984
LETTERS TO THE EDITOR
MAY 2014–VOL. 62, NO. 5
JAGS
(Timed Up-and-Go), computerized dynamic posturography assessment, and balance confidence assessment (ActivitiesSpecific Balance Confidence (ABC) Scale).
EFFECTS OF LONG-TERM TAI CHI BALL PRACTICE ON BALANCE PERFORMANCE IN OLDER ADULTS To the Editor: Balance decreases with age, resulting in greater risk of falls for people aged 65 and older.1 Physical activity can address some aspects of this age-associated physiological decline,2 with exercise programs that incorporate balance retraining having been found to improve postural stability.3 Tai chi has been reported as a safe and enjoyable form of exercise that could improve balance in community-dwelling elderly adults, decreasing the risk of falls.4,5 Another form of exercise that has become increasingly popular among many elderly people of Chinese descent is tai chi ball (TCB). TCB consists of more wholebody rotational and multisegmental circular movements than tai chi, with sequential weight shifting. TCB requires fine equilibrium control. A 12-month survey of the effect of TCB on postural balance of community-dwelling elderly women has provided information of unique value and is presented here.
METHODS Seventy-two elderly persons (mean age 65.4 6.9) were recruited from the community as the participants of the project. None had previous experience with TCB. The criteria for recruitment were age 60 to 70; ability to walk without support; and no symptoms of motor paresis, sensory deficits, vertigo, or uncorrectable visual defects. Participation was strictly voluntary. Participants were randomized into two groups: 36 who participated in TCB and 36 nonparticipating controls. Subjects in both groups participated in a physical exercise program. The training program was 12 months long, with three 1- to 2-hour sessions per week. Each session began with 5 minutes of warm-up and ended with 5 minutes of cool-down stretching exercises. The remaining time was devoted to TCB. The control group did not participate in TCB. Three clusters of outcome measures were used for each subject at baseline and 12 months later: static balance measures (unipedal and tandem stance), dynamic balance measures
RESULTS After 12 months of TCB, participant performance improved in the unipedal stance (F = 7.332, P = .009), tandem stance (F = 7.227, P = .009), and sensory organization test for balance measurements composite (F = 14.865, P < .001) and on the visual (F = 5.922, P = .02) and vestibular (F = 6.425, P = .01) test and the ABC Scale (F = 8.486, P = .005) and worsened on the Timed Up-and-Go (F = 4.751, P = .03). After 12 months, the performance of the control group worsened on the Timed Up-and-Go (F = 6.34, P = .01); no other changes were observed (Table 1).
DISCUSSION The aim of this study was to compare changes in balance ability and balance confidence of TCB participants with those of a control group. TCB includes a series of graceful movements, constant weight shifting with different rotational and multi-segmental circular movements, and changes in the base of support from double- to single-leg standing and is known for its particular benefit to balance function. Analysis indicated that static balance performance (unipedal and tandem stance) improved significantly after a 12-month TCB intervention. This finding is consistent with those of a previous report.6 Dynamic balance performance data analysis showed that mean Timed Up-and-Go had decreased significantly in both groups 12 months later. TCB had a positive effect on muscle strength, endurance and muscle reaction time are likely to have contributed to the improvement in the walking speed,7,8 and daily walking of the control group is likely to have contributed to their improvement in walking speed.9 Computerized dynamic posturography indicates the relative importance and proper use of sensory inputs,
Table 1. Performance Measure Scores over Two Repeated Tests According to Group Tai Chi Ball Pretest
Control 12 Months
11.7 18.6 7.3 73.3
0.2 0.2 0.4 1.1
13.7 20.6 6.4 78.8
0.3b,d 0.3b,c 0.2 2.7b,c
11.7 18.4 7.2 74.2
