Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
SUMMARY POINTS
- The authors of this meta-analysis presented results from 10 randomized, controlled studies regarding tai chi practice in at-risk and older adults, including more than 2,500 subjects between the ages of 56 and 98.
- The analysis showed high-quality evidence for medium protective effect for rate of falls in the short-term and a weaker protective effect over the long-term (after 12 months.)
- When looking at falls causing injury, there is low-quality evidence of a medium protective effect in the short term and even less of an effect in the long term.
- There is moderate-quality evidence that tai chi practice does not affect time to first fall.
SYNOPSIS: Tai chi practice in the older and at-risk population reduces the risk of falls (with the most robust results in the short-term) and may reduce the risk of injury from falls; no effect is seen when measuring time to the first fall.
SOURCE: Lomas-Varga R, Obrero-Gaitan E, Molina-Ortega FJ, Del-Pino-Cassado R. Tai chi for risk of falls. A meta-analysis. J Am Geriatr Soc 2017;65:2037-2043.
Falls and fall-related complications hold the dubious honor of ranking first as the primary cause of death via injury in older adults worldwide.1 It is no wonder that efforts to reduce the incidence of falls and injury from falls are underway. Exercise, environmental modification, and reduction of polypharmacy, especially in cases in which dizziness, sedation, or unsteady gait may occur, are among interventions proposed and studied to address this issue.2
Tai chi is a traditional Chinese systemic exercise program known for improving balance, flexibility, and endurance. It is one of several exercise programs that has produced promising preventive data from multiple studies. However, Lomas-Varga et al noted shortcomings and limitations, such as lack of control groups and small sample size, with many of the tai chi studies. Additionally, it is important to note that there are several major styles of tai chi and that practitioners may vary in skill and ability to teach.
This meta-analysis targeted recent randomized, controlled studies that looked at specific outcome points, including the effect of tai chi on the fall rate in general, the rate of injurious fall, and time to the first fall in a homogenous population of older and at-risk adults. Additionally, the effect of tai chi in both the short term (< 12 months) and long term were compiled using data from the appropriate studies.
From an initial pool of 891 references, 10 studies met the rigid eligibility criteria to be included in the final meta-analysis. All were randomized, controlled trials (RCT). Four of these studies included data on short-term results only, another four recorded long-term data, and one study contained both short- and long-term outcomes. Participants numbered just under 3,000 older adults between the ages of 56 and 98.
The quality of evidence backing the results of each study was evaluated based on a standard system — the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).3 Using these guidelines, quality of evidence was placed on a range stemming from very low to low, moderate (needing further research), and high (indicating that further research is unlikely to change confidence in the assessment of impact).
None of the included RCTs documented any adverse effect from the practice of tai chi. All of the studies included about an hour of practice time in each session. The frequency of sessions ranged from one to three times weekly; studies lasting less than 12 months were grouped separately from those continuing longer than one year. Documentation of the type or style of tai chi were not included in the final analysis.
Selected results are presented in Tables 1, 2, and 3. These results point to high-quality evidence (using the GRADE system) that the practice of tai chi may reduce the risk of fall by 43% in the short term, but that this effect is reduced in long-term follow-up to about 13%, although both results are statistically significant. The evidence toward risk of injurious fall reduction is low quality, as per the GRADE system and based on fewer studies. The time to first fall has moderate-quality evidence (GRADE) of no effect from tai chi
practice.
Table 1: Incidence of Falls |
||
|
Short-term Results |
Long-term Results |
|
|
Number of studies |
5 studies |
6 studies |
|
Number of subjects |
1,432 subjects |
1,546 subjects |
|
Incidence risk ratio |
0.57 (95% CI, 0.46-0.70) |
0.87 (95% CI, 0.77-0.98) |
|
Quality of evidence |
High |
High |
|
P value |
0.000 |
0.029 |
|
Falls risk reduction |
43% |
13% |
Table 2: Incidence of Injurious Falls |
||
|
Short-term Results |
Long-term Results |
|
|
Number of studies |
1 study |
1 study |
|
Number of subjects |
357 subjects |
334 subjects |
|
Incidence risk ratio |
0.50 (95% CI, 0.33-0.75) |
0.72 (95% CI, |
|
Quality of evidence |
Very low |
Very low |
|
Risk of bias |
Serious |
Serious |
|
Injurious fall risk reduction |
50% |
50% |
Table 3: Time to First Fall |
|
|
Number of studies |
5 studies |
|
Number of subjects |
1,320 subjects |
|
Incidence risk ratio |
0.98 (95% CI, 0.69-1.32) |
|
Quality of evidence |
Moderate |
|
P value |
0.883 |
COMMENTARY
The cost of falls in older adults is considerable and multifaceted. In 2015, direct healthcare costs associated with falls totaled more than $30 billion, while indirect costs due to factors such as disability, loss of independence, and reduced quality of life, magnified the effect of what often appears to be a preventable event.4 Modifiable risk factors include lower body weakness, deterioration of balance, poor vision, use of medications affecting balance and/or walking, and environmental factors, such as poor footwear and uneven floors.2,3
Primary care providers often are well-positioned to address many of these issues with patients at risk. Some of these factors require external modifications, such as changing footwear and/or critically looking at areas of risk within the home. Improving balance and lower body strength — two key areas in preventing falls and potentially reducing injury from falls — seem more suited to specific individual efforts. This meta-analysis points to promoting tai chi practice as a possible fall prevention intervention and gives some hard evidence of efficacy, at least in the short-term, but still leaves some unanswered questions.
