The Effect of Tai Chi Chuan in Reducing Falls in Elderly People at Risk

Transcription

1 Professional Assignment Project 2008 The Effect of Tai Chi Chuan in Reducing Falls in Elderly People at Risk Systematic review Carla Boehm Linda Gunnarsdóttir European School of Physiotherapy, Hogeschool van Amsterdam, Tafelbergweg 51, Amsterdam, The Netherlands Received 24 th January 2008

2 Table of content: Foreword... 3 Abstract... 4 Introduction... 4 Methods... 5 Search strategy... 5 Selection criteria... 5 Methodological quality assessment... 5 Data extraction... 5 Data analysis... 5 Results... 6 Search strategy... 6 Methodological quality of individual trials... 6 Study characteristics... 6 Analysis... 8 Discussion... 8 Conclusion... 9 Acknowledgements... 9 References

3 Foreword Relevance Client Our client, Fazil Bacchus is a Tai Chi Chuan (TCC) teacher and is planning to offer classes especially for older people. Therefore he wanted to know about the effects of Tai Chi Chuan in an elderly population and if there is evidence for reducing falls. Relevance for us During our study of physiotherapy, we have been in contact with several geriatric patients, some of these patients experienced injuries due to falling. We have learned about assessment tools for measuring balance for this patient population. In one of our projects for evidenced based practice we discussed screening tools for assessing balance and concluded that balance impairments should be detected as early as possible to prevent future falls. But how to prevent future falls? For which treatment intervention exists evidence? How can one systematically measure prevention of falls? To answer these questions we searched for interventions that showed evidence in fall reduction. We realized that there are many programs available for older people to help them prevent falls, fall-related injuries and maintain their highest level of independence. These programs include resistance, endurance, balance, feedback, and educational training, and home hazard modification. (Wu 2002; Hass et al, 2004). As one of our group members has personal experience with Tai Chi Chuan (TCC) we were eager to find out, if there was any evidence available about the effectiveness of TCC on fall reduction. Relevance Physiotherapy Falls among older people are a significant public health problem therefore interventions to prevent fall and to improve balance are needed. Older people usually prefer non-vigorous and gentle movements (Wu 2002), and during the TCC movements practitioners have to control their centre of gravity and remain stable (Zeeuwe 2006, Verhagen 2004) which could be a parallel to activities of daily living (ADL s). Therefore we wanted to analyse if TCC could be an effective alternative to other existing exercise interventions aiming to reduce falls. Acknowledgements We would like to thank Cia Kesselaar, Fazil Bacchus, J.W. van Rhijn, Sigurður Eggert Halldóruson and Helena Gunnarsdottir for their advice and support. 3

4 Professional Assignment Project 2008 The Effect of Tai Chi Chuan in Reducing Falls in Elderly People at Risk Systematic review Carla Boehm Linda Gunnarsdóttir European School of Physiotherapy, Hogeschool van Amsterdam, Tafelbergweg 51, Amsterdam, The Netherlands Received 24 th January 2008 Abstract Objectives: The purpose of this study was to assess the effect of Tai Chi Chuan (TCC), Yang-style, on fall incident rates in elderly at risk. Method: A systematic review was carried out according to the Cochrane standards. An extensive search for relevant literature was conducted in PubMed, Pedro and additional reference tracking from potentially relevant papers. Studies were selected if they were randomised control trials; the study population was 65 years and at risk of falling; one of the interventions was TCC Yang-style and falls were the primary measurement outcome. The search identified 36 abstracts and a total of five studies met the inclusion criteria. In two of these studies the population was not exclusively at risk of falling of which one TCC was supplemented with another intervention. Result: All of the studies were of higher methodological quality. Three studies, which included a community-dwelling elderly population, showed a significant reduction in fall occurrence in favour for the TCC intervention. The study involving participants from long-term care centers and the study involving participants from congregate living facilities showed no statistically significant differences between groups. Conclusion: TCC seems to have a positive effect on fall reduction in community-dwelling elderly but not in residents of long-term care or congregate living facilities. Hogeschool van Amsterdam, All rights reserved. Key words. Tai Chi; elderly; fall prevention; risk of fall and frail Introduction Falls among older people are a significant public health problem because of the rapid increase in the elderly population and their disproportionately high medical expenses (Chang et al, 2004; Li et al, 2005; Lin et al, 2007; Nnodim et al, 2006; Tsang et al, 2004; Verhagen et al, 2004; Voukelatos et al, 2007; Wolf et al, 2003; Wong et al, 2001; Zhang et al, 2006) % of the elderly of 65 years and older fall each year (Gillespie et al, 2003; Li et al, 2005; Voukelatos et al, 2007; Wong et al, 2001, Wu et al, 2002; Zwick et al, 2000) % of the fall accidents need medical care and about 5-10 % result in fracture (Greenspan et al, 2007; Li et al, 2005; Verhagen et al, 2004; Zeeuwe et al, 2006; Zwick et al, 2000). Falls can result in disabilities, increased fear of falling, social isolation, decreased 4

