Thai Yoga improves physical function and well-being in older adults: A randomised controlled trial

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Journal of Science and Medicine in Sport journal homepage: www.elsevier.com/locate/jsams

Original research

Thai Yoga improves physical function and well-being in older adults: A randomised controlled trial Chaiya Noradechanunt a,c , Anthony Worsley b , Herbert Groeller a,∗ a b c

Centre for Human and Applied Physiology, School of Medicine, University of Wollongong, Australia Centre for Physical Activity & Nutrition Research, Deakin University, Australia Sirindhorn College of Public Health Phitsanulok, Thailand

a r t i c l e

i n f o

Article history: Received 26 August 2015 Received in revised form 3 October 2016 Accepted 4 October 2016 Available online xxx Keywords: Thai Yoga Tai Chi Elderly Flexibility Strength Quality of life

a b s t r a c t Objectives: Compare two 12-week low-intensity exercise regimens on components of physical function and quality of life in community-dwelling healthy yet sedentary adults aged over 60. Design: This study used a randomised, multi-arm, controlled trial design. Methods: Thirty-nine sedentary participants (29 women), aged 67.7 ± 6.7 years were randomly allocated to either a 12-week Thai Yoga (TY) or Tai Chi (TC) for 90 min twice per week, or telephone counselling Control (C). A Senior Fitness Test (chair-stand, arm-curl, sit-&-reach, back-scratch, 8-foot up-&-go and 6-min walk) and Short-Form 36 Health Survey, Centre for Epidemiological Studies of Depression, Physical Activity Scale for the Elderly and the Physical Activity Enjoyment Scale were assessed at baseline, six, 12 weeks, and three months after the completion of the regimen. Results: After 12 weeks, chair-stand (mean difference, 2.69; 95% CI, 0.97–4.41; P < 0.001), arm-curl (2.23; 95% CI, 0.06–4.52; P = 0.009), sit-&-reach (1.25; 95% CI, 0.03–2.53; P = 0.013), back-scratch (2.00; 95% CI, 0.44–3.56; P = 0.005), 8-foot up-&-go (−0.43; 95% CI, −0.85 to 0.01; P = 0.013), 6-min walk (57.5; 95% CI, 20.93–94.07; P < 0.001), vitality (13.27; 95% CI, 2.88–23.66; P = 0.050) and enjoyment (7.96; 95% CI, 3.70–12.23; P = 0.001) significantly improved in TY compared to C, however no change was observed in TC compared to C. TY improved in chair-stand (2.31; 95% CI, 0.59–4.03; P = 0.007), sit-&-reach (1.38; 95% CI, 0.10–2.66; P = 0.007), 6-min walk (32.31; 95% CI, −4.26–68.88; P = 0.015), vitality (12.88; 95% CI, 2.50–23.27; P = 0.040) and enjoyment (5.65; 95% CI, 1.39–9.92; P = 0.010) compared to TC after 12 weeks. Conclusions: The findings suggest that older adults can make significant improvements in their health and well-being by engaging in low intensity Thai Yoga exercise. © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

1. Introduction Lifelong physical inactivity is associated with increased mortality and risk of chronic disease, reduced quality of life, early onset of physical frailty and declining function.1 Such effects of sedentary living impose a considerable burden on society, with older adults being the most physically inactive of any age group.2 In contrast, the introduction of physical activity has been shown to ameliorate many of the effects of secondary ageing.3 Therefore, it is recommended that all healthy older adults participate in a minimum of 30 minutes of moderate-intensity aerobic physical activity 5 days per week and resistance exercise regimens twice weekly.3 How-

∗ Corresponding author. E-mail address: [email protected] (H. Groeller).

ever, less than 14% and 9% of older adults over the age of 65 and 75 years respectively are currently meeting these standards.4 Clearly many older adults have difficulty in meeting these minimum recommended levels of physical activity, yet evidence suggests significant health benefits are still afforded to older individuals when participating in significantly lower levels of physical activity than recommended.5,6 Furthermore, low intensity physical activity is associated with maintenance of physical fitness7 and enhanced well-being in older adults.8 Given the linkages between recommended physical activity and health benefits gained from low-intensity physical activity, we sought to investigate the effects of two forms of structured low-intensity exercise that have an emphasis on range of motion and balance; Tai Chi and Thai Yoga. Tai Chi originated in China as a martial art and the practice of this form is associated with a low metabolic load9 and significant health benefits.11–13 While, Tai Chi has been shown to afford participants with significant physiological benefits9,10 such as; improved car-

http://dx.doi.org/10.1016/j.jsams.2016.10.007 1440-2440/© 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Noradechanunt C, et al. Thai Yoga improves physical function and well-being in older adults: A randomised controlled trial. J Sci Med Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.10.007

