercises [31]. Each exercise was planned so as to be near the instability of the participant in an one-to-one session guidance by the physical therapist. Pushing/retrieving the participant, ball games, etc. were used to create an unbalance stimulus. This one-on-one interven-tion was adapted by the treating physiotherapist to the condi-tion of each participant, permitting a gradient of difficulty in each exercise over time.

Supervised Tai Chi exercisesThe supervised Tai Chi exercises consisted of movements which included a combination of body alignment and specific orientations, weight transfer and changes of direction. The 10 movements chosen were taken from the global sequence of Tai Chi used in previous studies [32,33]. Warm-up exercises were done at the beginning of each session. The participants were also told about the most important principles of Tai Chi: body awareness, relaxation, and breathing.

A series of eight movements stemming from Tai Chi Chuan called BA-DUAN-JIN was taught by a Tai Chi instructor. The supervised intervention was given to two to four participants at same time. The exercises were adapted to each participant at the beginning of the intervention by the Tai Chi instructor and the treating therapist. Furthermore, the Tai Chi instructor individually adapted each movement to ensure that participants reached a significant level of instability. Even if the same movement sequence was taught to all participants, the Tai Chi instructor made individual adjustments in the gradient of difficulty over time. Because of the constant stability/instability challenge, a non-profes-sional assistant stayed close to each patient ensuring his/her security. Exercises were not prescribed between the sessions.

Outcome and instrumentThe primary outcome measure was an incident fall defined as a new fall during the follow-up period. A fall was defined as “Unintentionally coming to the ground or some lower level other than a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in a stroke or an epileptic seizure” [34]. Additional information was collected on fall severity (need to consult or not a medical practitioner following the fall) and the time between the end of the inter-vention and the first fall in the follow-up period.

Sociodemographic variables (gender, living environment, marital status, age) were collected when the participant signed the consent form. Some clinical variables were collected to describe the two groups before the beginning of the interven-tion: comorbidity [35], balance [36,37], sensory interaction on balance (Foam and Dome Test) [38], and self-rated health [39]. The same trained research agent made the assessments in these clinical measurements and questionnaires.

Documenting falls in the follow-up period was a crucial aspect of this research. We used two methods in order to decrease the information bias related to the main outcome “fall”: (i) the calendar technique [40] and (ii) the phone inter-view [41]. A calendar was given to each participant at the end of the intervention. They were instructed to document each fall occurrence, including the date and their consequences, such as absence of injury, minor injuries and health services consultation. In addition, once a month during the 12-month follow-up period, the research assistant called the partici-pants to retrieve information from the fall related calendar (date and severity) that occurred during the previous month. This monitoring falls method is one of the optimal method suggested by the scientific literature [41], based on cues writ-ten in the calendar. The retrieval of the calendar from the participant was not anticipated at the end of the follow-up period. Indeed, participants were told to use it for personal and research data marking: it was a strategy to ensure its appropriate use.

Statistical analysisDescriptive statistics for the demographic and clinical vari-ables were used to describe the two groups in the sample (Tai Chi and conventional physical therapy). T-tests for indepen-dent samples and Mann–Whitney U tests were used to com-pare the continuous variables between groups. A χ2 test for two independent samples was used for the categorical vari-ables. The groups were compared on fall severity with a χ2 test for the need to consult or not a medical practitioner following the fall. The relative effect of the Tai Chi and the conventional physiotherapy exercise intervention on the occurrence of per-son having one or more falls was assessed by a relative risk (RR) with a 95% confidence interval.

Among all the participants who completed the last follow-up, the mean number of falls over the 12-month follow-up period was compared using the Mann–Whitney U test. Finally, the time between the end of the intervention and the occurrence of the first fall was modelized with a Cox propor-tional hazards model. For all these tests, the significant level was set at α = 0.05. All statistical analyses were performed using SPSS for Windows, version 15.0.

Results

On the 224 potential participants who were approached to participate in the study, a total of 152 participants enrolled (46 refused to participate and 26 were not eligible). Of these 152 participants, 24 did not finish the supervised Tai Chi intervention and 26 did not complete the conventional physi-cal therapy program (Figure 1). Moreover, 10 participants in the Tai Chi group and 12 in the conventional group did not complete the 12-month falls follow up. The main reasons for these losses (during and after the intervention) are voluntary withdrawal (drop-outs), loss of contact, health deterioration, hospitalization and death. There was no difference in the characteristics of the participants who dropped out based on the main risk factors for falls (age, comorbidity, balance, vision and self-rated health) in each group.

