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T’ai chi
Falls prevention research
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T’ai chi and falls prevention
A
ccording to recent guidelines published by the American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel on Fall Prevention, “Falls are the most common and serious problems facing elderly persons. Falling is associated with considerable mortality, morbidity, reduced functioning and premature nursing home admissions.”1 Approximately 5% of older people who fall require hospitalisation, say the guidelines. Furthermore, recurrent falls (and fears of falling) would appear to be a major reason for the admission of previously independent elderly people to long-term care and nursing homes.
While the general human, emotional and social cost (i.e., mortality, morbidity and reduced functioning, loss of independence, self-confidence and increased depression) to individuals and society is massive, the financial cost is also considerable. In the UK, a report published in 20032 revealed that there were approximately 650,000 emergency visits and over 240,000 hospital admissions associated with falls among people aged 60 or over, at a cost of £981m to the tax payer.
Risk factors for falling Risk factors for falling in the elderly have been identified in a number of studies3 and may be classified as either intrinsic or
Everyone falls down occasionally, but the problem with falls in the older age group is that there is a much greater susceptibility to injury. T’ai chi is said to be beneficial on stability, so Tony Lycholat takes a look at the research. extrinsic. Intrinsic risk factors include lower extremity weakness, balance disorders, functional and cognitive impairment and visual deficits. Major extrinsic risk factors cited include taking four or more prescription medicines (polypharmacy) and local environmental issues, such as poor lighting and loose carpets.
T’ai chi and joint proprioception Bearing in mind the scale of the problem, a number of researchers have in recent years looked at exercise or physical activity interventions to help address some of the intrinsic factors associated with falling. In particular, researchers based in Hong Kong have published more of their work looking at
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the effect of t’ai chi on joint proprioception and stability in the elderly.4 The authors, William Tsang and Christina Hui-Chan, define proprioception as “a sense of position and movement of one’s own limbs and body in the absence of vision, termed limb-position sense and kinaesthesia respectively.” They point out that “limb proprioception is mediated via cutaneous receptors in the skin and proprioceptors in muscles, tendons, ligaments and joints, signalling to the central nervous system both the stationary position of a limb and the speed and direction of limb movement.” Unfortunately, with advancing age, limb proprioception diminishes. In addition, some conditions affecting the elderly (such as stroke and osteoarthritis) will also impair proprioception. However, exercise has been shown to improve joint proprioception. T’ai chi emphasises exact joint and limb positioning, plus controlled movement in specified directions, and involves precisely controlled weight transfer (both double and single leg stances). This study set out to investigate whether elderly practitioners of t’ai chi had better knee joint proprioception compared with elderly control subjects. In addition, the ability of subjects to control body sway was determined along with an investigation of any relationship between knee joint proprioception, static standing and the limits of stability during weight transfer.
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Method 42 elderly subjects were involved in the study. 21 were t’ai chi practitioners who had been practising t’ai chi for a minimum of 1.5hrs each week for at least three years. 21 elderly active individuals who had no experience of t’ai chi acted as controls. All subjects were independent, healthy and with no history of falls in the previous 12 months. All subjects were tested for knee joint proprioception by determining their lowest threshold for detecting joint movement and by their ability to match contralateral joints and position limb segments without the aid of vision (a passive joint repositioning test). A static standing balance test lasting 30 seconds was developed using a force plate and the centre of pressure measured throughout. Finally, in a “limits of stability” test, two force plates were used, with eight target positions shown on screen that each subject had to meet through controlled weight transfer via their base of support without moving their feet. Data collected from this
Bearing in mind the scale of the problem, a number of researchers have in recent years looked at exercise or physical activity interventions test included reaction time, maximum excursion and directional control.
Results In the knee joint repositioning test, the t’ai chi practitioners exhibited significantly less absolute angle error than the control group who had approximately twice the angle of error. In the static standing balance test, both groups performed equally well. In the third test (the limits of stability test), the t’ai chi group had shorter reaction times when leaning to each target position, could lean further towards the targets and travelled with a smoother pathway.
Conclusions This data, the authors conclude, show that the t’ai chi practitioners studied had a heightened sense of knee joint proprioception, brought about, they believe, through practising slow movements in which the body and limbs have to be placed accurately and precisely. In this respect, this study agrees with other research referenced by the authors that showed an improvement in glenohumeral
joint positioning following 12 weeks of t’ai chi training. And, while the results from the static balance test were similar in both groups, the dynamic balance test, in which subjects had to lean quickly and smoothly and as far as possible to eight different targets, showed that the t’ai chi practitioners appeared to have greater dynamic balance control. This last test has previously been used as a predictor of performance in functional activities of daily living and is believed to play a role in indicating one’s susceptibility to falls (see related research). Therefore, say the authors, “Because our study showed that long-term t’ai chi practitioners achieved greater limits of stability, they are likely to have relevant functional activities enhanced and/or the possible occurrence of falls minimised.” This finding would be consistent with an earlier study that showed that the risk of multiple falls was reduced by 47.5% in elderly t’ai chi practitioners.5 Finally, the knee joint positioning data arguably emphasises the importance of accurate knee joint position sense in functional activities. fp
Related research Two additional research papers looking at t’ai chi training in the elderly are worth mentioning. In a follow-up study by Tsang and Hui-Chan, the authors looked at the effects of either four or eight weeks of intensive t’ai chi on balance control in the healthy elderly. The results from this study showed that after both training periods (i.e., either the four- or eight-week programme), there was a significant improvement in balance control. Note that “intensive training” in this study was the equivalent of a 90-minute class performed six days a week. As the authors conclude, “our present findings indicate that t’ai chi has the potential of being a cost effective falls prevention programme, which can easily be implemented community wide.”6 A longer term study by Fuzhong Li et al involved 256 healthy, physically active older adults aged between 70 and 92 years participating in a six-month, randomised controlled trial with groups allocated to
either t’ai chi or exercise stretching. Functional balance measures were performed at regular intervals throughout the study and at six-months post-study, with fall counts also recorded. The analysed data from this study showed that t’ai chi participants who showed improvements in measures of functional balance at the intervention endpoint significantly reduced their risk of falls during the six-month post-intervention period, compared with those in the control group. The authors conclude that “healthcare providers and clinicians contemplating fall-prevention programmes for older persons at risk of falling should consider t’ai chi, both as a balance retraining programme and as part of a multi-faceted treatment intervention for fall prevention.”7
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