There are five major styles of tai chi. The Yang style seems the most popular worldwide, and most likely to be the type of tai chi practiced in larger groups often seen in parks or gatherings. Movements tend to be slow and steady, as opposed to the older Chen style, which includes more energetic and faster movements interspersed with slower movements. The Sun style, on the other hand, concentrates almost entirely on internal movements and stillness.5 It is unfortunate that most of the studies do not mention or control for style, as the type of tai chi practiced may influence results.
The strength of this meta-analysis was the high number of studies and subjects, which allows the results to be generalized more readily. Only one qualifying study looked at either short- or long-term injurious falls, making these results less meaningful. Hopefully, future investigations of tai chi will focus not just on fall rate but also on the effect of injurious falls.
Although this meta-analysis included an impressive number of subjects, the authors noted that the studies varied in specific details. While statistical analysis controlled for heterogeneity, some of these details may affect clinical adaptation. In particular, a review of the studies in this meta-analysis revealed a range of control groups from “activity as usual” to specific exercise programs. A comprehensive 2017 review (also a meta-analysis) of fall prevention associated with a different exercise intervention (Step Training Program) revealed results similar to those found with tai chi.5 Notably, however, a 2011 Australian study found tai chi to be the most cost-effective intervention for fall prevention for community-dwelling older adults compared to several other interventions, including other exercise programs. Interestingly, medication review and vitamin D supplementation emerged as most cost-effective for older adults in residential facilities in this same study.6
Results of a 2017 Chinese meta-analysis, including 18 studies of tai chi and fall prevention, suggested that the impact of tai chi on fall prevention is more robust with exercise frequency.7 However, noting significant bias in some of the studies, the authors recommended future direction aimed at reducing bias and eliciting more data regarding length of sessions, number of practices weekly, and overall effect. Additionally, this group noted a variation in response to different types of tai chi and mentions a likelihood that the Yang style of tai chi may be more effective than the Sun style. More studies documenting specific style of tai chi are recommended.
The variability in the types of control groups among the studies, in the frequency of tai chi practice (from one to three times weekly), and unclear documentation of the type or style of tai chi make generalizability of results of this meta-analysis difficult. All of these factors may very well prove to be essential in understanding the effect of tai chi for any individual. Future studies paying particular attention to these details are needed.
Talking with older adults about fall prevention and recommending specific interventions is a vital component of medical care of the aging population. A 2017 public health study covering older adults in Hawaii suggested that this group tends to “deny their risk of falls before they actually fall” and, in general, view their own risk of falling more optimistically than statistics bear out.8 Efforts promoting risk reduction seem less relevant if the targeted population is not on board. One proposed solution is to promote the positives, such as “maintain your independence,” rather than warn about fall prevention per se.
Prevention of falls often requires a multipronged approach; the integrative provider is on solid ground reviewing both environmental and personal interventions with patients. Noting the positive results from tai chi studies, combined with an understanding of the limitations of these studies, can help shape a fall prevention strategy that suits each individual according to unique needs and circumstances. Developing such a plan with a focus on the positives may help with acceptance and buy-in. As future studies with more rigid criteria and results emerge, these recommendations and interventions can be adjusted accordingly, with the goal of helping our patients maintain a healthy lifestyle throughout the age continuum.
Although suggestive evidence points to best results from practice of the Yang style of tai chi several times weekly, many patients will find a specific choice of tai chi style and frequency, limited by practical considerations (such as community availability and scheduling). Even with specific questions remaining, the potential benefits from tai chi are clear. In the aging population and those at risk of significant health consequences from falls, waiting for results of more definitive studies may prove to be too late. With no identified adverse effects from tai chi and clear potentially devastating adverse health consequences from falls, promoting tai chi should be adopted as part of an overall strategy for fall prevention.
REFERENCES
- Cigolle CT, Ha J, Min LC, et al. The epidemiological data on falls, 1998-2010: More older Americans report falling. JAMA Intern Med 2015;175:443-445.
- World Health Organization. WHO Global Report on Falls Prevention in Older Age. Geneva: World Health Organization; 2007. Available at: http://www.who.int/ageing/publications/Falls_prevention7March.pdf. Accessed Nov. 1, 2017.
- Kavanagh BP. The GRADE system for rating clinical guidelines. PLoS Med 2009;6:e1000094. doi:10.1371/journal.pmed.1000094.
- Centers for Disease Control and Prevention. Costs of Falls Among Older Adults. Available at: https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html. Accessed Oct. 17, 2017.
- Beginners Tai Chi.com. Yang Tai Chi: The Most Popular Style. Available at: https://www.beginnerstaichi.com/yang-tai-chi.html. Accessed Nov. 10, 2017.
- Okubo Y, Schoene D, Lord SR, et al. Step training improves reaction time, gait and balance, and reduces falls in older people: A systematic review and meta-analysis. Br J Sports Med 2016;51:586-593.
- CSIRO Publishing. NSW Public Health Bulletin. An economic evaluation of community and residential aged care falls prevention strategies in NSW. Available at: http://www.publish.csiro.au/NB/NB10051. Accessed Oct. 20, 2017.
- Huang ZG, Feng YH, Li YH, Lv CS. Systematic review and meta-analysis: Tai chi for preventing falls in older adults. BMJ Open 2017;7:e013661.
- Yamazaki Y, Hayashida CT, Yontz V. Insights about fall prevention of older adults in the state of Hawai‘i. Hawaii J Med Public Health 2017;76:3-8.
Tai chi practice in the older and at-risk population reduces the risk of falls (with the most robust results in the short-term) and may reduce the risk of injury from falls; no effect is seen when measuring time to the first fall.
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