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diorespiratory capacity,11 strength, balance,11–13 flexibility,7,11,12 and quality of life7,11 ; Thai Yoga has received considerably less scientific attention. Thai Yoga is a traditional form of exercise practiced extensively in Thailand for many centuries.14 It includes a low-impact, lowto moderate-intensity range of motion incorporating elements of muscle-strength, balance, flexibility, and body alignment. It also combines meditation with slow, gentle, graceful movements, as well as deep breathing and relaxation.14 The main principles and techniques of Thai Yoga are similar to the hatha style, both yoga styles are classified as low-intensity exercise.15,16 However, Thai Yoga differs from hatha yoga in that it is less strenuous with postures that are reported to be less challenging and therefore easier to perform than those of hatha yoga.14 Thus, the practice of this form of yoga may be more accessible to older sedentary cohorts. However, clear evidence from a randomised controlled investigation on the effectiveness of Thai Yoga currently does not exist. Furthermore, it is common for scientific investigations to focus exclusively upon the treatment phase of experimental regimens.13,17 In contrast, significantly less evidence exists about the sustainability of physical gains made when formal experimental treatments are withdrawn. This is a critical consideration for older cohorts that have significantly lower levels of engagement in physical activity, yet are likely to yield the greatest relative physical gains from participation in exercise regimens.2 Therefore, this investigation sought to determine the effect of two 12-week low-intensity exercise regimens on components of physical function relevant to activities of daily living and quality of life in community-dwelling healthy yet sedentary adults aged over 60. 2. Methods Participants were recruited from several communities in the Illawarra region, NSW, Australia. Information about the study was mailed to older adults who had volunteered to participate in the study during our earlier study. All interested people received an information package with detailed information about the study. They were asked to complete a screening questionnaire, which included the Physical Activity Readiness Questionnaire (PARQ) and the Physical Activity Scale for the Elderly (PASE) to determine trial eligibility. A postage free envelope was included and reminders were sent after two weeks. Individuals were considered eligible to participate in the study if they were aged over 60 years, apparently healthy as determined by the PARQ, participating in less than 150 min of moderate-tovigorous physical activity per week as determined by the PASE. Thirty-nine volunteers (29 female) age 66.6 years (SD 6.7), mass 72.7 kg (SD 14.7), stature 1.62 m (SD 0.09), fulfilled the preliminary eligibility criteria and provided written informed consent. This was an assessor-blinded, randomised controlled trial approved by the University of Wollongong Human Research Ethics Committee (HE10/392). Eligible subjects first completed baseline assessments and were then randomly allocated by researcher (H.G., blinded to subject recruitment and baseline assessment phases) using Graphpad QuickCalcs (http://www.graphpad.com/ quickcalcs/randMenu/, GraphPad Software, La Jolla California USA). Subjects were allocated in triplet (three participants) blocks to one of two low-intensity exercise groups (Thai Yoga or Tai Chi) or a Control group. Participants then completed either a 12-week lowintensity exercise regimen, twice weekly or received information on exercise. All participants were reassessed at Week 6 and Week 12 and then 3 months after the completion of the regimen (Week 24). All components of the investigation were undertaken at the Illawarra Health and Medical Research Institute, University of Wollongong

The Thai Yoga (TY) intervention employed a modified, 80 min, 15-posture TY routine (30) taught by a qualified instructor (see Supplementary Fig. S1A–C in the online version at doi:10.1016/j. jsams.2016.10.007). Each session began with a 15-min warm-up consisting of diaphragmatic breathing and meditation in a seated position, followed by stretching exercise in a standing position. The 15-posture routine then commenced and involved six seated postures, six standing postures and three final postures All postures within the TY routine were held for a maximum of 20 s and repeated 3–5 times. Each class ended with 10 min of supine and standing relaxation. A 12-movement Sun style Tai Chi (TC, see Supplementary Fig. S1D–O in the online version at doi:10.1016/j.jsams.2016.10.007) program suitable for older adults was implemented by a qualified instructor.17 Participants were expected to stand upright and adapt each movement according to their individual capability. One set of the basic and advanced movements took about approximately two minutes, and 10–15 sets of these movements were performed in each session. A session consisted of a 10-min warm-up, 60 min of TC and a 10-min cool down. Participants in TC and TY were also encouraged to complete unsupervised home-based training for 20 min on alternate days to the 12-week intervention. Following this 12-week period subjects were encouraged to continue their unsupervised home sessions, using an instructional DVD or attend community-based classes up to Week 24 of the investigation. Subjects recorded the frequency and duration of self-practice in a daily activity log. Participants in the Control group (C) received telephonesupervised exercise regimen advice that encouraged increased home-based physical activity. All participants attended a faceto-face meeting and were provided with written information to facilitate exercise. Weekly telephone counselling sessions for the first four weeks, then fortnightly phone contact for the remainder of the investigation were provided. In summary, all participants were assessed at four time points; Baseline, midway (Week 6), completion of the exercise regimen (Week 12) and 12 weeks after the end of the exercise regimen (Week 24) using the Senior Fitness Test battery18 and four validated questionnaires to assess quality of life. The Senior Fitness Test consists of six assessments of physical performance required for daily living.18 The assessment battery comprises of assessments of power and strength, 30-s chair-stand and arm-curl; range of motion, chair sit-&-reach and back-scratch; agility and dynamic balance, 8-foot up-&-go and endurance, 6-min walk test. Each test was conducted individually, with the exception of the 6-min walk, which was conducted in small groups of four participants who were staggered 10-s apart and walked at their own pace. Research assistants were blinded to participant experimental groupings. Participants also completed four validated self-report questionnaires. Physical activity for a 7-day period was assessed using the Physical Activity Scale for the Elderly (PASE)19 and enjoyment in the activity was evaluated using the Physical Activity Enjoyment Scale (PACES).20 A Short-Form Health Survey (SF-36) was completed to determine physical and mental health outcomes21 and symptoms associated with depression were assessed using the Center for Epidemiological Studies of Depression (CES-D) questionnaire.22 A sample size of 13 subjects per group was required for a power of 0.80 to detect a difference between means of three with an alpha of 0.05.13 Data were analysed on an intention-to-treat basis. Baseline group mean comparisons were performed using one-way analyses of variance (ANOVA) with post hoc analysis to determine group differences. Repeated-measures ANOVA procedures were conducted for each instrument, contingent on the multivariate ANOVA reaching statistical significance (ANOVA, Wilk’s criterion). Bonferroni post hoc analyses were used to determine group differ-

