Fall prevention

[GeneChing]

There's probably several posts relevant to this topic but I'm not going to search them out right now. There's probably some in the Tai-Chi-as-medicine thread. Maybe later I'll copy them over at some future date. This WSJ article got me inspired to launch this thread because it is becoming such a major application of Tai Chi now.

How Tai Chi Can Help Conquer Fear of Falling as We Age
Researchers explore the power of exercise to help seniors overcome apprehension and stay active
Fear of falling causes many older people to shun physical activity, which perversely increases their risk of falls. WSJ health reporter Melanie Evans joins Tanya Rivero to discuss. Photo: Tamar Searles/La Paz County Health Department
Melanie Evans
May 23, 2016 1:10 p.m. ET

The odds of a bone-shattering fall increase with age, as muscles grow weak and vision fades.

Yet seniors who fear falling are at higher risk of falling, research shows, even if they have never taken a spill before. Those most fearful of falling may decide to avoid risk by avoiding activity—and then grow weaker and more likely to fall as a result.

“It can become this vicious cycle,” said Susan Friedman, a geriatrician at the University of Rochester Medical Center who studies falls and hip fractures among the elderly. Bad falls send about 250,000 seniors to the hospital each year for hip fractures that can leave them depressed and increasingly frail, even after extensive physical therapy.

Research on fall prevention suggests the slow and meditative exercise of tai chi, with its disciplined focus on balance, may help lessen apprehension.

In Arizona, the state’s Healthy Aging Program launched tai chi classes in January across Arizona’s four counties with the largest number of falls among residents 55 years of age or older. When Laura Rhodes, 85 years old, joined a class four weeks ago, she wasn’t able to stand through the hour-long session.

Ms. Rhodes fractured her pelvis three years ago. She embraced exercise to recover, but didn’t enjoy it. Then, while visiting her daughter last year, she stopped exercising. She grew weak and her daughter became worried, Ms. Rhodes says. “I knew I had to do something, because I was getting to where I could hardly do anything.”

She returned home and joined tai chi at the local senior center. She enjoys it and says she has seen early benefits. Instructors described the discipline during the first class and introduced easy warm-up and cool-down routines.

The warm-up includes a slow, deliberate walk. Instructors demonstrate exercises that combine multiple gentle movements and then have students repeat the motions, said Lee Ann Anderson, an instructor and the prevention education and outreach manager for the La Paz County Department of Health.

Seniors are encouraged to do only what they can. In a recent class, students raised the arms to shoulder height, then tucked in the chin as they pulled arms to the chest. Students don’t move on until they feel they have mastered each exercise. “They are usually not shy at all about that,” Ms. Anderson said.

Exercise is one of the best ways to prevent falls, and research suggests it could moderately reduce fear of falling, according to a 2014 review of multiple studies on fear of falling and various exercises, including tai chi, to improve strength, coordination, balance and walking; it also found more research is needed to understand how long benefits last. Another study found tai chi was more effective than other exercises, though the benefit faded over time.

Ms. Rhodes finished a recent class standing up through almost every exercise. “The worst thing I can think of right now is fracturing something and being in a hospital bed the rest of my life,” she said. She says her neighborhood is deserted in the summer as seasonal residents leave, and she worries no one will be nearby to help if she should fall on a hot summer day. ”When it’s 110, 112 degrees, it won’t take long,” she says.

Fear of falling becomes a serious problem when seniors do less to avoid falls. Seniors are likely to eliminate social events before errands, leaving themselves isolated, said Helen Lach, a St. Louis University nursing professor who studies fear of falling. They then do even less, and grow even more frail. “There’s a point when you get older when you just can’t get away with that,” Ms. Lach said. “If you don’t exercise, it will start to catch up with you.”

Psychology researchers are focusing on cognitive behavioral techniques, which encourage discussion, to help identify fear and find ways to think differently about it. Screening tools and studies tease out how fearful a senior might be—from worried to phobic—and what are the best ways to allay concerns.

A small French study tested the use of virtual reality exposure therapy, which is commonly studied as an antidote to fear of flying or public speaking. “It shows some promise,” said Skip Rizzo, a psychologist and director of medical virtual reality at the University of Southern California Institute for Creative Technology, who wasn’t involved in the research. The area is ripe for study, Dr. Rizzo said. “We recognize this is a significant problem that leads to disability and chronic progression into loss of functional independence.”


