Falls prevention
Is t’ai chi really that good for you? FitPro reviews the latest research with specific emphasis on the evidence for improved joint proprioception, falls prevention and healthy ageing.
One of the most recent systematic reviews of the evidence for the effects of t’ai chi on health outcomes acknowledges that research interest in t’ai chi has increased dramatically in the last six years1. However, to complicate matters, the authors of this review – Michele Solloway and colleagues − note that, “Many forms of t’ai chi exist, but in western culture it is most commonly taught as a series of slow, gentle, low-impact movements that integrate the breath, mind and physical activity to achieve greater awareness and a sense of inner peace and well-being. The meditative movement is designed to strengthen and stretch the body, improve the flow of blood and other fluids, improve balance, proprioception, and awareness of how the body moves through space, and it may be practised in a group format or alone.”
“Exercise was by far the most effective intervention to reduce falls in older adults”
t’ai chi – in all its formats – is widely recommended as a very practical physical activity intervention for healthy ageing. However, and despite apparent widespread support, there exist points of contention among researchers. For example, in a review of the effectiveness of non-pharmacological interventions to prevent falls in older people2, Joseph Rimland and co-researchers argue that, “Exercise was by far the most effective intervention to reduce falls in older adults, although not all types of exercise were equally effective in all participant groups and in all settings. Effective exercise programmes to prevent falls include a combination of demanding and progressive balance exercises carried out in weight-bearing positions, with lower limb strength training … in some instances, exercise is effective only among a sub-set of trial participants. For example, t’ai chi was effective only when performed by people at low risk of falling. Since t’ai chi involves maintaining specific positions to increase balance and muscle strength, this type of exercise could be more challenging for people with poor balance, dizziness and postural hypotension.”
In a paper that takes a public health perspective on t’ai chi and falls prevention, Judy Stevens and colleagues argue that, “t’ai chi is a plausible approach for reducing falls; it is well suited for older adults because it is a moderate-intensity exercise that consists of continuous, rhythmic and low-impact movements. t’ai chi addresses a number of important fall risk factors by improving leg strength, balance, co-ordination, postural control, mobility and reducing fear of falling.”
These researchers additionally report that randomised controlled trials both in Australia and the US have shown a reduction in falls in older adults. They also acknowledge that not all studies have found t’ai chi to be effective in reducing falls, “For some ineffective t’ai chi interventions, participants may not have obtained a sufficient ‘dose’; participants may have attended classes infrequently or the programme may not have continued long enough to demonstrate effectiveness.”3 The emphasis in the conclusion to this paper is one that all fitness professionals will recognise: not everyone wants to do the same physical activity, exercise programme or falls prevention intervention and, even when they do, the programme must be adapted to meet individual needs and abilities.
t’ai chi and joint proprioception
One paper that most researchers include in their literature review focuses on t’ai chi and joint proprioception and stability in the elderly4. The authors, William Tsang and Christina Hui-Chan, define proprioception as “a sense of position and movement of one’s own limbs and body in the absence of vision, termed limb-position sense and kinaesthesia respectively.”
They point out that, “Limb proprioception is mediated via cutaneous receptors in the skin and proprioceptors in muscles, tendons, ligaments and joints, signalling to the central nervous system both the stationary position of a limb and the speed and direction of limb movement.” Unfortunately, with advancing age, limb proprioception diminishes. In addition, some conditions affecting the elderly (such as stroke and osteoarthritis) will also impair proprioception.
t’ai chi emphasises exact joint and limb positioning plus controlled movement in specified directions and involves precisely controlled weight transfer in both double and single leg stances. This study set out to investigate whether practitioners of t’ai chi had better knee joint proprioception compared with control subjects. In addition, the ability of subjects to control body sway was determined along with an investigation of any relationship between knee joint proprioception, static standing, and the limits of stability during weight transfer.
A total of 42 participants were involved in the study; 21 were elderly t’ai chi practitioners who had been practising t’ai chi for a minimum of 1.5 hrs each week for at least three years, and 21 were elderly active individuals who had no experience of t’ai chi and acted as controls. All were independent, healthy, and had no history of falls in the previous 12 months. All participants were tested for knee joint proprioception by determining their lowest threshold for detecting joint movement and by their ability to match limb positions without the aid of vision (known as a passive joint repositioning test). A static standing balance test lasting 30 seconds was developed using a force plate. Finally, in a ‘limits of stability’ test, two force plates were used with eight target positions shown on screen that each subject had to meet through controlled weight transfer. Data collected from this test included reaction time, maximum excursion, and directional control.