0.2 1.2 0.3 2.9
12.1 20.0 6.6 74.4
0.2 2.0 0.2a 3.9
73.5 96.8 79.1 67.1
1.2 2.9 5.9 3.0
82.9 97.2 87.0 75.5
2.8b,d 2.9 4.2b,d 1.3a,c
74.7 96.4 80.4 69.8
2.9 3.2 5.1 3.2
75.7 97.0 81.3 70.1
3.4 3.6 4.5 3.7
P < .05 compared with baseline. P < .01 compared with baseline. c P < .05 tai chi ball compared with control after 12 months. d P < .01 tai chi ball compared with control after 12 months. a
b
12 Months
Mean Standard Deviation
Measure
Unipedal stance, seconds Tandem stance, seconds Timed Up-and-Go, seconds Activities-specific balance confidence score Sensory organization test for balance measurements Composite Somatosensory Visual Vestibular
Pretest
JAGS
MAY 2014–VOL. 62, NO. 5
namely, somatosensation, vision, and vestibular sensation. The present study showed that the TCB group had greater improvement in their vestibular score (12.1%) than controls (0.51%); there was a significant difference between the TCB and control groups after the 12-month intervention. Practicing TCB involves head movements that could stimulate the vestibular system through head and body rotation and fixation of the eyes on the moving ball during the practice of its many forms.8 The finding showed that 12 months of TCB exercise improved visual and composite scores. The result is consistent with improvement in balance using tai chi as a form of exercise.4,5 The average ABC Scale score of the TCB group increased after 12 months of intervention (mean change 7.3%). This change was similar to that reported in the only other progressive resistance training intervention study to have administered the ABC Scale (mean change 6%).10 The results suggest that it is possible to recommend a TCB program for 12 months to significantly improve balance confidence. These findings have demonstrated that a TCB intervention was both effective for community-dwelling elderly persons in improving balance performance in relation to falls and might delay the onset of deterioration of motor function. These findings can contribute to the future planning of community-based exercise programs. Chun-Mei Xiao, MA Department of Health Promotion and Physical Education, Beijing Institute of Graphic Communication, Beijing, China
ACKNOWLEDGMENTS Conflict of Interest: The author has declared no conflict of interest. Author Contributions: Chun-Mei Xiao: study concept and design, performed the experiments, acquisition of subjects and data, analysis and interpretation of data, preparation of first draft and final manuscript. Sponsor’s Role: No funding was received for this study.
REFERENCES 1. Feder G, Cryer C, Donovan S et al. Guidelines for the prevention of falls in people over 65. The Guidelines’ Development Group. BMJ 2000;321:1007–1011. 2. Skelton DA, Dinan SM. Exercise for falls management: Rationale for an exercise programme to reduce postural instability. Physiother Theory Pract 1999;15:105–120. 3. Hill K, Smith R, Fearn M et al. Physical and psychological outcomes of a supported physical activity program for older carers. J Aging Phys Act 2007;3:257–271. 4. Li F, Harmer P, Mack KA et al. Tai chi: Moving for better balance-development of a community-based falls prevention program. J Phys Act Health 2008;5:445–455. 5. Wayne PM, Kaptchuk TJ. Challenges inherent to tai chi research: Part I— t’ai chi as a complex multicomponent intervention. J Altern Complement Med 2008;14:95–102. 6. Lai X-H. Influence of taiji ball on health physical fitness and biochemical indexes of old people. J China Sport Sci Technol 2010;46:122–124. 7. Liu-Ambrose T, Khan KM, Eng JJ et al. Balance confidence improves with resistance or agility training. Gerontology 2004;5:373–382.
LETTERS TO THE EDITOR
985
8. Yong Z. The influences of taiji softball exercise with drug therapy in mild Parkinson’s patients on the rehabilitation. Fu Jian Sports Sci Technol 2009;28:15–20. 9. Manor B, Wolenski P, Li L. Faster walking speeds increase local instability among people with peripheral neuropathy. J Biomech 2008;41:2787–2792. 10. Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) scale. J Gerontol A Biol Sci Med Sci 1995;50A:M28–M34.