Ann Moore realized she was avoiding nature walks and museum visits because she was afraid of falling. She participated in a cognitive behavioral therapy program last year to discuss fears and coping strategies and now enjoys going on outings in Phoenix. PHOTO: ELIZA HAWS/CHANDLER SENIOR CENTER

Ann Moore, 78, said she avoided guided nature walks and visits to museums in Phoenix because she worried about the uneven trails, museum parking ramps and stairs. But she didn’t fully recognize how much fear was holding her back until she joined an eight-week course designed to tackle the anxiety, she said.

“I really thought I was living a nice, full life,” said Ms. Moore, who volunteers at the senior center and serves on the Chandler, Ariz., mayor’s committee for the aging. Instructors challenged her to closely consider her choices, and Ms. Moore said she was surprised when she realized how many activities she shunned.

The course, which she took a year ago, is run by A.T. Still University, which trains future physical therapists, physician assistants and other health professionals. Cognitive behavioral techniques used in the course teach seniors to reconsider their fear and think differently about how to respond to anxiety.

The courses, developed at Boston University’s Roybal Center, have expanded to dozens of locations in hospitals, retirement communities and churches, said Jeffrey Alexander, an associate professor at A.T. Still University who trains instructors in the program and has evaluated its results. The course, called A Matter of Balance: Managing Concerns About Falls, is free to seniors.

Ms. Moore and other students used journals to record potential fall risks at home and at frequent haunts. During class, they shared fears and discussed strategies that could minimize risks. Instructors demonstrated how to get up after a fall and taught students exercises to improve balance.

Since taking the course, Ms. Moore has visited the Phoenix Art Museum and the Arizona Capitol Museum. One evening, she joined a guided tour in the Usery Mountain Regional Park in nearby Mesa. She felt confident navigating a dark trail with a flashlight, she said, and she enjoyed seeing owls, geckos and other nocturnal animals. “There are all sorts of little creatures that come out at night,” she said.

[PalmStriker]

I think fear of falling is more a "Western Thing" than it is, by far, an "Eastern Thing" or prevalent in any societies around the World that are more "floor culture" based. In Asia or places like Africa or the Arab World people are much more used to doing things closer to the ground on a daily basis. Squatting, kneeling or sitting on the floor and getting back up without any endeavor is done without any prior thought. In Western society people are always walking on "stilts" and rarely approach the ground floor without an episodic crash landing or carefully planned out endeavor. The muscles required to move up and down from the ground are undeveloped to confront an emergency or any daily routine that is commonplace activity for "Floor People". The older people get , the less inclined they are to change their habits, thus, fear of hitting the deck. * I am 64 years old and almost everyone I encounter can not believe how easy it is for me to move up and down. This is Kung Fu. One should not limit one's mobility base on societal expectations.

[GeneChing]

Become a Tai Chi instructor
22 hrs ago

The Oklahoma State Department of Health will be hosting Tai Chi instructor training workshops across Oklahoma.

Trainings will be held in Altus, Elk City, Alva and Durant with a limited number of spots available. To enroll in a workshop, contact Avy Redus by phone at 405-271-3430 or by email at AvyD@health.ok.gov.

The classes will be held on the following dates:

Altus Aug. 10-11 9 a.m. – 4 p.m. Jackson County Health Department.

Elk City Aug. 23-24 9 a.m. – 4 p.m. Beckham County Health Department.

Alva Sept. 12-13 9 a.m. – 4 p.m. Woods County Health Department.

Durant Sept. 27-28 9 a.m. – 4 p.m. Bryan County Health Department.

Individuals who successfully complete this two-day workshop will be qualified to lead Tai Chi: Moving for Better Balance classes. Participants will be expected to expand this program by teaching classes in their communities to help prevent injuries from preventable falls, which are a growing public health problem nationally and in Oklahoma.

Nationally, falls are the leading cause of nonfatal injuries treated in hospital emergency departments in every age group except ages 15-24 years, and are the leading cause of injury death among adults 65 years and older. Every year in Oklahoma, about 7,000 older adults are hospitalized, and more than 450 die from a fall. Acute care hospital charges alone total more than $250 million a year.

Tai Chi: Moving for Better Balance is an evidence-based fall prevention program for community-based organizations. This exercise program focuses on improving functional abilities, such as balance and physical function, to help reduce fall-related risks and the frequency of falls.

The OSDH offers the following tips on simple things you can do to help prevent falls:

Exercise regularly. Exercises that improve strength, balance and coordination are the most helpful in lowering the risk of fall‐related injuries.

