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Taiji (Tai Chi) For Fall Prevention in the Elderly: Training the Trainers Evaluation Project
Author’s Accepted Manuscript TAIJI (TAI CHI) FOR FALL PREVENTION IN THE ELDERLY: TRAINING THE TRAINERS EVALUATION PROJECTTAIJI TRAINING TO REDUCE ELDERLY FALL RISK L. Bartimole, M.A. Fristad www.elsevier.com/locate/jsch
PII: DOI: Reference:
S1550-8307(17)30042-3 http://dx.doi.org/10.1016/j.explore.2017.02.004 JSCH2180
To appear in: Explore: The Journal of Science and Healing Cite this article as: L. Bartimole and M.A. Fristad, TAIJI (TAI CHI) FOR FALL PREVENTION IN THE ELDERLY: TRAINING THE TRAINERS EVALUATION PROJECTTAIJI TRAINING TO REDUCE ELDERLY FALL R I S K , Explore: The Journal of Science and Healing, http://dx.doi.org/10.1016/j.explore.2017.02.004 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.
Taiji (Tai Chi) for Fall Prevention in the Elderly: Training the Trainers Evaluation Project
L. Bartimole, CPT1 M. A. Fristad, PhD, ABPP2
1
Shift: Grandview 1520 W 1st Ave Grandview Heights, OH 43212 2
Center for Integrative Health and Wellness The Ohio State Wexner Medical Center 1670 Upham Drive Suite 460G Columbus, OH 43210-1250 [email protected] 614-293-4572 Corresponding Author Support: Ohio Injury Prevention Partnership Running Head: Taiji Training to Reduce Elderly Fall Risk
Author Disclosure Statement Ms. Bartimole directs a Taiji studio where Taiji for Balance Training is taught. Dr. Fristad has no relevant conflicts of interest.
Abstract Context: Falls in the elderly are common and a major, costly health problem. Taiji addresses many issues related to fall risk. Objectives: Determine whether an intensive weekend training can sufficiently train persons who have baseline familiarity with Taiji to model and teach fundamentals of Taiji. Design: Prior to training, registrants received a manual, video and online links for review and practice. Assessments were completed pre/post training. Setting: Training occurred in four cities of one state. Participants: 34 adults completed training, two did not complete evaluations (ns=12, 13, 4 and 5 at the four sites). Intervention: Each training course consisted of two 9-hour days that educated prospective instructors on issues pertinent to the elderly, evaluation techniques, warm-up and cool-down movements and seated and standing Taiji postures. Main Outcome Measures: Pre-/post knowledge test, Timed Up and Go and Functional Reach Assessment. Results: Nearly all participants with pre/post assessments (30/32, 94%) demonstrated adequate skills post-training. Knowledge of Taiji increased significantly from pre- to post-training (p<.01). Brief, intensive weekend training can increase the available workforce to train the elderly in fundamentals of Taiji for fall prevention.
