Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
SUMMARY POINTS
- Li et al randomized 670 older adults determined to be at high risk of falling into one of three interventions: Tai Ji Quan: Moving for Better Balance (TJQMBB), multimodal exercise (MME), or stretching exercise program.
- The primary outcome was incidence of moderate to severe injurious falls at 12 months, representing the culmination of a six-month period of active intervention and six months of follow-up.
- There were 102 serious injurious falls documented in the entire group: 15 in the TJQMBB arm, 32 in the MME arm, and 55 in the stretching group.
- For moderate injurious falls (strains or sprains but no hospital admission), the TJQMBB and MME groups both showed significant advantage over the stretching exercise group. There was no significant difference between the two interventions (TJQMBB and MME).
- For severe injurious falls (hospital or emergency department admission), both the TJQMBB and MME groups showed a significant advantage over the stretching group. The TJQMBB group also showed a significant greater reduction in these types of falls vs. the MME group.
SYNOPSIS: In this three-arm study, a therapeutic form of Tai ji quan is superior to either a multimodal exercise or a stretching program in reducing severe injurious falls among at-risk older, community-dwelling Americans.
SOURCE: Li F, Harmer P, et Eckstrom E, et al. Effectiveness of Tai ji quan vs multimodal and stretching exercise interventions for reducing injurious falls in older adults at high risk of falling: Follow-up analysis of a randomized clinical trial. JAMA Netw Open 2019;2:e188280.
The top cause of injury in older Americans is falls. Reported in almost 30% of community-dwelling adults older than 65 years of age, the economic effect of this potentially preventable problem is considerable and growing. In 2015, the healthcare-related cost of falls was $50 billion yearly, and it is projected to reach almost $70 billion by 2020 as the population ages.1,2
Researchers have determined that exercise is helpful in reducing the severity and incidence of falls, but evidence-based investigations with specific recommendations regarding the type and frequency of optimal intervention are in short supply. To address this growing public health problem, Li et al set the goal of determining if Tai Ji Quan: Moving for Better Balance (TJQMBB) was more effective and efficient than other more conventional exercise programs for preventing falls in the at-risk population and, more specifically, for preventing falls resulting in moderate to severe injuries.
Tai ji quan, also known as tai chi, has evolved into multiple branches and styles since originating more than 300 years ago in the Henan province in China. Moving away from its origins under the general umbrella of martial arts, this stylized mind-body technique involving movement, breath, and spirit is recognized widely for its inherent health benefits.3
This work by Li et al is a follow-up to an earlier published study describing a six-month randomized, controlled trial involving TJQMBB, a multimodal exercise program (MME), and a stretching program.3 The authors randomized 670 older adults meeting inclusion criteria to one of three study arms: TJQMBB, MME, or stretching exercises. All interventions occurred twice weekly for 60 minutes.
Eligible participants included community-dwelling adults 70 years of age or older who either had fallen in the year preceding the study, had a health provider referral indicating an elevation in fall risk because of recent falls or other factors, or had measurable impaired mobility indicated by a standardized timed test (Timed Up and Go).
In this original six-month study, both TJQMBB and MME were significantly superior to the stretching exercise program for reducing falls in an at-risk population. When comparing the TJQMBB and MBB groups head to head at six months, fall rates in the TJQMBB group were 31% lower than in the MBB group.
Li et al continued the study past the intervention phase for a six-month follow-up period, during which time there was no active intervention. The group collected data monthly and analyzed the incidence of moderate and injurious falls among the participants at the end of 12 months (six-month intervention and six-month follow-up).
In the study protocol, all participants were asked to maintain a daily “fall calendar.” Attrition and dropout from the study was low across all groups; at the end of 12 months, data for outcomes was available from 94.6% of the group.
Interventions
TJQMBB is a specialized program, derived from tai chi (more properly known as Tai ji quan) and developed specifically as a therapeutic intervention for fall prevention. It incorporates eight modified Tai ji quan exercises and maintains a focus on breathing and movements, emphasizing weight shifting, balance, alignment, and rotation. MME involved a structured combination of aerobic exercise and interventions geared toward increased flexibility, strength, and balance. This group began using gym machines and tools such as hand weights by month 4. The stretching exercise intervention included breathing, stretching, and relaxation programs, mostly in a seated or prone position. All interventions were twice weekly for 60 minutes for 24 weeks. Each intervention included a standard structure of warm-up, core exercise, and cool-down.
Results
Moderate injurious falls were defined as falls resulting in sprains, strains, or abrasions without the need for medical assistance or care. Severe injurious falls were falls resulting in hospitalization or an emergency department encounter. Records documenting the visit were collected when available.
Table 1 depicts incident rate ratios (IRR) adjusted for multiple covariates, including age, health status, number of falls prior to the study, and level of exercise after the six-month intervention period. Notably, the groups practicing TJQMBB and MBB showed a reduction in moderately injurious and severe injurious falls when compared with the stretching group. When comparing the TJQMBB and MME arms head to head, there was no significant difference in incidence of moderate injurious falls. When looking at severe injurious falls, there was a significant reduction of such falls in the TJQMBB group (P = 0.03). (See Table 2.)