ALZHEIMER’S DISEASE COOPERATIVE STUDY PREVENTION INSTRUMENT PROJECT ASSESSING RESOURCE USE AND VOLUNTEER AND PAID WORK IN HEALTHY ELDERS: A LONGITUDINAL STUDY To the Editor: Therapy for dementia is rapidly shifting to prevention as recognition grows that interventions at the time of symptoms may be “too late.”1 A major challenge in designing prevention trials is the measurement of subtle changes at presymptomatic stages of the disease. Currently available instruments are designed for individuals with dementia and may not be sufficiently sensitive to measure changes in asymptomatic individuals. To fill this gap, the Alzheimer’s Disease Cooperative Study (ADCS) conducted a 4-year simulated prevention trial, the Prevention Instrument (PI) Study, to develop instruments capable of capturing changes that occur as elderly adults transition from normal aging to the earliest stages of cognitive and functional impairment.2 Among these instruments is the Resource Use Inventory (RUI), designed to assess health-related resource use (e.g., hospitalizations, doctor visits, informal care). A unique aspect of the RUI is the addition of items that assess subjects’ participation in productive activities. Specifically, the RUI asks about subjects’ participation in volunteer and paid work and, for those who participated, hours of participation. An earlier study demonstrated that the RUI was sensitive to demographic and clinical characteristics in an elderly population without dementia. Feasibility, reliability, and efficiency of administering the RUI at home have also been reported.3 Active and socially integrated lifestyles have been shown to be associated with better cognitive status,4–6 but whether subtle differences in cognition affect participation in productive activities, such as volunteerism and participation in the workforce, is yet to be documented. As retirement age is delayed and demand for volunteerism and continued participation in the workforce grows, preventing cognitive impairment and maintaining paid or volunteer work efforts may become an increasingly important component of the economics of cognitive impairment. The current study used data from the PI Study to examine participation in volunteer and paid work over 4 years. Subjects were recruited from 39 ADCS sites in the United States. At study entry, subjects were aged 75 and older, living in the community, without dementia, in good physical and mental health, with no exclusionary medical conditions, and not taking any excluded medications. Cognitively normal subjects (Clinical Dementia Rating (CDR) = 0) and subjects with mild cognitive impairment (MCI, CDR = 0.5) were included and followed for
LETTERS TO THE EDITOR
MAY 2014–VOL. 62, NO. 5
JAGS
(Timed Up-and-Go), computerized dynamic posturography assessment, and balance confidence assessment (ActivitiesSpecific Balance Confidence (ABC) Scale).
EFFECTS OF LONG-TERM TAI CHI BALL PRACTICE ON BALANCE PERFORMANCE IN OLDER ADULTS To the Editor: Balance decreases with age, resulting in greater risk of falls for people aged 65 and older.1 Physical activity can address some aspects of this age-associated physiological decline,2 with exercise programs that incorporate balance retraining having been found to improve postural stability.3 Tai chi has been reported as a safe and enjoyable form of exercise that could improve balance in community-dwelling elderly adults, decreasing the risk of falls.4,5 Another form of exercise that has become increasingly popular among many elderly people of Chinese descent is tai chi ball (TCB). TCB consists of more wholebody rotational and multisegmental circular movements than tai chi, with sequential weight shifting. TCB requires fine equilibrium control. A 12-month survey of the effect of TCB on postural balance of community-dwelling elderly women has provided information of unique value and is presented here.
METHODS Seventy-two elderly persons (mean age 65.4 6.9) were recruited from the community as the participants of the project. None had previous experience with TCB. The criteria for recruitment were age 60 to 70; ability to walk without support; and no symptoms of motor paresis, sensory deficits, vertigo, or uncorrectable visual defects. Participation was strictly voluntary. Participants were randomized into two groups: 36 who participated in TCB and 36 nonparticipating controls. Subjects in both groups participated in a physical exercise program. The training program was 12 months long, with three 1- to 2-hour sessions per week. Each session began with 5 minutes of warm-up and ended with 5 minutes of cool-down stretching exercises. The remaining time was devoted to TCB. The control group did not participate in TCB. Three clusters of outcome measures were used for each subject at baseline and 12 months later: static balance measures (unipedal and tandem stance), dynamic balance measures
RESULTS After 12 months of TCB, participant performance improved in the unipedal stance (F = 7.332, P = .009), tandem stance (F = 7.227, P = .009), and sensory organization test for balance measurements composite (F = 14.865, P < .001) and on the visual (F = 5.922, P = .02) and vestibular (F = 6.425, P = .01) test and the ABC Scale (F = 8.486, P = .005) and worsened on the Timed Up-and-Go (F = 4.751, P = .03). After 12 months, the performance of the control group worsened on the Timed Up-and-Go (F = 6.34, P = .01); no other changes were observed (Table 1).