Key words: Taiji (Tai Chi), elderly, fall risk, geriatric, prevention
Introduction Falls in the elderly represent a significant public health concern. Statistics are staggering; in Ohio alone, almost 300,000 residents over 65 fall every 2 minutes, over 100,000 are injured from a fall every 5 minutes, and 66,000 visit an emergency room (8/hour) due to a fall, resulting in 17,000 hospitalizations and 1,000 deaths1. Additional complications from falls, including fear, decreased quality of life from self‐imposed activity restriction, social isolation and depressive symptoms2. Countering these statistics, several strategies, including maintaining and/or building gait, proprioception, range of movement, strength and stability all contribute to decreased fall risk. They are also features enhanced by Taiji. In addition, due to Taiji’s internal practice of mindfulness, focus, concentration and meditation, Taiji can lead to a sense of inner strength and reduced fear of falling. Taiji, which originated as a Chinese martial art, is practiced by approximately 3% of the American population, predominantly for wellness/disease prevention 3. While Taiji has been proven to decrease falls and improve balance and gait in the elderly4; there are not enough qualified teachers to address the need. Falls in the elderly are common. In one state poll, 17.3% of participants report having experienced a fall in the past three months; of these, 34% required a doctor visit or restricted activity as a result1. “Near-miss” falls can increase risk for future falls if not adequately assessed and managed. Training trainers who could offer classes to the elderly in community settings has the potential to improve the overall health and wellbeing of the elderly. This program evaluation
sought to evaluate the impact of a brief train-the-trainers program disseminated throughout one state. We hypothesized that knowledge would increase from pre- to post-training and that the majority of participants would adequately demonstrate skills following completion of training. Method Participants Trainers were identified via outreach to statewide elder care health organizations. They were required to have either a minimum two years of tai chi practice or have a 200RYT yoga teacher training, a personal training license, a physical therapy or occupational therapy degree. Trainings were offered throughout the state to reduce travel burden for participants. Procedure The affiliated Institutional Review Board deemed this program evaluation exempt from formal review; however, informed consent was obtained from all participants. An introductory training program (Taiji for Balance: Level l), was offered by the first author, a certified Taiji instructor and trainer. Prior to training, participants received a manual8, video and online links9 for review and to familiarize and practice before the weekend training course. Each training course consisted of two 9-hour days, as required by the funding agency. Taiji Course The course included education on: limited mobility and range of motion evaluation; core strengthening exercises for stability; experiential exercises to mimic instability and risk of
falling; gait, foot position and body mechanics awareness and evaluation; cross-lateralization and neural pathway education. Participants learned how to teach: safe warm up movements – specific to muscles, as well as lubricating joints; eight Taiji postures – seated and/or standing; and safe cool down exercises. The eight postures were chosen specifically for persons who struggle with balance: Strike Palm, Grasp Bird’s Tail, Single Whip, Wave Hands Like Clouds, High Pat on Horse, Cross Wave of Water Lily, Bend Bow to Shoot Tiger and Closing Movement). In contrast to the traditional Taiji teaching model, in which students replicate the master’s demonstrated movement with little spoken direction, Taiji For Balance trains via verbal, oral and kinesthetic methods to support all learning styles. Participants are educated in how to correctly perform and verbally guide students through the movements, breaking down footwork, arm work and core work. The training provides a wide variety of mindful meditation practices to support the practice of stress reduction. Meditation is a KEY factor in each class. Each class has at least 1015 minutes of guided meditation, with a focus on coming back to the senses, and observing thoughts that might draw one away from being in the moment. Assessment A 35-item knowledge test created by the first author, Taiji for Balance: Level 1, was administered to participants prior to, and upon completion of their weekend training. It consists of 21 multiple choice questions and 14 true/false questions about Taiji. 5 Scores can range from 0 to 35, with higher scores reflecting a better understanding of Taiji. Participants demonstrated skill attainment via administration of two standardized balance tests, the Timed
