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Home-based Tai Chi Chuan May Reduce Fall Rate Compared to Lower Extremity Exercise Training in Older Adults with History of Falls
Author’s Accepted Manuscript HOME-BASED TAI CHI CHUAN MAY REDUCE FALL RATE COMPARED TO LOWER EXTREMITY TRAINING IN OLDER ADULTS WITH HISTORY OF FALLS Richard Glickman-Simon www.elsevier.com/locate/jsch
PII: DOI: Reference:
S1550-8307(16)30176-8 http://dx.doi.org/10.1016/j.explore.2016.10.015 JSCH2158
To appear in: Explore: The Journal of Science and Healing Cite this article as: Richard Glickman-Simon, HOME-BASED TAI CHI CHUAN MAY REDUCE FALL RATE COMPARED TO LOWER EXTREMITY TRAINING IN OLDER ADULTS WITH HISTORY OF F A L L S , Explore: The Journal of Science and Healing, http://dx.doi.org/10.1016/j.explore.2016.10.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
SECTION HEAD: Evidence-based Integrative Medicine Updates
Home-based Tai Chi Chuan May Reduce Fall Rate Compared to Lower Extremity Training in Older Adults with History of Falls Richard Glickman-Simon, MD
DynaMed is an evidence-based clinical reference, which is updated daily through systematic surveillance and critical appraisal of the research literature. DynaMed editors and reviewers select content of interest for integrative medicine, summarize the current evidence, and describe challenges in evidence analysis and application. Evidence quality is rated level 1 (likely reliable) evidence for studies with clinical outcomes and minimal risk of bias, level 2 (mid-level) evidence for studies with clinical outcomes and significant methodological or statistical limitations, and level 3 (lacking direct) evidence for reports that do not include scientific analysis of clinical outcomes. When applicable, the number of patients needed to be treated to lead to one patient having an improved outcome (NNT for number needed to treat) or a worse outcome (NNH for number needed to harm) is presented. DynaMed is available at http://www.dynamed.com/. For more information, contact Brian S. Alper, MD, MSPH, FAAFP, at [email protected].
Level 2 [mid-level] evidence J Am Geriatr Soc 2016 Mar;64(3):518 Falls are the leading cause of injury in older adults. Thirty percent of community-dwellers over 65 fall each year.1 Roughly 6% suffers a non-fatal injury due to a fall annually (10% of which are factures), and 58 per 100,000 die of their injuries.1,2 The US Preventive Services Task Force recommends exercise or physical therapy for community-dwelling elderly individuals at risk for falling.3 Risk factors include older age, history of previous falls or mobility problems, and the results of a timed Get-Up-And-Go test.4,5 Tai chi chuan (TCC) is a multicomponent, mind-body practice originating in ancient China. It combines meditation with slow, gentle, graceful movements; deep breathing; and relaxation.6 While there is some evidence that TCC reduces the risk of falls, not all trials are in agreement, and the results of the few studies that directly compare the effectiveness of TCC vs. conventional exercise training have been inconsistent.7, 8 In the present Taiwanese study, researchers recruited 456 patients ≥ 60 years-old (mean age 72.4) who visited an emergency department for evaluation of a fall-related injury at least 6 months previously and who could now independently ambulate.10 They randomized the participants to receive 24 weekly sessions of either TCC or conventional lower extremity exercise training (LET). Both 60-min interventions were conducted at home or at a nearby park or community center. Participants were asked to practice their respective interventions daily between sessions and after the end of 6 months for an additional year. Yang-style TCC
consisted of 18 movements taught individually by instructors. Each movement incorporated deep diaphragmatic breathing, weight shifting, center of mass displacement, ankle sways, and leg stepping. LET consisted of stretching, muscle strengthening and balance training at progressive difficulty levels. Follow-up was incomplete. At 6 months, 80% and 77% of TCC and LET participants, respectively, were available for assessment. By 18 months, the completion rate dropped to 73% for both groups. At the end of each follow-up period (6 and 18 months), however, baseline characteristics of each group remained similar. Adherence rates for those remaining in the study were also low. At 6 months, 78% and 72% of the TCC and LET patients participated in ≥ 20 of the weekly exercise sessions, respectively. At 18 months, 42% and 44% independently practiced their respective TCC and LET exercises at least 7 times per week. Comparing TCC to LET, the percentage of fallers at 6 and 18 months were 22.2% vs. 