5 mobility and even in increased mortality. The risk of fall is strongly related to previous falls, disturbed balance, decreased muscular strength and flexibility, fear of falling, use of medication and changes in walking pattern (Verhagen et al, 2004; Wong et al, 2001; Wu et al, 2002; Zeeuwe et al, 2006). Immobility resulting from falls in older people can lead to severe depression, malnutrition, increased chance of infection (Greenspan et al 2007; Wu et al, 2002) and declines in perceived health status and quality of life (Greenspan et al, 2007). Therefore efforts to reduce the incidents of falls among the elderly and associated healthcare costs have received increased attention (Li et al, 2005). Currently, many programs are available for older people to help them prevent falls and fallrelated injuries and maintain their highest level of independence. The most recent Cochrane review on the effectiveness of interventions to prevent fall incidents states that TCC exercise intervention is likely to be beneficial to prevent fall incidents, although the evidence is limited (Gillespie et al, 2003; Hass et al, 2004; Zeeuwe et al, 2006). Older people usually prefer non-vigorous and gentle movements therefore TCC has drawn more attention within the rehabilitation/geriatric community (Wu et al, 2002). Wu et al (2002) reported in a recent review that results from studies about TCC as an exercise program for improving balance and preventing falls are scattered and inconsistent. Differences in balance measurement, subject population, the type and duration of TCC and the design of the study cause this inconsistency (Zhang et al, 2006). TCC is derived from a martial art form and is an integral part of the Traditional Chinese Medicine. There are several TCC styles practiced such as Yang, Wu and Sun style. Each style has its own emphasis and movements. The most commonly practiced is the Yang style (Suzuki et al, 2004), which emphasizes multidirectional weight shifting, awareness of body alignment, and multisegmental movement coordination (Li et al, 2005). The traditional Yang style consists of 108 movements that were simplified to forms with 24, 10, 7 or 6 movements. The aim of this paper is to summarize systematically the evidence of the effect of TCC Yang style in reducing fall in the elderly who are at risk of falling. Methods Search strategy Broad computerized literature search on PubMed and manual search reference lists from potentially relevant papers was carried out. Key words used were: Tai Chi; elderly; fall prevention; risk of fall and frail. The search was restricted to articles in English to exclude bias. Selection criteria Studies were selected when the design of the study was randomised controlled trial; the age of the study population was >65 and at risk of falling; one of the interventions was TCC Yang-style and falls were the primary measurement outcome. Methodological quality assessment Methodological scoring of the trials was performed independently, using a specific methodological quality checklist. The criteria list was developed by the researchers on the base of existing quality criteria lists (Aufdemkampe et al 2000, pp ; Tulder van et al, 1999) and consists of 12 items (Table 1). Four items were disregarded, because they were used as inclusion criteria (random allocation and direct fall outcome measure) or were not applicable to the evaluated interventions (blinding of participants and care provider). In order to test the applicability of the methodological quality checklist, the reviewers scored one unrelated trial independently. Data extraction Titles and abstracts were reviewed independently and full papers were obtained if the study met the inclusion criteria. Data analysis The quality list consisted of 12 items, each item was scored yes if the criterion was fulfilled, no if the criterion was not fulfilled, and? if the information was not mentioned or was unclear. All yes scores were summed to produce an overall quality score (Table 2). In this systematic review, an article was considered of higher methodological quality when the total quality score was at least 50% of the maximum available scores. 5