Up and Go (TUG)6 and functional reach assessment (FRA) upon completion of their weekend training.7 These were scored on a pass/fail basis. Data Analysis Descriptive statistics were used to characterize the sample. Analysis of variance was used to compare pre-test to post-test scores, potential site differences were tested by examining the site X time interactions. T-tests were used to compare the number of correct responders for each item at pre- and post-test administrations. Bonferroni corrections were used to account for multiple comparisons. Results Thirty-four participants attended the weekend trainings and 32 completed all study assessments. Two participants did not complete study pre- or post-testing although ultimately passed their training. Training was completed at four sites, with 4, 5, 12 (11 with data) and 13 (12 with data) completers at the sites. There were no significant differences in outcomes based on site, so results are presented for the entire group of participants. Participants, on the whole, were knowledgeable about Taiji when they began training. Average pre-training scores were 27.7±4.1 (range, 15-34). Scores increased significantly [F[1,28)=29.70, p<.01] by post-training (32.5±.2.0, range, 27-35). Two items had fewer correct responses after training (What are neural pathways? How should Taiji students breathe?). Responses to two items did not change with training; these items (Equilibrioception is…? Why do people lose their balance?) were answered correctly by nearly all respondents at pre-test
(32 and 31, respectively). The remaining 31 items all increased in correct responses from pre- to post-test. After correcting for multiple comparisons, four items showed significant improvement (When shifting weight, where should the weight be focused for students of Taiji for Balance: Level 1? When stepping to the side, what part of the foot should touch down first? What part of the body does the qua include? Taiji classes should be held in a carpeted area for softer falls-true or false.”). Nearly all participants with pre/post assessments (30/32, 94%) were successful in demonstrating the ability to administer the TUG and FRA assessments following training. The remaining two, as well as the two who did not complete study assessments, successfully passed training with additional remediation. Discussion A series of brief weekend trainings to train trainers in fundamentals of Taiji successfully prepared a workforce of 34 who now are able to train elderly across the state of Ohio. Recruitment efforts indicated trainers should have some background in Taiji; they were also provided training materials to review prior to the weekend workshop. This combination likely led to very high pre-test scores. Despite this, post-test scores indicated improved understanding of Taiji. Examination of items that did not improve from pre- to post-test provided the instructor with useful feedback for future trainings. Demonstration of skills was achieved by 94% of those trained, with the remainder successfully demonstrating skills with additional training, indicating that this brief weekend format is successful. Future evaluations should determine functioning of the trainees in their subsequent role as trainers.
Conclusions Brief Taiji train-the-trainer programs appear to be a viable means by which the elderly fall-prevention workforce can be increased. Acknowledgements This study was made possible by a grant awarded by the Ohio Injury Prevention Partnership, which had no role in the study design, preparation or submission of this manuscript. We thank Mandy Howenstine, Brad Campbell and Kyle Nemergut, who assisted with execution of this project. References 1. Falb M & Beeghly C. The burden of injury in Ohio: 2000-2010. Ohio Department of Health, Division of Prevention and Health Promotion, Bureau of Health Ohio, Violence and Injury Prevention Program. 2012. 2. Parrya SW, Steenb N, Gallowaya SR, Kennya RA, Bondb J. Falls and confidence related quality of life outcome measures in an older British cohort. Postgrad Med J 2001;77:103108 doi:10.1136/pmj.77.904.103 3. Lauche R, Wayne PM, Dobos G, Cramer H. Prevalence, patterns, and predictors of T’ai Chi and Qigong use in the United States: Results of a nationally representative survey. Journal of Alternative and Complementary Medicine 2016; 22(4): 336-342. 4. Leung DP, Chan CK, Tsang HW, Tsang WW, Jones AY. Tai chi as an intervention to improve balance and reduce falls in older adults: A systematic and meta-analytical review. Altern Ther Health Med. 2011 Jan-Feb;17(1):40-48. 5. Bartimole, L. Taiji for Balance: Level 1. Unpublished document. 2013. 6. Podsiadlo D & Richardson S. The timed “up & go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 1991; 39, 142-148. 7. Duncan PW, Weiner DK, et al. Functional reach: a new clinical measure of balance. J Gerontol 1990; 45(6): M192-197. 8. Bartimole, L. (2015). Taiji for Balance: Level 1. Self-published manual, available from [email protected]. 9. https://urldefense.proofpoint.com/v2/url?u=https3A__www.dropbox.com_sh_ijr0pina2ah36hf_AAA-2DpdHMgZgH1Qox2wgrkUCOa-3Fdl3D0&d=CwIBaQ&c=k9MF1d71ITtkuJx-
PdWme51dKbmfPEvxwt8SFEkBfs4&r=UEHvz8C9NiSyHb_2eo1Q5xgeHxqPcVN1JhNvZ6K2tY&m=cVDnOO6VDIMAdCRyJIgREfREkUUM2dFZEWVA_Cw RfQw&s=hyPsyLzgoQb7tW3DK6hqeUUuBW9iQJKErIk02SN46F8&e=
PII: DOI: Reference:
S1550-8307(17)30042-3 http://dx.doi.org/10.1016/j.explore.2017.02.004 JSCH2180
To appear in: Explore: The Journal of Science and Healing Cite this article as: L. Bartimole and M.A. Fristad, TAIJI (TAI CHI) FOR FALL PREVENTION IN THE ELDERLY: TRAINING THE TRAINERS EVALUATION PROJECTTAIJI TRAINING TO REDUCE ELDERLY FALL R I S K , Explore: The Journal of Science and Healing, http://dx.doi.org/10.1016/j.explore.2017.02.004 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.