Table 1: Adjusted IRR After 6 Months of Intervention and 6-Month Follow-Up |
|||
Adjusted IRR |
95% Confidence Interval |
P Value |
|
|
Moderate Injurious falls Month 12: TJQMBB vs. stretching |
0.53 |
0.36-0.76 |
0.001 |
|
Moderate Injurious falls Month 12: MME vs. stretching |
0.65 |
0.45-0.94 |
0.02 |
|
Moderate Injurious falls Month 12: TJQMBB vs. MME |
0.85 |
0.58-1.25 |
0.42 |
|
Severe Injurious falls Month 12: TJQMBB vs. stretching |
0.25 |
0.13-0.48 |
< 0.001 |
|
Severe Injurious falls Month 12: MME vs. stretching |
0.56 |
0.33-0.94 |
0.03 |
|
Severe Injurious falls Month 12: TJQMBB vs. MME |
0.47 |
0.24-0.92 |
0.03 |
|
IRR: incident rate ratio; TJQMBB: Tai Ji Quan: Moving for Better Balance; MME: multimodal exercise program |
|||
Table 2: Numbers of Falls and Number of Participants |
|||
Number of Participants |
Moderate injurious Falls
|
Severe Documented Injurious Falls After 12 months(P = 0.001) |
|
|
TJQMBB |
224 |
127 |
15 |
|
MME |
223 |
148 |
32 |
|
Stretching Group |
223 |
232 |
55 |
|
P values represent overall between-group differences in the mean number of falls in each category. The intervention groups have significantly fewer mean injurious falls than the stretching or control group. TJQMBB: Tai Ji Quan: Moving for Better Balance; MME: multimodal exercise program |
|||
COMMENTARY
Falls are the top cause of injury and death in older Americans and the second leading cause of accidental death worldwide.1,2 Addressing this issue at the root of the problem requires developing a multipronged strategy; prevention must serve as the linchpin.
Li et al clearly recognized the importance of offering an evidence-based program to address fall prevention. Their work, published in two parts, is best viewed as one study progressing from a randomized, clinical trial looking at fall incidence among three intervention groups to a more nuanced look at the numbers by analyzing the incidence of injurious falls among these same three groups: TJQMBB, MME, and stretching.
The protocol used for the intervention groups attempted to match structure of the instruction and frequency. During the six-month follow-up period, information about exercise frequency revealed no significant differences between the three groups. It still is possible that subtle between-group differences in the delivery method or factors other than the intervention itself were significant in affecting fall incidence. Future studies with larger numbers, more rigorous methods of controlling interventions, and more advanced mechanisms to quantify falls will be helpful in advancing this field.
Although perhaps inadvertent, this study puts a spotlight on the sheer number of injurious falls in at-risk community-dwelling older adults. The aftermath of falls may range from inconvenience to hospitalization, from disability to death — making the case for fall prevention quite compelling.1,2 With 232 moderately injurious falls in the stretching group of 223 participants, it is clear that there was more than one fall per group member. Investigating the number of falls per person would be useful in further understanding the effect of each intervention and determining any subgroup more or less likely to respond.
With the significant reduction in severe injurious falls in the TJQMBB group at month 12, it is interesting to consider that there may be specific benefits in either fall prevention or strengthening from this intervention. As there was no significant difference between the TJQMBB group and the MME group in the incidence of moderate injurious falls, it may be that the TJQMBB intervention helped protect participants from more severe injuries even with a fall. Understanding more about the effect and protective mechanism of TJQMBB is a target for future studies in this area.
It is notable that the incidence of falls in all groups appeared high compared to the 30% rate typically seen in the general population of older adults. Most likely, this is because the study population included high-risk adults by definition (this was part of the eligibility criteria). As we consider prevention efforts, it would be interesting to see if a more diverse population of older adults would perform similarly. Likewise, as age is one of the global risk factors for falls, broadening the study to other age groups could trigger early prevention interventions.
At this point, the information we have points to a role for specialized exercise, perhaps derived from Tai ji quan, to assist with fall prevention programs in the at-risk community-dwelling older population. Li et al did not review other specialized exercise programs for fall prevention, but there are several previous studies confirming the utility of Tai ji quan training in fall prevention.4 Citing these studies, the Centers for Disease Control and Prevention includes specialized forms of Tai ji quan (including TJQMBB) in the list of exercises for “effective fall prevention for community-dwelling older adults.”5
Although there are not many studies exploring fall prevention for other groups, such as nursing home residents or not yet at-risk patients, there is no reason to suspect that this type of intervention (modified Tai ji quan) cannot be helpful and convey protection in these and other populations. This study revealed no adverse effects from any of the interventions.
It seems a clear choice for providers to promote modified or other available Tai ji quan interventions to at-risk community-dwelling older adults and also to consider extending the recommendation to others who may fall outside this group. Partnering or establishing a basic familiarity with certified providers in the community may help assure quality and provide solid information about the types of Tai ji quan available for patients.
REFERENCES
- World Health Organization. Falls. Available at: https://www.who.int/news-room/fact-sheets/detail/falls. Accessed April 10,2019.
- National Council on Aging. Fall Prevention Facts. Available at: https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/. Accessed April 10, 2019.
- Guo Y, Qiu P, Liu T. Tai ji quan: An overview of its history, health benefits, and cultural value. Available at: https://www.sciencedirect.com/science/article/pii/S2095254613000999. Accessed May 15, 2019.
- Li F, Harmer P, Fitzgerald K, et al. Effectiveness of a therapeutic tai ji quan intervention vs a multimodal exercise intervention to prevent falls among older adults at high risk of falling: A randomized clinical trial. JAMA Intern Med 2018;178:1301-1310.
- Lan C, Chen SY, Lai JS, Wong AM. Tai chi chuan in medicine and health promotion. Evid Based Complement Alternat Med 2013;2013:502131.
- CDC. Home and Recreational Safety. Compendium of Effective Fall Interventions, 3rd Edition. Available at: https://www.cdc.gov/homeandrecreationalsafety/falls/compendium.html. Accessed May 15, 2019.
In this three-arm study, a therapeutic form of Tai ji quan is superior to either a multimodal exercise or a stretching program in reducing severe injurious falls among at-risk older, community-dwelling Americans.
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