6 Table 1. Methodological Quality 1 Eligibility criteria were specific 2 Precise details of the interventions administered are given 3 Follow-up period of at least 6 months 4 The size of the treatment effect and measures of variability are presented for direct fall incidence 5 The sample is adequate in size > 50 6 Results of between-group statistical comparisons are reported 7 Concealed allocation 8 The subjects are comparable regarding the most important prognostic indicators 9 Control of co-interventions 10 Blinding of all assessors to the intervention 11 Drop out of each group is described and less than 25% 12 Intention to treat analysis Results Search strategy 36 abstracts from the database search were identified of which 9 abstracts were excluded due to not meeting the inclusion criteria (Figure 1). Of the 27 potentially relevant abstracts 25 full papers could be retrieved, of which 18 were excluded. Seven articles were excluded because they had no direct fall outcome measurement; five articles were excluded due to the age and impairment level of the study population; four articles did not use Yangstyle; one study did not mention the TCC style used; and one excluded study was a cohort study. Finally 7 papers met the inclusion for the systematic review, of which two concerned the same study by Wolf/Sattin et al (2003/2005) and another two concerned the same study by Li et al (2004/2005). Methodological quality of individual trials Results of the methodological quality of individual trials are shown in Table 2. All included trials were of higher methodological quality. The total score on fulfilled criteria ranged from 6 to 11, with a mean of 9,2. Of all items across the 5 trials (n =60), 76,7% were fulfilled (46/60), 16,6% were not fulfilled (10/60) and 6,7% were not provided or unclear (4/60). Most papers provided sufficient information on between group baseline characteristics and withdrawal at follow-up, although reporting whether there was control of cointerventions was less common. Study characteristics Table 3 presents general characteristics and outcomes of the trials. Three trials included community-dwelling subjects (Suzuki et al, 2004; Voukelatos et al, 2007; Li et al, 2005) of which one stated that the subjects were susceptible to falling (Li et al, 2005) and the other two included relatively healthy subjects but analysed a subgroup of fallers (Suzuki et al, 2004; Voukelatos et al, 2007). One trial was done at congregate living facilities and included subjects who are transitioning to frailty (Wolf/Sattin, 2003/2005). The trial by Faber et al (2006) evaluated pre- and frail subjects from long-term care centres. Trials were aimed to reduce falls and to improve balance (Voukelatos et al, 2007), to determine the effects on falls, physical function and disability (Faber et al, 2006), to reduce risk of falls, Table 2. Methodological Quality of Included Trials per Total Trial ? Farber et al ? Li et al Suzuki et al ? Voukelatos et al ? Wolf/ Sattin 2003/ ?

7 Table 3 Study Faber et al, 2006 Wolf/ Sattin 2003/2005 General Characteristics and Outcome of Individual Trails Primarily aimed at Definition of fall Subjects Duration Interventions Follow up* Fall outcome Falls, Coming 278 subjects aged 79- physical unintentionally to 91, pre- and frail, function and the ground or other long-term care disability lower level centres Reduce risk of falls Unintentionally coming to rest on an object, floor or lower object 291 subjects aged 70-97, transitionally frail, congregate living facilities 5 months TCC: simplified 7 form, 1x week for 4 weeks, 2x week for 16 weeks. 60min Functional walking: exercises for balance, mobility and transfers. 1x week for 4 weeks, 2x weeks for 16 weeks. 60min Control Group (CG): no intervention 11 months TCC: simplified 6 form, 10-50min, 2x week Wellness education: instructions and handouts. 60 min, 1x week Control group: no intervention 5, 12 months Daily fall calendar, institutional fall registration systems? Weekly report forms Results of fall incidents rates No significant differences between groups No significant difference between groups Suzuki et al, 2004 Leg muscle strength and reduce future falls Not mentioned 52 subjects aged >73, community-dwelling, subgroup fallers 6 months TCC and exercises: simplified 3-5 forms, and general exercises, 60min, every two weeks CG: pamphlet and advice on fall prevention 6, 8 and 20 months Interview Significant difference between groups in favour of TCC Voukelatos et al, 2007 Li et al, 2005 Reducing falls, improving balance Predicting subsequent falls Unintentionally coming to rest on ground, floor, or other level Landing on floor/ground or fall and hit objects by accident 702 subjects aged 60, communitydwelling, relatively healthy, subgroup fallers 256 subjects, aged 70-92, susceptible to falling, communitydwelling 4 months TCC: no restriction in style, Yang-style 3%, 60 min, 1x week CG: no intervention 6 months TCC: simplified 24 form, 60min, 3 x week Stretching control: stretching trunk and upper body, breathing and relaxation exercises, 60 min, 3x week 3 and 6 months Daily fall calendar 3, 6 and 12 months Daily fall calendar Significant difference between groups in favour of TCC Significant difference between groups in favour of TCC * Follow up measurements after randomisation 7