Taiji (Tai Chi) for Fall Prevention in the Elderly: Training the Trainers Evaluation Project
L. Bartimole, CPT1 M. A. Fristad, PhD, ABPP2
1
Shift: Grandview 1520 W 1st Ave Grandview Heights, OH 43212 2
Center for Integrative Health and Wellness The Ohio State Wexner Medical Center 1670 Upham Drive Suite 460G Columbus, OH 43210-1250 [email protected] 614-293-4572 Corresponding Author Support: Ohio Injury Prevention Partnership Running Head: Taiji Training to Reduce Elderly Fall Risk
Author Disclosure Statement Ms. Bartimole directs a Taiji studio where Taiji for Balance Training is taught. Dr. Fristad has no relevant conflicts of interest.
Abstract Context: Falls in the elderly are common and a major, costly health problem. Taiji addresses many issues related to fall risk. Objectives: Determine whether an intensive weekend training can sufficiently train persons who have baseline familiarity with Taiji to model and teach fundamentals of Taiji. Design: Prior to training, registrants received a manual, video and online links for review and practice. Assessments were completed pre/post training. Setting: Training occurred in four cities of one state. Participants: 34 adults completed training, two did not complete evaluations (ns=12, 13, 4 and 5 at the four sites). Intervention: Each training course consisted of two 9-hour days that educated prospective instructors on issues pertinent to the elderly, evaluation techniques, warm-up and cool-down movements and seated and standing Taiji postures. Main Outcome Measures: Pre-/post knowledge test, Timed Up and Go and Functional Reach Assessment. Results: Nearly all participants with pre/post assessments (30/32, 94%) demonstrated adequate skills post-training. Knowledge of Taiji increased significantly from pre- to post-training (p<.01). Brief, intensive weekend training can increase the available workforce to train the elderly in fundamentals of Taiji for fall prevention.
Key words: Taiji (Tai Chi), elderly, fall risk, geriatric, prevention
Introduction Falls in the elderly represent a significant public health concern. Statistics are staggering; in Ohio alone, almost 300,000 residents over 65 fall every 2 minutes, over 100,000 are injured from a fall every 5 minutes, and 66,000 visit an emergency room (8/hour) due to a fall, resulting in 17,000 hospitalizations and 1,000 deaths1. Additional complications from falls, including fear, decreased quality of life from self‐imposed activity restriction, social isolation and depressive symptoms2. Countering these statistics, several strategies, including maintaining and/or building gait, proprioception, range of movement, strength and stability all contribute to decreased fall risk. They are also features enhanced by Taiji. In addition, due to Taiji’s internal practice of mindfulness, focus, concentration and meditation, Taiji can lead to a sense of inner strength and reduced fear of falling. Taiji, which originated as a Chinese martial art, is practiced by approximately 3% of the American population, predominantly for wellness/disease prevention 3. While Taiji has been proven to decrease falls and improve balance and gait in the elderly4; there are not enough qualified teachers to address the need. Falls in the elderly are common. In one state poll, 17.3% of participants report having experienced a fall in the past three months; of these, 34% required a doctor visit or restricted activity as a result1. “Near-miss” falls can increase risk for future falls if not adequately assessed and managed. Training trainers who could offer classes to the elderly in community settings has the potential to improve the overall health and wellbeing of the elderly. This program evaluation