Please cite this article in press as: Noradechanunt C, et al. Thai Yoga improves physical function and well-being in older adults: A randomised controlled trial. J Sci Med Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.10.007

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ences. The results are presented as mean and standard deviation or mean difference from baseline at 6, 12 and 24 weeks with 95% confidence intervals, alpha set at 0.05. All experimental randomisations were performed using GraphPad QuickCalcs (www.graphpad.com/ quickcalcs/randomize2.cfm) using a block (triplet) method by one investigator (HG) who was blinded to subject recruitment and baseline evaluations. HG generated the random allocation sequence and assigned participants to the interventions, CN enrolled participants into the groups.

3. Results Thirty nine subjects undertook a baseline evaluation and were randomly assigned to treatment (TY, TC) or control (C) groups (Fig. 1). During the training period, four and three subjects dropped out in TC and C respectively. No significant differences were observed in the general characteristics of study participants between the experimental groups at baseline (Table 1, ). Similarly, prior to commencement of the training regimen no significant differences in assessments of physical performance or self-report measures (Table 2, ) were detected. The C group participated in telephone counselling with a mean telephone call length of 9.8 ± 4.3 min. At the completion of the study (Week 24), participants in the C were offered to take part in either the Thai Yoga or Tai Chi classes at the community centre. No significant difference was observed in the number of exercise sessions participants attended in TY 23.1 ± 1.9 (96%) and TC 20.5 ± 2.2 (85%). However, time spent undertaking self-practice was different between the experimental groups. During the 12-week intervention TY 138.5 ± 26.1 min.wk−1 engaged in significantly (P = 0.003) more self-practice than TC 105.0 ± 13.1 min week−1 . Similarly, between Weeks 12 and 24 when the regimen had ceased, TY 102.3 ± 17.9 min week−1 maintained significantly (P = 0.017) higher levels of self-practice participation than TC 81.3 ± 18.1 min week−1 . The TY group exhibited a significant improvement in cardiorespiratory fitness, strength and range of motion compared to C. 6-min walk improved at 6 weeks, 12 weeks and 24 weeks with a mean difference of 43.08 yards (P = 0.025), 57.70 yards (P < 0.001) and 59.36 yards (P = 0.001) respectively. Lower- and upper-body strength differed significantly at weeks 12 and 24 with a mean difference in chair stand repetitions of 2.69 (P < 0.001) and 3.33 (P = 0.001) and arm-curl repetitions of 2.23 (P = 0.009) and 2.54 (P = 0.006) respectively, when compared to C. Range of motion for the back-scratch improved at 6 weeks (1.77 inches [P = 0.018]), 12 weeks (2.0 inches [P = 0.005]) and 24 weeks (1.94 inches [P = 0.021]) and sit-&-reach at 12 weeks (1.25 inches [P = 0.013]) only. Compared to C leg power in TY improved during the 8-foot up-&-go at 12 weeks (−0.43 s [P = 0.013]) and 24 weeks (−0.51 s [P = 0.013]). No difference was observed between TC and C in physical performance at any time point in the investigation. Compared to the TC group TY had improved 6-min walk distance at 12 weeks with a mean difference of 32.31 yards (P = 0.015). Lower body and upper body strength improved at weeks 6 <(2.0 reps [P = 0.025]) and 12 (2.31 reps [P = 0.007]) for the chair-stand, and at 24 weeks (2.00 reps [P = 0.027]) for the arm-curl. No difference was observed in back-scratch range of motion, but sit-&-reach improved after 12 weeks with a mean difference of 1.38 inches (P = 0.007). TY showed improved 8-foot up-&-go compared to TC at 6 weeks (−0.48 s [P = 0.022]). The TY group compared to C demonstrated increased mean difference SF-36 Vitality scores at 6 weeks (16.15 [P = 0.009]), 12 weeks (13.27 [P = 0.050]), and 24 weeks (13.33 [P = 0.035]); and enjoyment from physical activity (PACES) scores at 6 weeks (6.54 [P = 0.010]), 12 weeks (7.96 [P = 0.001]) and 24 weeks (8.44

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[P = 0.002]). No change in self-report measures was observed between TC and C. Compared to the TC group TY had improved SF-36 Vitality scores at 6 weeks (14.23 [P = 0.023]) and 12 weeks (12.88 [P = 0.040]). Enjoyment from physical activity (PACES) was also higher in TY compared to TC at 12 weeks and 24 weeks with a mean difference of 5.65 (P = 0.010) and 6.28 (P = 0.014) respectively.