8 36 abstracts 27 potentially relevant abstracts 9 abstracts were excluded due to not meeting the inclusion criteria 2 papers could not be retrieved 25 potentially relevant papers 7 papers met the inclusion criteria of which two concerned the same study 18 were excluded due to: - no direct fall outcome measurement (n=7) - age and impairment level of the study population (n=5) - no Yang- style TCC (n=4) - cohort study (n=1) - did not mention the TCC style (n=1) Figure 1. Progress of search for relevant trials. (Wolf/Sattin, 2003/2005; Suzuki et al, 2004), to increase leg muscle strength (Suzuki et al, 2004) and to predict subsequent falls (Li et al, 2005). All trials had similar definitions of falls. Only one trial did not mention the definition of fall and evaluated falls by means of interviews (Suzuki et al, 2004). Most trials used a daily falls calendar as an outcome measurement (Li et al, 2005; Voukelatos et al, 2007) of which one also included institutional fall registration systems (Faber et al, 2006). In the trial by Wolf/ Sattin et al (2003/2005), the participants were asked to hand in 2 weekly report forms. The size of the population ranged from 52 to 702 per trial. All trials differed regarding which form of the Yang-style TCC was taught and one trial did not mention which form was taught (Voukelatos et al, 2007). In the trial by Li et al (2004) the 24 form were taught, the trial by Faber et al (2006) used the 7 form, one trial used the 6 form (Wolf/Sattin, 2003/2005), one trial used 3-5 forms (Suzuki et al, 2004), and one trial had no restriction in style but 3% of the study population was taught in Yangstyle (Voukelatos et al, 2007). Analysis A statistically significant reduction in falls in favour of the TCC group was determined in the 3 trials with a community-dwelling subject population (Table 3) (Li et al, 2005; Suzuki et al, 2004; Voukelatos et al, 2007). The 2 studies involving subjects transitioning to frailty from long-term care centres (Faber et al, 2006) and prefrail and frail subjects from congregate living facilities (Wolf/Sattin, 2003/2005) showed no statistically significant differences between groups, although a reduction of falls in the TCC group was seen. Wolf et al (2003) suggested that the findings might be of clinical importance. Discussion All 5 trials were of higher methodological quality according to the predefined criteria. To minimize bias due to study design and quality, only randomized, controlled trials were included. 8

9 This review showed hardly consistent findings in reducing falls in elderly at risk. Three studies, which included a community-dwelling elderly population, showed a significant reduction in fall occurrence (Suzuki et al, 2004; Voukelatos et al, 2007; Li et al, 2005) in favour for the TCC intervention. Out of these 3 trials, 2 trials by Voukelatos et al (2007) and Suzuki et al (2004) had a relatively healthy subject population. The trial by Li et al (2005) involved subjects who were susceptible of falling' but did not state what this implies. The 2 studies involving subjects transitioning to frailty from long-term care centres (Faber et al, 2006) and prefrail and frail subjects from congregate living facilities (Wolf/Sattin et al, 2003/2005) showed no statistically significant differences between groups, although a reduction of falls in the TCC group was seen. The difference in the results could be explained regarding the differences in study population. A community dwelling elderly population could be more active and have less comorbidities than an elderly population living in care centres or facilities. Nowalk et al (2001) concluded in a study about the effect of two different exercise programs in reducing falls that residents of long-term care facilities may require individualized exercise interventions that can be adapted to their changing needs. The differences of the study population of included trials might be a limitation to our study. The purpose of our review was to evaluate the effect of TCC interventions on elderly at risk of fall. We defined at risk as having a history of falling and/or balance impairments and/or having fear of fall. This definition might be too vague. All studies included subjects at risk of falling, but in most trials it remained unclear which subjects are defined as being at risk of falling. Given that % of the elderly of 65 years and older fall each year (Gillespie et al, 2003; Li et al, 2005; Voukelatos et al, 2007; Wong et al, 2001; Wu et al, 2002; Zwick et al, 2000), we hypothesized that all studies including elderly of 65 years and older would at least have a proportion of 30-50% of subjects at risk of falling. Therefore we also included the study by Voukelatos et al, (2007) and Suzuki et al (2004) who analyzed a subgroup of fallers. Another limitation of our study could be that we included only trials that used Yang-style TCC as an intervention. All of the included trials used a different simplified form of the Yang-style TCC and one trial did not mention how many forms were taught (Voukelatos et al, 2007). Furthermore it remains unclear if the interventions were performed according to protocol and how far standardization is possible and warranted. Further research should therefore include all styles of TCC but they should analyse the degree of difficulty and the time required to learn the movements. Because of the time delay required for older people to be able to fully perform the TCC forms the follow-up period should be long enough to be able to detect long-term effects. Conclusion TCC seems to have a positive effect on fall reduction in community-dwelling elderly but not in residents of long-term care or congregate living facilities. Older people usually prefer non-vigorous and gentle movements (Wu 2002), therefore TCC seems to be an alternative to other existing exercise interventions aiming to reduce falls. Furthermore during the TCC movements practitioners have to control their centre of gravity and remain stable (Zeeuwe 2006, Verhagen 2004) which could be a parallel to activities of daily living (ADL s). Acknowledgements We would like to thank Cia Kesselaar, Fazil Bacchus, J.W. van Rhijn, Sigurður Eggert Halldóruson and Helena Gunnarsdottir for their advice and support. 9

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