sought to evaluate the impact of a brief train-the-trainers program disseminated throughout one state. We hypothesized that knowledge would increase from pre- to post-training and that the majority of participants would adequately demonstrate skills following completion of training. Method Participants Trainers were identified via outreach to statewide elder care health organizations. They were required to have either a minimum two years of tai chi practice or have a 200RYT yoga teacher training, a personal training license, a physical therapy or occupational therapy degree. Trainings were offered throughout the state to reduce travel burden for participants. Procedure The affiliated Institutional Review Board deemed this program evaluation exempt from formal review; however, informed consent was obtained from all participants. An introductory training program (Taiji for Balance: Level l), was offered by the first author, a certified Taiji instructor and trainer. Prior to training, participants received a manual8, video and online links9 for review and to familiarize and practice before the weekend training course. Each training course consisted of two 9-hour days, as required by the funding agency. Taiji Course The course included education on: limited mobility and range of motion evaluation; core strengthening exercises for stability; experiential exercises to mimic instability and risk of
falling; gait, foot position and body mechanics awareness and evaluation; cross-lateralization and neural pathway education. Participants learned how to teach: safe warm up movements – specific to muscles, as well as lubricating joints; eight Taiji postures – seated and/or standing; and safe cool down exercises. The eight postures were chosen specifically for persons who struggle with balance: Strike Palm, Grasp Bird’s Tail, Single Whip, Wave Hands Like Clouds, High Pat on Horse, Cross Wave of Water Lily, Bend Bow to Shoot Tiger and Closing Movement). In contrast to the traditional Taiji teaching model, in which students replicate the master’s demonstrated movement with little spoken direction, Taiji For Balance trains via verbal, oral and kinesthetic methods to support all learning styles. Participants are educated in how to correctly perform and verbally guide students through the movements, breaking down footwork, arm work and core work. The training provides a wide variety of mindful meditation practices to support the practice of stress reduction. Meditation is a KEY factor in each class. Each class has at least 1015 minutes of guided meditation, with a focus on coming back to the senses, and observing thoughts that might draw one away from being in the moment. Assessment A 35-item knowledge test created by the first author, Taiji for Balance: Level 1, was administered to participants prior to, and upon completion of their weekend training. It consists of 21 multiple choice questions and 14 true/false questions about Taiji. 5 Scores can range from 0 to 35, with higher scores reflecting a better understanding of Taiji. Participants demonstrated skill attainment via administration of two standardized balance tests, the Timed
Up and Go (TUG)6 and functional reach assessment (FRA) upon completion of their weekend training.7 These were scored on a pass/fail basis. Data Analysis Descriptive statistics were used to characterize the sample. Analysis of variance was used to compare pre-test to post-test scores, potential site differences were tested by examining the site X time interactions. T-tests were used to compare the number of correct responders for each item at pre- and post-test administrations. Bonferroni corrections were used to account for multiple comparisons. Results Thirty-four participants attended the weekend trainings and 32 completed all study assessments. Two participants did not complete study pre- or post-testing although ultimately passed their training. Training was completed at four sites, with 4, 5, 12 (11 with data) and 13 (12 with data) completers at the sites. There were no significant differences in outcomes based on site, so results are presented for the entire group of participants. Participants, on the whole, were knowledgeable about Taiji when they began training. Average pre-training scores were 27.7±4.1 (range, 15-34). Scores increased significantly [F[1,28)=29.70, p<.01] by post-training (32.5±.2.0, range, 27-35). Two items had fewer correct responses after training (What are neural pathways? How should Taiji students breathe?). Responses to two items did not change with training; these items (Equilibrioception is…? Why do people lose their balance?) were answered correctly by nearly all respondents at pre-test
