By Dr Paul Lam, Dr Pamela Kircher and Maureen Miller
© Copyrights 2009 Dr Paul Lam. All rights reserved, except copy for non-profit making educational purpose. For example, you may make copies for your fee-paying students as long as no fee is charged for this material.
An Evidence Based ApproachOne in three adults over the age of 65 takes a fall each year, according to the US Center for Disease Control and Prevention. Treatment of injuries, due to falls, is rapidly moving up the list of most expensive health conditions. In 2000, the total direct cost, of fall injuries for people 65 and older, exceeded $19 billion. This financial toll is expected to increase, as the population ages, and may reach $54.9 billion by 2020 (adjusted to 2007 dollars).
There are many studies on measures to prevent falls. A recent review of 111 randomised trials involving over 55,000 subjects singled out exercising in supervised groups, participating in tai chi, and carrying out individually prescribed exercise programs at home to be effective. The researchers concluded that the effect of exercise programs in reducing the risk and rate of falling should now be regarded as established. This extensive study also found little or no clear evidence that some other interventions such as; drug dose adjustments, home safety interventions, or re-mediation, reduced falls.
Despite robust evidence indicating that practicing tai chi is one of the most effective ways to prevent falls, there remain sceptics who see tai chi as too gentle an exercise to have such significant effects. True, tai chi movements appear to be gentle and graceful, but tai chi is more than what meets the eyes. The flowing movements contain much internal strength, not unlike the power beneath a seemingly calmly flowing river. The objective of tai chi is to achieve physical balance by strengthening muscles and improving co-ordination, while at the same time improving mental balance.
A number of studies indicate that being confident results in having less falls, since the fear of falls increases the risk of falling. One could conclude, then, that practicing a mind-body exercise, such as tai chi, has added effect of helping to alleviate the fear of falling.
Modified Tai Chi for fall prevention
In 2000, the Accident Compensation Corporation (ACC) in New Zealand, a national government body that has a no-fault policy and compensates all accidents and injuries in the country, realised that prevention is often much cheaper than treatment. Their medical experts recommended using tai chi, among other specific exercises, to prevent falls. Being new to tai chi, the ACC’s initial foray into contracting for tai chi instruction was met with several major challenges. The initial instructors taught different styles of tai chi making it difficult to assess outcome and enforce safety standard. For example, the main provider, who franchised half of the instructors nationally, based the teaching on Chen style, which was too complex and martial. Also the teaching methodology was inappropriate and contained a high risk of injury for older adults. However, once the ACC adapted a less complex and easier to learn tai chi program — a Modified Tai Chi program — more positive results were obtained. This Modified Tai Chi program was an adaption of the Tai Chi for Arthritis program created by Dr. Paul Lam, in 1997. It was brought to the attention of the ACC by nurse and arthritis educator, Susan Fry, who studied under the tutelage of Dr. Lam in Sydney, Australia.
As the ACC discovered, tai chi encompasses a vast number of styles and forms. Plus there are a myriad ways of teaching tai chi. So, in translating medical evidence to benefit a community, not only is content important, but equally so is the teaching method applied. Therefore, the ACC worked with Dr Lam to install a training program that included safety and quality control. Within a year, instructors were trained and excellent quality maintained with minimal cost. By 2009, approximately 80% of the ACC teachers were using the Modified Tai Chi program.
Evidence for the Modified Tai Chi program for fall prevention
Many published tai chi studies do not specify standardised, replicable tai chi content and methods of teaching. Since there are a variety of tai chi styles and forms, the contents and the method of delivery will often determine the outcome. For example, some studies involve the use of only one teacher. What would be the result if a different teacher were used? In contrast, all studies using the Modified Tai Chi program include clearly defined tai chi contents and standardised training of teachers. Some also include quality control monitoring. As a result, a number of governmental bodies in Australia and other countries are using this program for fall prevention.
In the early 2000s, it was determined that hospital expenses incurred following fall related injuries were costing New South Wales Health, Australia, over 324 million (Australian) dollars a year—an amount far higher than from injuries of any other source, including road trauma. In an attempt to lower these costs, the Rural Falls Injury Prevention Program adopted the Modified Tai Chi program as a service to the community. Libby Godden, Rehabilitation Co-ordinator for Forbes Health Service, implemented the program in 2004. For the next two years, approximately 20% of the population of the town of Forbes participated in tai chi classes. Of the 576 persons, age 65 or over, who participated, a qualitative evaluation of their health improvement was undertaken. The evaluation, which sampled 31 participants, found that 99% had improved balance and flexibility and 100% improved strength.