4. Discussion Several important findings were observed with respect to the effectiveness of Thai Yoga and Tai Chi on physical function relevant to activities of daily living and quality of life in community-dwelling healthy yet sedentary adults aged over 60. Firstly, twelve weeks of TY was effective in improving strength, power, flexibility and endurance. In contrast, no significant changes in physical function were observed in TC. Secondly, participants completing the Thai Yoga regimen reported improved vitality and enjoyment compared to TC and C. We observed that TY was the most effective regimen with significantly greater gains observed in strength, flexibility and endurance compared to TC and C. These are interesting findings, as TY is recognised as a low intensity regimen requiring an average oxygen consumption of 35% of V˙ O2peak (5.3 mL kg−1 min−1 ) in healthy sedentary middle-aged participants.16 Despite this light level of TY activity for two supervised sessions per week, significant gains in areas of physical fitness known to be determinants of functional independence were still realised.23 Our findings are consistent with the view that benefits are still accrued in older adults who engage in low intensity activity.1 Indeed, it has been suggested that physical activity at the lowermost intensity range, affords participants with the greatest health and functional benefits.2 Within our investigation we observed upper- and lower-body strength gains of approximately 30% in TY, an improvement consistent with those obtained via more traditional strength training regimens.13 Although, high load and intensity resistance training is very effective in older participants24 ; lower-load resistance training has been shown to be as effective in improving muscle strength25 confirming older participants are responsive to lower intensity regimen. We believe the enhanced lower body strength gains for TY, may be due to the progressive and repetitive nature of the unilateral weight bearing activities of the regimen, activities that are also known to generate deviations in centre of gravity away from the base-of-support.26 Thai Yoga therefore, may be an effective strategy to reduce sedentary behaviours and assist older adults to maintain muscular strength essential for the retention of independence in activities of daily living. Furthermore, the gains in strength displayed by TY were also observed with respect to muscular power (8-foot up-&-go) a physical characteristic believed to be of greater importance for the maintenance of independent living than muscular strength.27 The improvements in muscular strength and power of the lower limb also appeared to have facilitated enhanced balance and agility in TY.7,28 However, the most marked improvements were observed in range of motion, particularly the lower limb were sit and reach flexibility improved by over 100%. Other investigations have reported more modest improvements or no change in flexibility in older cohorts using a variety regimen.13 Consistent with our results, many of the reported improvements appear to have been made in lower-body flexibility; in contrast, upper-limb range of motion was less responsive to the exercise regimen. Physical activity regimens lasting up to 24 weeks in older adults are associated with a significant increase in cardio-respiratory fitness of approximately 6–8%, range: 0–15%,13 a change that is consistent with the 11% increase in 6-min walk distance observed within TY in our investigation. Although the TY intervention did

Please cite this article in press as: Noradechanunt C, et al. Thai Yoga improves physical function and well-being in older adults: A randomised controlled trial. J Sci Med Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.10.007

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Fig. 1. The design of the investigation according to CONSORT guidelines.

Table 1 Characteristics and compliance of study participants. Variable

Thai Yoga (n = 13)

Tai Chi (n = 13)

Control (n = 13)

P-value

Female sex — no. of subjects (%) Couple status — no. of subjects (%) Education status — no. of subjects (%) High school or higher Employment status — no. of subjects (%) Full- or part-time or volunteer Retired or unemployed General health status — no. of subjects (%) Good/very good/excellent Self-reported health conditions — no. of subjects (%) Arthritis/musculoskeletal conditions High blood pressure/hypertension Heart disease Diabetes Age — mean ± SD BMI — mean ± SD Blood pressure (mmHg) — mean ± SD Systolic BP Diastolic BP Attendance in the 12-week program (session) Self-practice during program (min/wk) Self-practice after program ended (min/wk)

10 (76.9) 9 (69.2)

9 (69.2) 7 (53.8)

10 (76.9) 10 (76.9)

0.874* 0.446*

11 (84.6)

10 (76.9)

12 (92.3)

0.554* 0.899*

5 (38.5) 8 (61.5)

5 (38.5) 8 (61.5)

6 (46.2) 7 (53.8)

12 (92.3)

12 (92.3)

13 (100)

2 (15.4) 2 (15.4) 1 (7.7) 0 67.6 ± 4.9 28.2 ± 4.6

3 (20.0) 2 (13.3) 1 (7.7) 1 (6.7) 67.2 ± 8.3 27.2 ± 3.8

1 (6.7) 3 (20) 1 (7.7) 1 (6.7) 65.2 ±6.7 27.3 ± 5.4

0.641† 0.824†

139.3 ± 16.3 83.8 ± 6.0 23.1 ± 1.9 138.5 ± 26.1 102.3 ± 17.9

136.8 ± 17.2 86.1 ± 13.5 20.5 ± 2.2 105.0 ± 13.1 81.3 ± 18.1

137.2 ± 14.9 81.5 ± 9.7 – – –

0.917† 0.534† 0.101† 0.003† 0.017†

0.590* 0.823†

Notes: Abbreviations: SD, Standard Deviation; BMI, Body Mass Index with bold font denoting significance at an alpha of 0.05. * P values were calculated with chi-square. † P values were calculated with one-way ANOVA.