(32 and 31, respectively). The remaining 31 items all increased in correct responses from pre- to post-test. After correcting for multiple comparisons, four items showed significant improvement (When shifting weight, where should the weight be focused for students of Taiji for Balance: Level 1? When stepping to the side, what part of the foot should touch down first? What part of the body does the qua include? Taiji classes should be held in a carpeted area for softer falls-true or false.”). Nearly all participants with pre/post assessments (30/32, 94%) were successful in demonstrating the ability to administer the TUG and FRA assessments following training. The remaining two, as well as the two who did not complete study assessments, successfully passed training with additional remediation. Discussion A series of brief weekend trainings to train trainers in fundamentals of Taiji successfully prepared a workforce of 34 who now are able to train elderly across the state of Ohio. Recruitment efforts indicated trainers should have some background in Taiji; they were also provided training materials to review prior to the weekend workshop. This combination likely led to very high pre-test scores. Despite this, post-test scores indicated improved understanding of Taiji. Examination of items that did not improve from pre- to post-test provided the instructor with useful feedback for future trainings. Demonstration of skills was achieved by 94% of those trained, with the remainder successfully demonstrating skills with additional training, indicating that this brief weekend format is successful. Future evaluations should determine functioning of the trainees in their subsequent role as trainers.
Conclusions Brief Taiji train-the-trainer programs appear to be a viable means by which the elderly fall-prevention workforce can be increased. Acknowledgements This study was made possible by a grant awarded by the Ohio Injury Prevention Partnership, which had no role in the study design, preparation or submission of this manuscript. We thank Mandy Howenstine, Brad Campbell and Kyle Nemergut, who assisted with execution of this project. References 1. Falb M & Beeghly C. The burden of injury in Ohio: 2000-2010. Ohio Department of Health, Division of Prevention and Health Promotion, Bureau of Health Ohio, Violence and Injury Prevention Program. 2012. 2. Parrya SW, Steenb N, Gallowaya SR, Kennya RA, Bondb J. Falls and confidence related quality of life outcome measures in an older British cohort. Postgrad Med J 2001;77:103108 doi:10.1136/pmj.77.904.103 3. Lauche R, Wayne PM, Dobos G, Cramer H. Prevalence, patterns, and predictors of T’ai Chi and Qigong use in the United States: Results of a nationally representative survey. Journal of Alternative and Complementary Medicine 2016; 22(4): 336-342. 4. Leung DP, Chan CK, Tsang HW, Tsang WW, Jones AY. Tai chi as an intervention to improve balance and reduce falls in older adults: A systematic and meta-analytical review. Altern Ther Health Med. 2011 Jan-Feb;17(1):40-48. 5. Bartimole, L. Taiji for Balance: Level 1. Unpublished document. 2013. 6. Podsiadlo D & Richardson S. The timed “up & go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 1991; 39, 142-148. 7. Duncan PW, Weiner DK, et al. Functional reach: a new clinical measure of balance. J Gerontol 1990; 45(6): M192-197. 8. Bartimole, L. (2015). Taiji for Balance: Level 1. Self-published manual, available from [email protected]. 9. https://urldefense.proofpoint.com/v2/url?u=https3A__www.dropbox.com_sh_ijr0pina2ah36hf_AAA-2DpdHMgZgH1Qox2wgrkUCOa-3Fdl3D0&d=CwIBaQ&c=k9MF1d71ITtkuJx-
PdWme51dKbmfPEvxwt8SFEkBfs4&r=UEHvz8C9NiSyHb_2eo1Q5xgeHxqPcVN1JhNvZ6K2tY&m=cVDnOO6VDIMAdCRyJIgREfREkUUM2dFZEWVA_Cw RfQw&s=hyPsyLzgoQb7tW3DK6hqeUUuBW9iQJKErIk02SN46F8&e=