Ask a doctor or pharmacist to review both prescription and over‐the‐counter medications to monitor side effects and interactions. The way medications work in the body can change with age. Some medications or combinations of medications can contribute to drowsiness or dizziness, which may increase the risk of falling.

Have vision screenings at least once a year. The wrong prescription eyeglasses or health conditions, such as glaucoma or cataracts, limit vision and may increase the risk of falling.

Reduce hazards in the home that may lead to fall‐related injuries. Keep floors clean and clear of clutter where people walk. Maintain adequate lighting throughout the home, especially near stairways. Remove throw rugs or use non‐skid throw rugs in the home, and use non‐slip mats in the bathtub or shower. Install handrails on stairways and grab bars in bathrooms. Keep items needed for regular use in easy‐to‐reach places that don’t require the use of a step stool.

To receive more information on classes and how to prevent falls, contact the OSDH Injury Prevention Service at (405) 271-3430 or visit http://falls.health.ok.gov.

Does anyone here know about Tai Chi: Moving for Better Balance? Anyone here certified? I'm intrigued because it's government supported.

[GeneChing]

Anyone here take one of these courses yet? I'm curious as to what they cover exactly.

Agency offers tai chi instructor training

Posted: Friday, January 20, 2017 8:31 am | Updated: 12:29 pm, Fri Jan 20, 2017.

Chillicothe – Care Connection for Aging Services is recruiting participants who want to become volunteer instructors for Tai Chi for Arthritis and Fall Prevention.
The agency, which operates senior centers in 13 West Central Missouri counties, including Johnson County would provide the instructor training with Master Trainer Linda Ebeling on March 11 and 12, in Chillicothe.
Basic knowledge of Tai Chi is recommended.
Benefits of Tai Chi are proven to include improved balance and mobility and reduce fear of falling. Other benefits include relieving pain and stiffness and relieving stress.
For details call Samantha Schnell at (800) 748-7826. The deadline for registering for instructor training is Feb. 17.
Care Connection for Aging Services provides resources and services to create healthy aging experiences. For more information, call (800) 748-7826 or email information@goaging.org.

[Oolong]

Basic breakfalks from Judo have saved my a$$ more times than I'd care to count

I'm a clutz.

[GeneChing]

Harvard Gazette
The balance in healthy aging
To grow old well requires minimizing accidents, such as falling, as well as ailments
April 25, 2017 | Editor's Pick Audio/Video Popular
By Liz Mineo, Harvard Staff Writer
Fourth in an occasional series on how Harvard researchers are tackling the problematic issues of aging.

The morning light is pouring into the senior living community in Canton, where six residents are performing an exquisite choreography of sweeping, lyrical movements, emulating their Tai chi instructor.

“Wave hands like clouds,” urges Kerry Paulhus, leading them in the classic low-impact and slow-motion exercises of the ancient Chinese martial art. With relaxing music playing in the background, the students shift their weight from one leg to the other, turn their waists, and rotate their arms as if they indeed were clouds.

When class ended, Elaine Seidenberg and Fran Rogovin, both 84 and close friends for four years, were glowing.

“Tai chi calms me down and has lowered my blood pressure,” said Rogovin at Orchard Cove, a facility that is part of Hebrew SeniorLife. “It’s just amazing what Tai chi has done for me.”



“In class, we wave hands like clouds,” agreed Seidenberg, a former Cape Cod resident. “And after class, we walk on clouds.”

While Tai chi may offer senior practitioners inner peace, scientists also value it for its fundamental, physical benefits. In addition to improving balance, flexibility, and mental agility, it also reduces falls, the largest preventable cause of death and injury among older adults. One way to help the aging have long and vital lives, researchers say, is to help protect them from injuries or worse.

According to the Centers for Disease Control and Prevention, one in three older adults falls dangerously each year. In 2014, about 27,000 older adults died from falls, more than 2.8 million were treated in emergency rooms, and 800,000 were hospitalized. Falls are the leading cause of death among adults over 65, and the death rate from them has soared in the past decade.

Over more than 30 years, researchers at the Institute for Aging Research have been studying what causes these falls among the elderly, and how to prevent them. The institute was started at Hebrew SeniorLife 50 years ago to take advantage of the proximity to senior residents living nearby, said Lew Lipsitz, institute director and chief academic officer.


Graphic by Judy Blomquist/Harvard Staff

Hebrew SeniorLife, a senior health care and housing organization affiliated with Harvard Medical School (HMS), serves 3,000 seniors in nine residential communities throughout Boston. One of a kind, the Harvard affiliate is the only long-term chronic care teaching hospital in the United States. The resulting access by researchers to seniors and their everyday lives provides a major boost to the real-time value of their research.