DISCUSSION The aim of this study was to compare changes in balance ability and balance confidence of TCB participants with those of a control group. TCB includes a series of graceful movements, constant weight shifting with different rotational and multi-segmental circular movements, and changes in the base of support from double- to single-leg standing and is known for its particular benefit to balance function. Analysis indicated that static balance performance (unipedal and tandem stance) improved significantly after a 12-month TCB intervention. This finding is consistent with those of a previous report.6 Dynamic balance performance data analysis showed that mean Timed Up-and-Go had decreased significantly in both groups 12 months later. TCB had a positive effect on muscle strength, endurance and muscle reaction time are likely to have contributed to the improvement in the walking speed,7,8 and daily walking of the control group is likely to have contributed to their improvement in walking speed.9 Computerized dynamic posturography indicates the relative importance and proper use of sensory inputs,
Table 1. Performance Measure Scores over Two Repeated Tests According to Group Tai Chi Ball Pretest
Control 12 Months
11.7 18.6 7.3 73.3
0.2 0.2 0.4 1.1
13.7 20.6 6.4 78.8
0.3b,d 0.3b,c 0.2 2.7b,c
11.7 18.4 7.2 74.2
0.2 1.2 0.3 2.9
12.1 20.0 6.6 74.4
0.2 2.0 0.2a 3.9
73.5 96.8 79.1 67.1
1.2 2.9 5.9 3.0
82.9 97.2 87.0 75.5
2.8b,d 2.9 4.2b,d 1.3a,c
74.7 96.4 80.4 69.8
2.9 3.2 5.1 3.2
75.7 97.0 81.3 70.1
3.4 3.6 4.5 3.7
P < .05 compared with baseline. P < .01 compared with baseline. c P < .05 tai chi ball compared with control after 12 months. d P < .01 tai chi ball compared with control after 12 months. a
b
12 Months
Mean Standard Deviation
Measure
Unipedal stance, seconds Tandem stance, seconds Timed Up-and-Go, seconds Activities-specific balance confidence score Sensory organization test for balance measurements Composite Somatosensory Visual Vestibular
Pretest
JAGS
MAY 2014–VOL. 62, NO. 5
namely, somatosensation, vision, and vestibular sensation. The present study showed that the TCB group had greater improvement in their vestibular score (12.1%) than controls (0.51%); there was a significant difference between the TCB and control groups after the 12-month intervention. Practicing TCB involves head movements that could stimulate the vestibular system through head and body rotation and fixation of the eyes on the moving ball during the practice of its many forms.8 The finding showed that 12 months of TCB exercise improved visual and composite scores. The result is consistent with improvement in balance using tai chi as a form of exercise.4,5 The average ABC Scale score of the TCB group increased after 12 months of intervention (mean change 7.3%). This change was similar to that reported in the only other progressive resistance training intervention study to have administered the ABC Scale (mean change 6%).10 The results suggest that it is possible to recommend a TCB program for 12 months to significantly improve balance confidence. These findings have demonstrated that a TCB intervention was both effective for community-dwelling elderly persons in improving balance performance in relation to falls and might delay the onset of deterioration of motor function. These findings can contribute to the future planning of community-based exercise programs. Chun-Mei Xiao, MA Department of Health Promotion and Physical Education, Beijing Institute of Graphic Communication, Beijing, China
ACKNOWLEDGMENTS Conflict of Interest: The author has declared no conflict of interest. Author Contributions: Chun-Mei Xiao: study concept and design, performed the experiments, acquisition of subjects and data, analysis and interpretation of data, preparation of first draft and final manuscript. Sponsor’s Role: No funding was received for this study.