Please cite this article in press as: Noradechanunt C, et al. Thai Yoga improves physical function and well-being in older adults: A randomised controlled trial. J Sci Med Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.10.007

TY Mean

TC SD

C

TY vs C

SD

Mean

SD

14.6

3.5

14.2

4.3

2.6 2.5 4.9

14.9 15.7 17.4

2.5 2.1 2.8

14.6 14.5 15.1

4.0 4.0 3.8

3.2

15.4

4.2

15.5

4.5

15.5 3.0 6 weeks 17.5 2.6 12 weeks 18.4 3.9 24 weeks Chair sit & reach (inches) 2.0 3.8 Baseline

16.2 16.9 17.5

2.9 2.6 2.4

16.1 16.3 17.2

5.0 4.7 4.7

1.0

4.2

1.6

4.6

6 weeks 3.3 4.1 12 weeks 4.0 24 weeks Back scratch (inches) −2.7 Baseline

4.0 3.6 4.3

1.3 1.2 2.0

3.9 4.5 3.5

2.1 1.9 2.3

4.1 4.2 4.4

5.5

−3.2

4.2

−1.5

4.2

−1.4 6 weeks −0.9 12 weeks −0.8 24 weeks 8-foot up and go (s) 5.4 Baseline

5.4 5.3 5.1

−3.3 −3.0 −2.4

3.9 3.6 3.3

−1.4 −1.3 −1.5

4.2 4.1 4.3

0.8

5.4

1.0

5.5

1.0

6 weeks 4.8 4.6 12 weeks 4.5 24 weeks 6-min walk (yards) 589.6 Baseline

0.7 0.7 0.6

5.3 4.9 4.9

0.9 0.7 0.7

5.2 5.2 5.2

1.0 0.9 0.9

105.2

603.9

45.5

618.5

66.4

67.4 72.8 80.1

619.6 624.2 628.8

45.8 53.6 48.4

609.6 613.1 612.7

50.5 50.1 63.1

15.3 6 weeks 16.7 12 weeks 24 weeks 18.5 30-s arm curl (reps) 13.6 Baseline

6 weeks 12 weeks 24 weeks

623.9 656.2 646.9

MD (95% CI)

P

ES

0.652 2.00 (0.17 to 3.83) 2.69 (0.97 to 4.41) 3.33 (1.46 to 5.20)

0.025 <0.001 0.001

0.54 0.95 1.29

MD (95% CI)

P

–

0.959

0.00 (−1.83 to 1.83) 0.38 (−1.34 to 2.11) 0.90 (−0.97 to 2.77)

1.000 0.61 0.26

0.441 1.31 (−1.03 to 3.64) 2.23 (0.06 to 4.52) 2.54 (0.52 to 4.55)

0.389 0.009 0.006

0.321 0.013 0.066

0.33 0.81 0.81

0.31 (−2.03 to 2.64) 0.54 (−1.75 to 2.83) 0.54 (−1.48 to 2.55)

0.018 0.005 0.021

0.19 0.42 0.32

−0.15 (−1.48 to 1.17) −0.13 (−1.41 to 1.15) 0.01 (−1.18 to 1.21)

0.181 0.013 0.013

0.24 0.33 0.37

0.42 (−1.12 to 1.97) 0.56 (−1.00 to 2.12) 0.65 (−0.71 to 2.01)

0.023 <0.001 0.001

0.02 0.20 0.50

2.00 (0.17 to 3.83) 2.31 (0.59 to 4.03) 2.44 (0.57 to 4.30)

0.954 0.978 0.850

0.772 0.558 0.395

0.34 0.61 0.74

0.17 (−0.26 to 0.60) −0.04 (−0.46 to 0.38) −0.10 (−0.54 to 0.34)

0.585 0.523 0.679

0.07 0.18 0.13

1.00 (−1.34 to 3.34) 1.69 (−0.60 to 3.98) 2.00 (−0.02 to 4.02)

24.62 (−14.37 to 63.60) 25.19 (−11.38 to 61.76) 27.05 (−9.02 to 63.12)

0.265 0.242 0.165

ES

0.025 0.007 0.078

F (6, 108) = 4.624 P < 0.001 0.64 0.84 0.86

0.536 0.056 0.027

F (6, 108) = 2.881 P = 0.01 0.27 0.64 0.70

0.804 0.04 0.03 0.07

0.92 (−0.40 to 2.24) 1.38 (0.10 to 2.66) 1.27 (0.06 to 2.45)

0.200 0.007 0.194

F (6, 108) = 2.806 P = 0.01 0.23 0.47 0.25

0.954 0.05 0.02 0.20

1.35 (−0.20 to 2.89) 1.44 (−0.12 to 3.00) 1.28 (−0.08 to 2.64)

0.087 0.068 0.304

F (6, 108) = 4.209 P = 0.001 0.28 0.32 0.20

0.988 0.18 0.26 0.22

−0.48 (−0.90 to 0.05) −0.39 (−0.81 to 0.04) −0.41 (−0.85 to 0.03)