From the results of this study, the researchers concluded that the t’ai chi practitioners studied had a heightened sense of knee joint proprioception – they believe through practising slow movements in which the body and limbs have to be placed accurately and precisely. While the results from the static balance test were similar in both groups, the dynamic balance test − in which participants had to lean quickly and smoothly, and as far as possible towards eight different targets − showed that the t’ai chi practitioners appeared to have greater dynamic balance control.
This last test has previously been used as a predictor of performance in functional activities of daily living and is believed to play a role in indicating one’s susceptibility to falls. Therefore, say the authors, “Because our study showed that long-term t’ai chi practitioners achieved greater limits of stability, they are likely to have relevant functional activities enhanced and/or the possible occurrence of falls minimised.” Finally, the knee joint positioning data arguably emphasises the importance of accurate knee joint position sense in functional activities.
Age UK: falls prevention
“Falls destroy confidence, increase isolation and reduce independence, with around 1 in 10 older people who fall becoming afraid to leave their homes in case they fall again”
Fitness professionals with an interest in healthy ageing and falls prevention will find that extremely helpful, evidence-based resources are freely available from Age UK5. In Age UK’s dedicated section on the topic, the first downloadable resource, Falls Prevention Exercise – following the evidence, is from its ‘Expert Series’ for health professionals. This 24-page guide provides the facts regarding falls in older people, reviews and summarises the evidence for falls prevention exercise, and provides examples of evidence-based programmes.
The facts are startling:
- Falls and fractures in people aged 65 and over account for more than four million hospital bed days each year in England alone
- The healthcare cost associated with fragility fractures is estimated at £2 billion a year
- Injurious falls, including 70,000 hip fractures annually, are the leading cause of accident-related mortality in older people
- After a fall, an older person has a 50% probability of having their mobility seriously impaired and a 10% probability of dying within a year
- Falls destroy confidence, increase isolation and reduce independence, with around 1 in 10 older people who fall becoming afraid to leave their homes in case they fall again
- A tailored exercise programme can reduce falls by as much as 54%
In the resource, Don’t Mention the F-Word, Age UK stresses the importance of emphasising the benefits of exercise – including balance and mobility – to older people, rather than necessarily talking about falls prevention. Its research indicates that falls prevention advice may be disregarded by older people for a number of reasons. Many over-75s, for example, consider this advice to be relevant only to people older and frailer than themselves.
A third downloadable booklet, Stop Falling: Start Saving Lives and Money, re-iterates the facts, emphasising that a fall can hasten a move into residential care. This document makes the observation, based upon a further review of the evidence, that, “If all over-65s followed a tailored exercise programme, we would prevent 7,000 unnecessary deaths a year – 19 a day – from hip fractures alone.” In the section on advice to stay active, Age UK reinforces the general physical activity guideline that everyone should participate in physical activity for at least 30 minutes on five or more days a week. In addition, they provide additional recommendations for older people. All people in later life should undertake physical activities to improve muscle strength at least twice a week, in addition to the primary recommendation of 150 minutes.
Activities can include heavy gardening or dancing, and need not be undertaken as gym-based exercise. Older adults at risk of falls should also undertake physical activity involving balance training on two or more days per week for the prevention of falls. This should be in addition to the primary recommendation of 150 minutes, although some aerobic activities can also enhance balance (e.g., dancing), and some movements simultaneously strengthen muscles and improve balance (e.g., t’ai chi). Also in this resource section are the ProFouND (Prevention of Falls Network for Dissemination) Falls Intervention Prevention factsheets (collated as one document). ProFouND is an EU-funded project on evidence-based best practice interventions to prevent falls in older people living in the community across Europe. It involves 21 partners in 12 countries. This resource includes guidance on multifactorial interventions and factsheets on exercise, vision, bone health, vitamin D, home and environment, footwear and protective clothing, and falls detection and prevention technologies.
If you enjoyed this research review, why not take a look at this analysis of resistance training.
References:
- Solloway, M.R. et al(2016) An evidence map of the effect of Tai Chi on health outcomes, Systematic Reviews, 5:126.
- Rimland, J.M. et al(2016) Effectiveness of non-pharmacological interventions to prevent falls in older people: a systematic overview. The SENATOR Project ONTOP series, PLoS ONE, doi: 10.1371/journal.pone.0161579.
- Stevens, J.A. et al(2014) Preventing falls with Tai Ji Quan: a public health perspective, J Sport Health Sci. 3(1):21-26.
- Tsang, W.W.N. and Hui-Chan, C.W.Y. (2003) Effects of Tai Chi on Joint Proprioception and Stability Limits in Elderly Subjects, Sci. Sports Exerc.35(12):1962-1971.
- age.org.uk/professional-resources-home/services-and-practice/health-and-wellbeing/falls-prevention-resources/, accessed 3 January 2017.