“Researchers really enjoy working here,” said Lipsitz, who is also chief of the Gerontology Division at Beth Israel Deaconess Medical Center and professor of medicine at HMS, “because in fact it is an environment where researchers can identify the problems they want to study and apply studies to solve those problems.”

When Lipsitz began working at the institute in 1980 as one of the first Harvard fellows in geriatric medicine, he noticed that many residents fell frequently. His area of research was born.

Lipsitz directs the institute’s Center for Translational Research in Mobility and Falls. The center has led a number of groundbreaking studies on reducing the risk of falls among older adults, ranging from the benefits of Tai chi, to the role of high blood pressure in falls, to the use of electrical stimulation to the brain to aid executive functions, to the benefit of vitamin D to increase bone density.

Many of these studies over time were funded by the National Institute on Aging of the U.S. Department of Health & Human Services, and the National Institutes of Health.

Lipsitz calls tai chi one of the most “exciting” interventions because it benefits both balance and mobility. It aids the muscular system, coordination, equilibrium, and the brain. In 2010, researchers at the institute ran a 12-week intervention, in which seniors practiced Tai chi twice a week. At the end of the trial, the investigators compared balance and mobility of those who did Tai chi to seniors who just sat in on the classes. “And lo and behold, Tai chi not only their improved gait and balance but improved their overall functional ability,” said Lipsitz. “If we could put Tai chi in a pill, everybody would take it. But unfortunately you actually have to practice it to have an effect.”

A study by Lipsitz, Brad Manor, and other researchers concluded that Tai chi training “may be a safe and effective therapy to help improve physical function.” The Arthritis Foundation now recommends Tai chi because it reduces stress and arthritis pain. (A study led by Fuzhong Li of the Oregon Research Institute, which examined results of a Tai chi program offered in 36 senior centers in 4 Oregon counties between 2012 and 2016, showed a 49 percent reduction in the number of falls and improved physical performance.)

It’s a simple fact that balance — the ability to maintain the body’s center of mass, located in the chest area, over the base of support or the feet — declines with age. Maintaining and bolstering it requires more than strong bones and firm muscles.

continued next post

[GeneChing]

“Social stimulation is an important part of our health, and this tends to decrease with aging. The social aspect of Tai chi becomes incredibly powerful, which helps with the enjoyment.”
— Brad Manor

“It’s not just a physical task; it’s also a mental task,” said Manor, director of the institute’s mobility and brain function lab, and an HMS assistant professor of medicine.

“We have to use our memory for the information that tells us how to perform the task of walking,” said Manor, “and we have to make decisions to slow down if there’s an icy road or the lighting is poor. So we need to use our attention, memory, and decision-making, which are all cognitive functions. It’s a very complex system that involves processes that take place in the brain.”

Because Tai chi requires attention, memory, and learning components to master its physical movements, its benefits go beyond improving mobility and reducing falls, the researchers say. It increases cognitive and mental functions and mindfulness. It also promotes social interaction because Tai chi is often practiced in a group setting.

“Social stimulation is an important part of our health, and this tends to decrease with aging,” said Manor. “The social aspect of Tai chi becomes incredibly powerful, which helps with the enjoyment. People really like it. It doesn’t really matter if you have a new intervention that may be more effective if people don’t enjoy doing it.”

In his lab, Manor studies the links between brain function and balance and falls. As part of his research, he monitors movements of participants while they walk and perform other mentally aware tasks such as counting backwards by threes, in what he calls a “dual-task assessment.” Often, falls among older adults happen when they’re walking while performing other tasks, because they get distracted and lose their balance.

“Walking is a cognitive task, and if we’re doing another cognitive task, like talking, one of the tasks will be diminished,” said Manor. “We’re studying how dual tasking interferes with losing balance. In one of the studies, we were able to demonstrate that people who did Tai chi improved their ability to walk and perform an additional cognitive task.”

Balance also depends on the ability to have feeling in the feet, which decreases as people age. Scientists at the institute partnered with the Wyss Institute for Biologically Inspired Engineering at Harvard to develop a ********y shoe insole, a device that sends tiny signals to people’s feet, which a study led by Lipsitz showed improved gait and balance. “It’s not available to the public,” Lipsitz said, “but this is a promising area of research.”