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Participants’ characteristicsThe supervised Tai Chi exercises group and the conventional physical therapy exercises group were similar at baseline on the sociodemographic and clinical variables presented in Table I.

Efficacy of interventions on fall incidenceAt the end of the follow-up, it was possible to establish the faller status for 29 out of 49 participants in the Tai Chi group and 35 out of 44 participants in the conventional therapy group. Thus, the RR was 0.74 (CI = 0.56–0.98) in favor of the Tai Chi group.

Fall severityIn the Tai Chi group, 27% of fallers consulted a medical prac-titioner after the incidence of a fall. A similar proportion was found in the control group (27.5%), thus there was no statisti-cal difference between the groups (p = 0.98).

Number of falls per participantMean number of falls between all participants and within subgroups (high and low risk) of each intervention group who completed the entire 12-month follow-up was not statisti-cally different (Table II). Nevertheless, a trend was observable, pointing to the greater impact of supervised Tai Chi exercises over the conventional therapy exercises on decreasing the number of falls following the intervention. Indeed, the differ-ence was greatest in the high risk subgroups, where the num-ber of falls in the comparison group was more than twice that in the experimental group.

Survival analysisThe result of Cox proportional hazards model was not significant according to the group although a propensity was observable (hazard ratio = 1.53; 95% CI = 0.94–2.50;

p value = 0.089). The median lifetime values of the Tai Chi group and comparison group were 10 and 5 months respectively.

Discussion

This randomized controlled trial showed that supervised Tai Chi exercises were more effective than the conventional

Figure 1. Flow diagram of the study.

Table I. Characterization of the groups at the beginning of the study (n = 152).Sociodemographic data

Tai Chi (n = 76)%

Comparison (n = 76)% p value

Gender Men 25 29 0.584a

High/low fall risk Berg <36 29 30 0.859a

Berg ≥36 71 70Marital status Single 67 63 0.804a

In a relationship

33 37

Mean ± SD Mean ± SDAge (years) 79.1 ± 6.4 80.7 ± 6.0 0.122b

Clinical variables Charlson

Comorbidity Index (/41)

2.3 ± 1.8 2.7 ± 2.1 0.253b

Berg Balance Test (/56)

38.3 ± 7.0 38.5 ± 9.0 0.928b

Foam and Dome Test (/24)

16.9 ± 3.1 17.3 ± 3.5 0.489b

Self-rated health

3.2 ± 1.0 3.4 ± 0.8 0.294c

aχ2 test.bT test.cMann–Whitney U test.SD, Standard deviation.

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physical therapy exercises in preventing a subsequent fall over a 12-month period in a frail older population. Indeed, frail older persons referred by a multidisciplinary team at a DHP for a fall problem were 30% less likely to fall in the following year if they joined the supervised Tai Chi exercises when com-pared to the conventional physical therapy exercise program. Furthermore, the mean number of falls for all participants who completed the entire follow-up was lower in the Tai Chi group, even though it was not statistically significant. These results thus support this therapeutic approach to prevent falls. Also, there was a higher number of falls in the high risk subgroup (<36 on the BBS) than the moderate risk subgroup (≥36 on the BBS). However, there was no difference between the groups in the severity of falls judged by consultation of a medical practitioner after the incident fall.

Also, interesting but not statistically significant, the time between the end of the intervention and the first incident fall (median lifetime) seemed longer in the supervised Tai Chi exercises group than the conventional physical therapy exercises group (10 and 5 months respectively). The 5-month difference before the first fall between groups is clinically rel-evant, particularly in frail older adults. Indeed, just one fall is often enough to be the trigger point for an elder to be institu-tionalized [42]. The results are in agreement with other stud-ies involving other populations, where it was found that the reduction in falls after a Tai Chi intervention was maintained for 8 weeks [42] or 6 months [43] depending of the length of the intervention (16 weeks and 6 months, respectively).