41.0% (p=0.001, NNT=6) and 41.1% vs. 55.9% (p=0.006, NNT=7), respectively. For recurrent fallers, percentages were 7.6% vs. 12.6% (p=0.1) and 23.4% vs. 31.4 (p=0.1). Similar differences were found for injured fallers [16.8% vs. 26.8% (p=0.02, NNT=10) and 33.1 vs. 45.7 (p=0.02, NNT=8)] and recurrent injured fallers [2.7% vs. 7.1% (p=0.05, NNT=23) and 13.1% vs. 15.1% (p=0.6). In this relatively large community-based trial, tai chi chuan appeared to reduce the risk of falls more than a comparable lower extremity exercise control in an elderly population with a previous history of injurious falls. The effect lasted at least one year. Unlike many studies with complex interventions, the present trial reduced the risk of performance bias by employing a comparable control that matched the stretching, strengthening and balancing inherent in TCC practice. Locating the interventions in participants’ homes and neighborhoods served to minimize between-group differences in attention (though the inconsistent effects of different instructors could not be eliminated), but it may have introduced variability in social support and environmental influences. Other limitations include a likely volunteer effect and sizeable dropout rate, both of which may compromise the generalizability of the results. Older patients, men, smokers, non-exercisers, and those with less education were less likely to enroll in the trial; and participants who were older, consumed alcohol regularly or used a walking stick were less likely to complete it.10 These findings support those of a previous systematic review (limited by risk of bias in all trials), in which TCC was found to be more effective than a control for risk of falling [(risk ratio = 0.71, 95% CI 0.57-0.87) in analysis of 6 trials with 1,625 adults], and rate of falls [(rate ratio = 0.72, 95% CI 0.52-1) in analysis of 5 trials with 1,563 adults].7 Only one of these trials, however, incorporated an active control (resistance training).9 Then again, the findings were inconsistent with those of another trial in New Zealand involving 684 elderly patients (mean age 74) randomized into three groups: tai chi once per week (TC1), tai chi twice per week (TC2) and a weekly low level exercise (LLE) program for 20 weeks conducted in a community-setting.8 No significant differences in rate ratios (RR) of falls were found between the TC1 and LLE groups (RR = 1.05, 95% CI = 0.83–1.33) or between the TC2 and LLE groups (RR = 0.88, 95% CI = 0.68– 1.16). The discrepancy between these results and those of the Taiwanese trial could be explained by differences in the patient population (59% vs. 100% had a previous history of
falls), intervention setting (group vs. individual sessions), and intervention frequency (daily practice in 0% vs. 43%). Primary outcome measures also differed between the two studies (rate ratio of falls vs. percentage of fallers). References 1.
Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age and Ageing 1990;19:136–41. 2. Injury Prevention and Control: Data and Statistics (WISQARS). Centers for Disease Control and Prevention. 2014. http://www.cdc.gov/injury/wisqars/index.html. Accessed Sep 29, 2016. 3. Final Recommendation Statement: Falls Prevention in Older Adults: Counseling and Preventive Medication. U.S. Preventive Services Task Force. May 2012. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/fallsprevention-in-older-adults-counseling-and-preventive-medication. Accessed Sep 29, 2016. 4. Michael YL, Lin JS, Whitlock EP, Gold R, Fu R, O'Connor EA, et al. Interventions to Prevent Falls in Older Adults: An Updated Systematic Review. Evidence Synthesis No. 80. AHRQ Publication No. 11-05150-EF1. Rockville, MD: Agency for Healthcare Research and Quality; December 2010. 5. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142-8. 6. Wayne PM, Kaptchuk TJ. Challenges inherent to t'ai chi research: part I--t'ai chi as a complex multicomponent intervention. J Altern Complement Med. 2008 Jan-Feb;14(1):95-102. 7. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD007146. 8. Taylor D, Hale L, Schluter P et al. Effectiveness of tai chi as a community-based falls prevention intervention: A randomized controlled trial. J Am Geriatr Soc 2012;60:841–848. 9. Woo J, Hong A, Lau E et al. A randomized controlled trial of tai chi and resistance exercise on bone health, muscle strength and balance in community- living elderly people. Age Ageing 2007;36:262–268. 10. Hwang HF, Chen SJ, Lee-Hsieh J, Chien DK, Chen CY, Lin MR. Effects of Home-Based Tai Chi and Lower Extremity Training and Self-Practice on Falls and Functional Outcomes in Older Fallers from the Emergency Department-A Randomized Controlled Trial. J Am Geriatr Soc. 2016 Mar;64(3):518-25.