0.878 0.85 1.15 0.94

P

0.498

0.966

0.606 43.08 (4.10 to 82.06) 57.50 (20.93 to 94.07) 59.36 (23.29 to 95.43)

0.942 0.732 0.843

RM ANOVA

0.483

0.605

0.994 −0.31 (−0.73 to 0.12) −0.43 (−0.85 to 0.01) −0.51 (−0.95 to 0.07)

MD (95% CI)

0.926

0.738 1.77 (0.22 to 3.31) 2.00 (0.44 to 3.56) 1.94 (0.58 to 3.30)

ES

0.995

0.964 0.77 (-0.55 to 2.09) 1.25 (0.03 to 2.53) 1.27 (0.08 to 2.46)

TY vs TC

0.022 0.481 0.271

F (6, 108) = 3.281 P = 0.005 0.54 0.33 0.50

0.884 0.49 0.50 0.43

18.46 (−20.52 to 57.44) 32.31 (−4.26 to 68.88) 32.31 (−3.77 to 68.38)

0.467 0.015 0.139

F (6, 108) = 5.395 P < 0.001 0.40 0.60 0.67

ARTICLE IN PRESS

Mean

Physical performance 30-s chair stand (reps) Baseline 13.0 2.6

TC vs C

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Please cite this article in press as: Noradechanunt C, et al. Thai Yoga improves physical function and well-being in older adults: A randomised controlled trial. J Sci Med Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.10.007

Table 2 Physical performance and self-report measures at baseline, week 6 and week 12 of exercise, and 12 weeks (week 24) after cessation of a formal exercise regimen.

5

TY Mean

TC SD

Self-report measures PASE Baseline 192.3 66.7

C

TY vs C

Mean

SD

Mean

SD

194.4

92.1

195.3

99.0

63.1 83.4 118.4

207.2 207.7 205.9

81.1 77.5 67.1

202.3 202.9 235.1

78.2 71.4 91.0

7.3

6.5

6.2

4.3

7.3

6.0

6 weeks 12 weeks 24 weeks SF-36 vitality Baseline

6.5 5.9 4.6

6.2 5.7 4.8

11.6 4.8 3.4

23.9 2.5 3.6

4.8 5.2 6.4

4.6 5.6 5.5

58.8

18.2

70.7

17.5

70.7

18.8

6 weeks 12 weeks 24 weeks SF-36 mental Baseline

71.1 69.2 70.4

15.6 20.7 15.5

68.8 69.6 74.2

15.6 16.0 15.7

66.9 70.7 68.8

21.8 18.1 21.4

78.5

12.5

83.1

11.3

86.0

12.2

80.1 6 weeks 12 weeks 83.7 24 weeks 83.6 SF-36 physical 75.3 Baseline

20.3 11.8 11.4

81.1 84.1 85.7

9.6 10.4 11.5

85.1 84.9 86.6

8.9 10.8 9.5

14.8

78.1

16.6

85.8

10.6

6 weeks 12 weeks 24 weeks PACES Baseline

75.7 75.1 71.9

20.6 17.2 21.0

75.8 77.1 74.9

16.5 17.3 18.5

84.3 85.1 85.1

12.8 13.2 13.0

61.6

5.3

62.4

6.5

62.8

8.1

6 weeks 12 weeks 24 weeks

70.5 76.4 76.3

9.2 4.6 3.9

67.4 69.9 69.6

8.2 8.1 8.0

65.2 68.2 68.1

11.6 11.2 10.6

ES

MD (95% CI)

0.996 48.15 (−24.52 to 120.83) 38.77 (−26.54 to 104.07) 26.41 (-36.18 to 89.00)

0.233 0.558 0.999

0.597 0.925 0.482

0.58 0.36 0.02

5.85 (−66.83 to 78.52) 5.85 (−59.46 to 71.15) −5.51 (−68.10 to 57.08)

0.009 0.050 0.035

0.38 0.23 0.05

1.69 (−2.87 to 6.25) 1.19 (−3.14 to 5.53) 0.15 (−3.64 to 3.95)

0.892 0.375 0.625

0.85 0.54 0.70

1.92 (−10.91 to 14.76) 0.38 (−10.00 to 10.77) 2.05 (−9.20 to 13.30)

0.888 0.985 0.927

0.19 0.50 0.35

−1.19 (−14.51 to 12.13) 0.42 (−10.35 to 11.19) 0.92 (−9.57 to 11.40)

0.010 0.001 0.002

42.31 (−30.36 to 114.98) 32.92 (−32.38 to 98.23) 31.92 (−30.67 to 94.51)

0.624 0.939 0.424

0.925 0.965 0.665

0.973 0.901 0.914

0.14 0.04 0.19

−0.77 (−11.15 to 9.61) −0.48 (−8.81 to 7.84) −1.12 (−10.90 to 8.66)

0.981 0.998 0.938

0.37 0.21 0.03

0.08 (−4.48 to 4.64) 0.08 (−4.26 to 4.41) 0.10 (−3.70 to 3.90)

2.62 (−2.68 to 7.92) 2.31 (−1.96 to 6.57) 2.15 (−2.20 to 6.50)