To our knowledge, this is the first study to compare super-vised Tai Chi exercises with the conventional physical therapy exercises with respect to fall prevention as a part of a reha-bilitation program specifically for a frail older population. One randomized controlled trial measured the risk of falls in transitionally frail older adults after a 48-week Tai Chi inter-vention or wellness education program [44]. Even though the results did not demonstrate a reduction in the risk ratio for falling (RR = 0.75; 95% CI = 0.52–1.08), the direction of the effect observed in this study suggested that Tai Chi may be clinically important. If we compared our results to the Wolf study [44], we must recognize that our participants seem to be quite different on balance capacities. Indeed, because of the constant stability/instability challenge it provided, a

non-professional assistant remained near each patient to ensure his/her security. Thus, it was impossible to perform two continuous minutes of unassisted Tai Chi exercises like it was the case in the other study.

The results of the present study are also comparable with those using Tai Chi in frail older adults. Indeed, a Tai Chi program significantly improved perceived health status in transitionally frail women (>70 years old) [24]. Another study conducted with a less robust elderly population (>60 years old) showed that balance and flexibility increased and fear of falling declined after an 8-week Tai Chi intervention com-pared to a control group [25].

In a recent paper [45], the possible underlying mecha-nisms of such intervention for frail older adults were addressed. Indeed, the effect of the present Tai Chi program on fall-related clinical variables was presented. The results demonstrated that both interventions improved the mea-sured outcome (balance, gait, and fear of falling), except for the general self-efficacy, which was improved only in the Tai Chi group. Consequently, the positive impact of supervised Tai Chi compared to conventional physical therapy exercises on fall prevention can be explained only by a differential effect of general self-efficacy. It was demonstrated that self-efficacy contributes to independent community ambulation in older adults, indicating the multidimensional complex nature of the task [46]. In fact, self-efficacy seems to have an influence on action and would consequently help in developing better strategies to prevent falls.

In view of the fact that all frail older adults referred to the DHP for a fall problem were included in the study, selection bias was not an issue, which provides good internal valid-ity. Randomization did not show any differences on key risk factors for falls at baseline. However, nearly 40% of the participants in both groups dropped out of the study. Also, participants who withdrew from the study during the follow-up period were included in some of the statistical analyses. The main reasons for these losses are voluntary withdrawal (drop-outs), loss of contact, health deterioration, hospitaliza-tion and death. Research with frail older adults can lead to a problem with attrition in longitudinal studies. Indeed, 15 weeks of intervention may tire frail persons. Moreover, it seems that their health status declines over time as illustrated by such factors as hospitalization and death. For all intents and purposes, the characteristics of the participants who did not complete the study did not reveal any differences when compared on the basis of the main risk factors for falls in each group. Thus, we can be confident that internal validity is not an issue, but we must remain cautious in the interpretation of the results. This study’s conclusions are based on frail older adults whose health status was stable over 1 year.

Information bias was a concern in this study. Data on descriptive and clinical variables were collected by a trained research assistant using instruments with good psychometric properties. Documentation of falls in the 12-month follow-up period was a challenge in order to reduce recall bias. Using the combined calendar technique and monthly phone interview should have reduced recall bias. As reported in epidemiologi-cal studies, it is a way to minimize this bias [41]. Confusion

Table II. Mean number of falls per participant in each group. Tai Chi group Comparison group

p valueaMean (SD)

Median (IQR)Mean (SD)

Median (IQR)All (n = 80) 3.3 (6.8) 3.8 (6.1) 0.059

1 (2) 1 (3)(n = 42) (n = 38)

High risk Berg <36 (n = 23)

3.2 (6.0) 8.0 (9.7) 0.0841 (2) 3 (19)

(n = 14) (n = 9)Lower risk Berg ≥36 (n = 57)

3.3 (7.2) 2.6 (3.6) 0.2770 (4) 1 (3)

(n = 28) (n = 29)IQR, Interquartile range; SD, Standard deviation.aMann–Whitney U test.

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bias was not an issue because of effective randomization showing no difference on key risk factors for falls at baseline.

With regards to external validity, the results of this study can be applied to typical frail older patients referred to a DHP for multiple problems where falling is the index problem.

Conclusions

Supervised Tai Chi exercises as part of a rehabilitation pro-gram seem to be a practical alternative to the usual balance exercises supervised by a physiotherapist for frail clients referred to a DHP for a fall problem.

Acknowledgements

We thank all the patients who participated in this trial and the research staff at the Research Centre on Aging.

Declaration of Interest: This study was supported exclusively by funding from the Canadian Institutes of Health Research [grant number mct-58344]. The authors report no conflicts of interest.

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