PII: DOI: Reference:
S1550-8307(16)30176-8 http://dx.doi.org/10.1016/j.explore.2016.10.015 JSCH2158
To appear in: Explore: The Journal of Science and Healing Cite this article as: Richard Glickman-Simon, HOME-BASED TAI CHI CHUAN MAY REDUCE FALL RATE COMPARED TO LOWER EXTREMITY TRAINING IN OLDER ADULTS WITH HISTORY OF F A L L S , Explore: The Journal of Science and Healing, http://dx.doi.org/10.1016/j.explore.2016.10.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
SECTION HEAD: Evidence-based Integrative Medicine Updates
Home-based Tai Chi Chuan May Reduce Fall Rate Compared to Lower Extremity Training in Older Adults with History of Falls Richard Glickman-Simon, MD
DynaMed is an evidence-based clinical reference, which is updated daily through systematic surveillance and critical appraisal of the research literature. DynaMed editors and reviewers select content of interest for integrative medicine, summarize the current evidence, and describe challenges in evidence analysis and application. Evidence quality is rated level 1 (likely reliable) evidence for studies with clinical outcomes and minimal risk of bias, level 2 (mid-level) evidence for studies with clinical outcomes and significant methodological or statistical limitations, and level 3 (lacking direct) evidence for reports that do not include scientific analysis of clinical outcomes. When applicable, the number of patients needed to be treated to lead to one patient having an improved outcome (NNT for number needed to treat) or a worse outcome (NNH for number needed to harm) is presented. DynaMed is available at http://www.dynamed.com/. For more information, contact Brian S. Alper, MD, MSPH, FAAFP, at [email protected].
Level 2 [mid-level] evidence J Am Geriatr Soc 2016 Mar;64(3):518 Falls are the leading cause of injury in older adults. Thirty percent of community-dwellers over 65 fall each year.1 Roughly 6% suffers a non-fatal injury due to a fall annually (10% of which are factures), and 58 per 100,000 die of their injuries.1,2 The US Preventive Services Task Force recommends exercise or physical therapy for community-dwelling elderly individuals at risk for falling.3 Risk factors include older age, history of previous falls or mobility problems, and the results of a timed Get-Up-And-Go test.4,5 Tai chi chuan (TCC) is a multicomponent, mind-body practice originating in ancient China. It combines meditation with slow, gentle, graceful movements; deep breathing; and relaxation.6 While there is some evidence that TCC reduces the risk of falls, not all trials are in agreement, and the results of the few studies that directly compare the effectiveness of TCC vs. conventional exercise training have been inconsistent.7, 8 In the present Taiwanese study, researchers recruited 456 patients ≥ 60 years-old (mean age 72.4) who visited an emergency department for evaluation of a fall-related injury at least 6 months previously and who could now independently ambulate.10 They randomized the participants to receive 24 weekly sessions of either TCC or conventional lower extremity exercise training (LET). Both 60-min interventions were conducted at home or at a nearby park or community center. Participants were asked to practice their respective interventions daily between sessions and after the end of 6 months for an additional year. Yang-style TCC
consisted of 18 movements taught individually by instructors. Each movement incorporated deep diaphragmatic breathing, weight shifting, center of mass displacement, ankle sways, and leg stepping. LET consisted of stretching, muscle strengthening and balance training at progressive difficulty levels. Follow-up was incomplete. At 6 months, 80% and 77% of TCC and LET participants, respectively, were available for assessment. By 18 months, the completion rate dropped to 73% for both groups. At the end of each follow-up period (6 and 18 months), however, baseline characteristics of each group remained similar. Adherence rates for those remaining in the study were also low. At 6 months, 78% and 72% of the TCC and LET patients participated in ≥ 20 of the weekly exercise sessions, respectively. At 18 months, 42% and 44% independently practiced their respective TCC and LET exercises at least 7 times per week. Comparing TCC to LET, the percentage of fallers at 6 and 18 months were 22.2% vs. 41.0% (p=0.001, NNT=6) and 41.1% vs. 55.9% (p=0.006, NNT=7), respectively. For recurrent fallers, percentages were 7.6% vs. 12.6% (p=0.1) and 23.4% vs. 31.4 (p=0.1). Similar differences were found