0.439 0.681 0.749

0.321 0.686 0.642

F (6, 108) = 0.835 P = 0.545 0.54 0.30 0.38

0.999 0.999 0.994

F (6, 108) = 0.986 P = 0.438 0.003 0.03 0.03

0.230 0.11 0.06 0.30

14.23 (1.39 to 27.07) 12.88 (2.50 to 23.27) 11.28 (0.03 to 22.53)

0.023 0.040 0.406

F (6, 108) = 2.387 P < 0.001 0.77 0.62 0.44

0.594 0.10 0.17 0.16

3.61 (−9.72 to 16.93) 3.96 (−6.81 to 14.73) 3.46 (−7.02 to 13.95)

0.777 0.631 0.859

F (6, 108) = 0.405 P = 0.875 0.30 0.36 0.21

0.876 0.05 0.01 0.17

2.69 (−7.69 to 13.07) 1.73 (−6.59 to 10.06) 1.08 (−8.70 to 10.86)

0.988 0.97 1.39 1.39

ES

0.879

0.354

0.888 6.54 (1.24 to 11.84) 7.96 (3.70 to 12.23) 8.44 (4.08 to 12.79)

0.06 0.06 0.30

0.817

0.157 1.92 (−8.46 to 12.30) 1.25 (−7.08 to 9.58) −0.04 (−9.82 to 9.74)

0.978 0.977 0.674

RM ANOVA P

0.998

1.000

0.264 2.42 (−10.90 to 15.74) 4.38 (−6.39 to 15.15) 4.38 (−6.11 to 14.87)

MD (95% CI)

0.879

0.230 16.15 (3.32 to 28.99) 13.27 (2.88 to 23.66) 13.33 (2.09 to 24.58)

ES

1.000

1.000 1.77 (−2.79 to 6.33) 1.27 (−3.06 to 5.60) 0.27 (−3.57 to 4.05)

TY vs TC P

0.793 0.974 0.999

F (6, 108) = 0.146 P = 0.989 0.17 0.05 0.02

0.945 0.36 0.28 0.26

3.92 (−1.38 to 9.22) 5.65 (1.39 to 9.92) 6.28 (1.93 to 10.64)

0.166 0.010 0.014

F (6, 108) = 3.415 P = 0.004 0.67 1.27 1.30

Notes: Thai Yoga (TY, n = 13), Tai Chi (TC, n = 13), Control (C, n = 13). Abbreviations: PASE, Physical Activity Scale for the Elderly; CES-D, Center for Epidemiological Studies of Depression; SF-36, 36-Item Short-Form Health Survey; PACES, Physical Activity Enjoyment Scale;. Values are either mean and standard deviation (SD) or mean difference (MD) and 95% confidence interval (95% CI) from baseline to week 6, 12 or 24 weeks. Statistical significance (P) and effect size (ES) for each treatment period is shown, with bold font denoting significance at an alpha of 0.05. Group x time interactions are shown using a two way repeated-measures ANOVA (RM ANOVA).

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6 weeks 12 weeks 24 weeks CES-D Baseline

MD (95% CI)

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Table 2 (Continued)

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not appear to have distinct components (e.g. power, strength, cardio-respiratory fitness) of physical activity contained within the regimen, participants none-the-less made meaningful gains in all physical attributes associated with independent living. However, our investigation did not observe similar gains within TC. The failure of the TC regimen to induce significant improvements in functional fitness within this investigation was contrary to our original hypothesis, and the observations of others.11,12 However, several investigations have also observed no significant improvement in functional fitness following participation in TC.7 Collectively, these findings suggest that for participants within this investigation, the intensity of the regimen may have been below the threshold required to elicit adaptation. TC participants are also required to commit to memory relatively complex movement patterns making recall of the movements more difficult, leading to reduced participation or less effective unsupervised practice. Indeed, we recorded significantly lower levels of reported homebased unsupervised practice in TC (Table 1) during (∼25%) and after completion (∼20%) of the program compared to TY. The movement characteristics associated with Tai Chi and reduced voluntary exposure to home-based unsupervised practice may have contributed to poorer relative functional outcomes observed within TC. One of the unique aspects of this investigation was the inclusion of the 12-week monitoring period at the completion of the exercise intervention. This allowed for an assessment of the sustainability of gains made whilst participating in the exercise regimen. While previous studies suggest that the functional performance benefits of exercise programs decline within two weeks after cessation of exercise,29 we found the physical performance gains from a TY intervention were maintained up 12 weeks after the completion of the intervention. Perhaps the fewer and simpler basic skills associated with TY were more easily acquired than the more complex TC movement skills. Thus, participants in TY may have continued to practice unsupervised at the cessation of the supervised regimen. In the current study, there was no significant change in depressive symptoms across all three study groups. This is consistent with previous research,11 which found that TC and low-impact exercise did not result in a change of depressive symptoms among healthy older adults. In contrast, self-reported levels of vitality and enjoyment did improve significantly in TY compared to C and TC a finding consistent with improved physical capacity.30 However, the generalisability of this investigation may be limited by the relatively small sample size, which contained participants who were advantaged in socioeconomic status and participation was voluntary, subjects were therefore self-selected and may not be representative of the characteristics of the broader population of older adults.