"The program won the 2006 Greater Western Area Health Service award," Godden reports.
In addition to the New South Wales Health Department, the Aged Care Department in Victoria, the South Australia Health Department, and Sport and Creation Department have funded training for this program.
The largest tai chi for fall prevention study, in a community setting, was published by the American Journal of American Geriatric Society. It used 80% of the Modified Tai Chi program and found that recurring falls were reduced by nearly 70%. The study also found that building confidence — a fundamental component of the Modified Tai Chi program — correlates closely to the reduced rate of falling.
A study published by the Journal of Rheumatology with 72 patients randomly assigned into a control and tai chi group, compared a tai chi group to a control group. It found that the tai chi group had 35% less pain, 29% less stiffness, and 29% more ability to perform daily tasks (like climbing stairs). Additionally, balance improved by 30%.
A Korean study of the use of the Modified Tai Chi program found it specifically improved balance and reduced risks of falls significantly with the older adults.
Probably the most interesting study for translational work was commissioned by ACC to determine the effectiveness of tai chi practice in preventing falls. This currently unpublished study examined 1000 subjects from classes across New Zealand and concluded that participation in the Modified Tai Chi program does have a positive impact on participants’ balance and stability and decreases their likelihood of suffering a fracture as a result of a fall. In fact, the overall trend was a decrease in the number of falls and resultant fractures experienced by participants between the initial and final assessments.
There are other factors that make the Modified Tai Chi program so successful. For example, adherence is often a major issue for exercise to succeed in improving health. If people don’t like an exercise, they will quickly stop doing it. The Modified Tai Chi program incorporates a teaching system which encourages enjoyment, positive feedback and a sense of achievement. This could be why the program has such a high adherence rate.
Reduce the burden of chronic disease.
Investing in tai chi programs can have cost savings in other areas. As the practice of tai chi improves many aspects of health, it can be an ideal preventive intervention. The U.S. National Institute of Health’s National Center for Complementary and Alternative Medicine suggests that people practice tai chi for a variety of health-related purposes, such as:
The largest study about the practice of tai chi by people with arthritis was published in the Arthritis Care and Research Journal. It found that Modified Tai Chi not only reduces pain, but also improves the quality of life. It has also been found to improve standing balance for people with strokes as well as six out of eight measurements of quality of live for older adults. Another study, recently accepted to be published by the Journal of Alternative and Complementary Medicine, followed 82 older women divided into tai chi and control groups. After six months, those practicing tai chi significantly increased knee extensor endurance and bone mineral density and had less fear of falling than the control group.
The May 2009 issue of the Harvard Health Newsletter suggests that while tai chi is often described as "meditation in motion", it might well be called "medication in motion". For, in addition to preventing falls, tai chi programs have been shown to be helpful for a number of medical conditions including: arthritis, low bone density, breast cancer and it’s side effects, heart disease and failure, hypertension, Parkinson’s disease, sleep problems, and stroke.
"A growing body of carefully conducted research is building a compelling case for tai chi as an adjunct to standard medical treatment for the prevention and rehabilitation of many conditions commonly associated with age," says Peter M. Wayne, assistant professor of medicine at Harvard Medical School and director of the Tai Chi and Mind-Body Research Program at Harvard Medical School’s Osher Research Center.
Tai Chi, is an evidenced based exercise. It helps to prevent falls and improve health and the quality of life. In utilising tai chi for health, it is important to consider the contents and delivery method for an effective translation of scientific data into real benefits to the community at large.
In a 2008, a Milken Institute report noted that the annual economic impact on the U.S. economy of the most common chronic diseases is calculated to be more than $1 trillion. However, if the impact of seven chronic diseases - diabetes, pulmonary conditions, hypertension, mental disorders, heart disease, cancers and stroke — could be prevented, by mid-century the annual GDP could be reduced by six trillion dollars a year.
Based on the research, it is probable that the use of Modified Tai Chi programs could prevent and/or improve the management of such chronic diseases, particularly for our ageing population, and, thus, be an effective measure to save significant health care costs.