REFERENCES 1. Feder G, Cryer C, Donovan S et al. Guidelines for the prevention of falls in people over 65. The Guidelines’ Development Group. BMJ 2000;321:1007–1011. 2. Skelton DA, Dinan SM. Exercise for falls management: Rationale for an exercise programme to reduce postural instability. Physiother Theory Pract 1999;15:105–120. 3. Hill K, Smith R, Fearn M et al. Physical and psychological outcomes of a supported physical activity program for older carers. J Aging Phys Act 2007;3:257–271. 4. Li F, Harmer P, Mack KA et al. Tai chi: Moving for better balance-development of a community-based falls prevention program. J Phys Act Health 2008;5:445–455. 5. Wayne PM, Kaptchuk TJ. Challenges inherent to tai chi research: Part I— t’ai chi as a complex multicomponent intervention. J Altern Complement Med 2008;14:95–102. 6. Lai X-H. Influence of taiji ball on health physical fitness and biochemical indexes of old people. J China Sport Sci Technol 2010;46:122–124. 7. Liu-Ambrose T, Khan KM, Eng JJ et al. Balance confidence improves with resistance or agility training. Gerontology 2004;5:373–382.
LETTERS TO THE EDITOR
985
8. Yong Z. The influences of taiji softball exercise with drug therapy in mild Parkinson’s patients on the rehabilitation. Fu Jian Sports Sci Technol 2009;28:15–20. 9. Manor B, Wolenski P, Li L. Faster walking speeds increase local instability among people with peripheral neuropathy. J Biomech 2008;41:2787–2792. 10. Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) scale. J Gerontol A Biol Sci Med Sci 1995;50A:M28–M34.
ALZHEIMER’S DISEASE COOPERATIVE STUDY PREVENTION INSTRUMENT PROJECT ASSESSING RESOURCE USE AND VOLUNTEER AND PAID WORK IN HEALTHY ELDERS: A LONGITUDINAL STUDY To the Editor: Therapy for dementia is rapidly shifting to prevention as recognition grows that interventions at the time of symptoms may be “too late.”1 A major challenge in designing prevention trials is the measurement of subtle changes at presymptomatic stages of the disease. Currently available instruments are designed for individuals with dementia and may not be sufficiently sensitive to measure changes in asymptomatic individuals. To fill this gap, the Alzheimer’s Disease Cooperative Study (ADCS) conducted a 4-year simulated prevention trial, the Prevention Instrument (PI) Study, to develop instruments capable of capturing changes that occur as elderly adults transition from normal aging to the earliest stages of cognitive and functional impairment.2 Among these instruments is the Resource Use Inventory (RUI), designed to assess health-related resource use (e.g., hospitalizations, doctor visits, informal care). A unique aspect of the RUI is the addition of items that assess subjects’ participation in productive activities. Specifically, the RUI asks about subjects’ participation in volunteer and paid work and, for those who participated, hours of participation. An earlier study demonstrated that the RUI was sensitive to demographic and clinical characteristics in an elderly population without dementia. Feasibility, reliability, and efficiency of administering the RUI at home have also been reported.3 Active and socially integrated lifestyles have been shown to be associated with better cognitive status,4–6 but whether subtle differences in cognition affect participation in productive activities, such as volunteerism and participation in the workforce, is yet to be documented. As retirement age is delayed and demand for volunteerism and continued participation in the workforce grows, preventing cognitive impairment and maintaining paid or volunteer work efforts may become an increasingly important component of the economics of cognitive impairment. The current study used data from the PI Study to examine participation in volunteer and paid work over 4 years. Subjects were recruited from 39 ADCS sites in the United States. At study entry, subjects were aged 75 and older, living in the community, without dementia, in good physical and mental health, with no exclusionary medical conditions, and not taking any excluded medications. Cognitively normal subjects (Clinical Dementia Rating (CDR) = 0) and subjects with mild cognitive impairment (MCI, CDR = 0.5) were included and followed for