5. Conclusion Low-intensity Thai Yoga improved physical attributes and selfreport measures associated with greater functional independence and quality of life in older adults. Furthermore, these adaptations were still realised 12 weeks after cessation of the regimen. In contrast, Tai Chi did not elicit significant adaptation compared to Control, suggesting the feasibility and simplicity of the low intensity exercise undertaken may be important to improve physical function in older individuals.

Practical implications - Consideration should be given to low intensity regimens as a safe and effective strategy to improve physical function and wellbeing in older relatively sedentary cohorts. In later work in the community we found that the program was easily replicated

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among older women, suggesting that the low intensity regimen may be scalable for use in larger populations. - Recommended levels of physical activity may not be required initially in older sedentary cohorts to improve physical function. The regimen was attractive to these older participants, many of whom had not been involved in formal exercise programs for many years. Therefore Thai Yoga may be a useful way to introduce older members of the community to structured regular exercise which could be extended in intensity over time. - The relative simplicity of a low intensity exercise regimen appears to be an important attribute to encourage home-based exercise when working with older adults. Financial disclosure Funded by the Faculty of Health and Behavioural Sciences, University of Wollongong under the HDR Student Funding Scheme. Acknowledgements CN was supported by the Faculty Student Funding Scheme. The authors thank staff of the Illawarra Older Women Network (OWN) Wellness Centre. References [1]. Sparling PB, Howard BJ, Dunstan DW et al. Recommendations for physical activity in older adults. BMJ 2015; 350:1–5. [2]. Powell KE, Paluch AE, Blair SN. Physical activity for health: what kind? How much? How intense? On top of what? Annu Rev Public Health 2011; 32(1):349–365. [3]. Nelson ME, Rejeski WJ, Blair SN et al. Physical activity and public health in older adults. Circulation 2007; 116(9):1094–1105. [4]. CDC. Prevalence of self-reported physically active adults— United States, 2007. Morb Mortal Wkly Rep 2012; 57(48) http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm5748a1.htm. [5]. Demakakos P, Hamer M, Stamatakis E et al. Low-intensity physical activity is associated with reduced risk of incident type 2 diabetes in older adults: evidence from the English Longitudinal Study of Ageing. Diabetologia 2010; 53(9):1877–1885. [6]. Healy GN, Dunstan DW, Salmon J et al. Objectively measured light-intensity physical activity is independently associated with 2-h plasma glucose. Diabetes Care 2007; 30(6):1384–1389. [7]. Song R, Lee EO, Lam P et al. Effects of Tai Chi exercise on pain balance, muscle strength, and perceived difficulties in physical functioning in older women with osteoarthritis: a randomised clinical trial. J Rheumatol 2003; 30:2039–2044. [8]. Resnick BPC, Spellbring AMPRN. Understanding what motivates older adults to exercise. J Gerontol Nurs 2000; 26(3):34–42. [9]. Li J, Hong Y, Chan K. Tai Chi: physiological characteristics and beneficial effects on health. Br J Sports Med 2001; 35(3):148–156. [10]. Liu HPPT, Frank AP. Tai Chi as a balance improvement exercise for older adults: a systematic review. J Geriatr Phys Ther 2010; 33(3):103–109. [11]. Frye B, Scheinthal S, Kemarskaya T et al. Tai Chi and low impact exercise: effects on the physical functioning and psychological well-being of older people. J Appl Gerontol 2007; 26(5):433–453. [12]. Choi JH, Moon J-S, Song R. Effects of Sun-style Tai Chi exercise on physical fitness and fall prevention in fall-prone older adults. J Adv Nurs 2005; 51(2):150–157. [13]. Takeshima N, Rogers NL, Rogers ME et al. Functional fitness gain varies in older adults depending on exercise mode. Med Sci Sports Exerc 2007; 39(11):2036–2043. [14]. National Institute of Thai Medicine. Thai physical exercise style Rusie Dotton 15posture basic form, Nonthaburi, National Institute of Thai Medicine, 1997. p. 16–63. [15]. Hagins M, Moore W, Rundle A. Does practicing hatha yoga satisfy recommendations for intensity of physical activity which improves and maintains health and cardiovascular fitness? BMC Complement Altern Med 2007; 7(1):1–9. [16]. Buranruk O, La Growy S, Ladawanz S et al. Thai Yoga as an appropriate alternative physical activity for older adults. J Complement Integr Med 2010; 7(1):1–14. [17]. Lam P, Horstman J. Overcoming arthritis: a holistic plan including a unique tai chi programme to relieve pain and restore mobility, Camberwell, Dorling Kindersely, 2002. [18]. Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. J Aging Phys Act 1999; 7(2):129–161. [19]. Washburn RA, Smith KW, Jette AM et al. The physical activity scale for the elderly (PASE): development and evaluation. J Clin Epidemiol 1993; 46(2):153–162. [20]. Motl RW, Dishman RK, Saunders R et al. Measuring enjoyment of physical activity in adolescent girls. Am J Prev Med 2001; 21(2):110–117.

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Please cite this article in press as: Noradechanunt C, et al. Thai Yoga improves physical function and well-being in older adults: A randomised controlled trial. J Sci Med Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.10.007