for injured fallers [16.8% vs. 26.8% (p=0.02, NNT=10) and 33.1 vs. 45.7 (p=0.02, NNT=8)] and recurrent injured fallers [2.7% vs. 7.1% (p=0.05, NNT=23) and 13.1% vs. 15.1% (p=0.6). In this relatively large community-based trial, tai chi chuan appeared to reduce the risk of falls more than a comparable lower extremity exercise control in an elderly population with a previous history of injurious falls. The effect lasted at least one year. Unlike many studies with complex interventions, the present trial reduced the risk of performance bias by employing a comparable control that matched the stretching, strengthening and balancing inherent in TCC practice. Locating the interventions in participants’ homes and neighborhoods served to minimize between-group differences in attention (though the inconsistent effects of different instructors could not be eliminated), but it may have introduced variability in social support and environmental influences. Other limitations include a likely volunteer effect and sizeable dropout rate, both of which may compromise the generalizability of the results. Older patients, men, smokers, non-exercisers, and those with less education were less likely to enroll in the trial; and participants who were older, consumed alcohol regularly or used a walking stick were less likely to complete it.10 These findings support those of a previous systematic review (limited by risk of bias in all trials), in which TCC was found to be more effective than a control for risk of falling [(risk ratio = 0.71, 95% CI 0.57-0.87) in analysis of 6 trials with 1,625 adults], and rate of falls [(rate ratio = 0.72, 95% CI 0.52-1) in analysis of 5 trials with 1,563 adults].7 Only one of these trials, however, incorporated an active control (resistance training).9 Then again, the findings were inconsistent with those of another trial in New Zealand involving 684 elderly patients (mean age 74) randomized into three groups: tai chi once per week (TC1), tai chi twice per week (TC2) and a weekly low level exercise (LLE) program for 20 weeks conducted in a community-setting.8 No significant differences in rate ratios (RR) of falls were found between the TC1 and LLE groups (RR = 1.05, 95% CI = 0.83–1.33) or between the TC2 and LLE groups (RR = 0.88, 95% CI = 0.68– 1.16). The discrepancy between these results and those of the Taiwanese trial could be explained by differences in the patient population (59% vs. 100% had a previous history of
falls), intervention setting (group vs. individual sessions), and intervention frequency (daily practice in 0% vs. 43%). Primary outcome measures also differed between the two studies (rate ratio of falls vs. percentage of fallers). References 1.
Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age and Ageing 1990;19:136–41. 2. Injury Prevention and Control: Data and Statistics (WISQARS). Centers for Disease Control and Prevention. 2014. http://www.cdc.gov/injury/wisqars/index.html. Accessed Sep 29, 2016. 3. Final Recommendation Statement: Falls Prevention in Older Adults: Counseling and Preventive Medication. U.S. Preventive Services Task Force. May 2012. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/fallsprevention-in-older-adults-counseling-and-preventive-medication. Accessed Sep 29, 2016. 4. Michael YL, Lin JS, Whitlock EP, Gold R, Fu R, O'Connor EA, et al. Interventions to Prevent Falls in Older Adults: An Updated Systematic Review. Evidence Synthesis No. 80. AHRQ Publication No. 11-05150-EF1. Rockville, MD: Agency for Healthcare Research and Quality; December 2010. 5. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142-8. 6. Wayne PM, Kaptchuk TJ. Challenges inherent to t'ai chi research: part I--t'ai chi as a complex multicomponent intervention. J Altern Complement Med. 2008 Jan-Feb;14(1):95-102. 7. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD007146. 8. Taylor D, Hale L, Schluter P et al. Effectiveness of tai chi as a community-based falls prevention intervention: A randomized controlled trial. J Am Geriatr Soc 2012;60:841–848. 9. Woo J, Hong A, Lau E et al. A randomized controlled trial of tai chi and resistance exercise on bone health, muscle strength and balance in community- living elderly people. Age Ageing 2007;36:262–268. 10. Hwang HF, Chen SJ, Lee-Hsieh J, Chien DK, Chen CY, Lin MR. Effects of Home-Based Tai Chi and Lower Extremity Training and Self-Practice on Falls and Functional Outcomes in Older Fallers from the Emergency Department-A Randomized Controlled Trial. J Am Geriatr Soc. 2016 Mar;64(3):518-25.