Institute scientists are also studying the effects of electrical stimulation to the brain region that control mobility, balance, and dual tasking. “It’s like taking a small battery and applying it to your forehead,” said Lipsitz. “Someday, I’ll be sitting at the desk feeling tired, perhaps after a meal, and all I’d have to do is attach a ‘battery’ to my forehead to get a boost.”

Even as research continues, falls remain a major, rising worry. In 2015, the financial toll from falls among older adults amounted to $31 billion, and the costs are expected to increase as life expectancy grows. In 2014, the population of U.S. seniors was 46 million, and by 2030 more than 20 percent of the country’s population is projected to be 65 and older. Beyond the financial costs, falls can dramatically undercut seniors’ lives in ways ranging to dependence, depression, isolation, and loneliness.

As for Rogovin and Seidenberg, neither has fallen since she began practicing Tai chi, three and two years ago, respectively. Both live an active life at Orchard Cove. While they also practice yoga and meditation, they rave about how Tai chi has enriched their lives.

“It keeps me mindful of what I’m doing,” said Rogovin, who taught students with learning disabilities in Newton and Brookline for 30 years. “It relaxes me and helps my thinking.”

Seidenberg agreed. She especially cherishes the positive effects on her mental wellbeing. Tai chi not only helps her cope with the stress of dealing with her husband’s Alzheimer’s disease, but it makes her feel better.

“When I come out, I feel at peace with myself and the world,” she said. “Somehow when we age, we become less coordinated and a bit more clumsy, but I feel more graceful.”

Tai Chi really has become the Grand Ultimate martial art. It combats the toughest enemy of all, the one that none of us can ever defeat - aging.

[GeneChing]

The two greatest enemies = old age + gravity.

Tai Chi for Risk of Falls. A Meta-analysis
Authors
Rafael Lomas-Vega PhD,
Esteban Obrero-Gaitán MSc,
Francisco J. Molina-Ortega PhD,
Rafael Del-Pino-Casado PhD
First published: 24 July 2017
DOI: 10.1111/jgs.15008
Cited by (CrossRef): 0 articles
Article has an altmetric score of 54
Abstract

Objectives

To analyze the effectiveness of tai chi for falls prevention.

Design

Systematic review and meta-analysis.

Setting

Pubmed, Scopus, CINHAL, and Physiotherapy Evidence Database (PEDro) were searched to May 26, 2016.

Participants

Older adult population and at-risk adults.

Intervention

Randomized controlled trials analyzing the effect of tai chi versus other treatments on risk of falls.

Measurements

The incidence rate ratio (IRR) for falls incidence and hazard ratio (HR) for time to first fall.

Results

The search strategy identified 891 potentially eligible studies, of which 10 met the inclusion criteria. There was high-quality evidence of a medium protective effect for fall incidence over the short term (IRR = 0.57; 95% CI = 0.46, 0.70) and a small protective effect over the long term (IRR = 0.87; 95% CI = 0.77, 0.98). Regarding injurious falls, we found very low-quality evidence of a medium protective effect over the short term (IRR = 0.50; 95% CI = 0.33, 0.74) and a small effect over the long term (IRR = 0.72; 95% CI = 0.54, 0.95). There was no effect on time to first fall, with moderate quality of evidence (HR = 0.98; 95% CI = 0.69, 1.37).

Conclusion

In at-risk adults and older adults, tai chi practice may reduce the rate of falls and injury-related falls over the short term (<12 months) by approximately 43% and 50%, respectively. Tai chi practice may not influence time to first fall in these populations. Due to the low quality of evidence, more studies investigating the effects of tai chi on injurious falls and time to first fall are required.

[GeneChing]

I was just alerted to this yesterday. Maybe we'll do something to honor it next year.

Falls Prevention Awareness Day observance on first day of fall
Sep 19, 2017 Updated 24 min ago

Warrensburg – Care Connection for Aging Services will observe the 10th annual Falls Prevention Awareness Day Sept. 22 – the first day of fall.

The national event, with the theme “10 Years Standing Together to Prevent Falls,” raises awareness about how to prevent fall-related injuries among older adults.

All of Care Connection’s 22 senior centers in 13 counties, including Warrensburg, will host activities and events to emphasize falls prevention.

Taking a fall is common among people 60 and older, with an older American is seen in the emergency room every 11 seconds because of a fall-related injury.

The National Council on Aging offers these tips to help prevent falls...

Find a good balance and exercise program. Care Connection offers exercise classes to keep older individuals fit and on their feet. Care Connection periodically offers “A Matter of Balance,” a specialized program that has been proven to prevent falls in older adults.

Let a health care provider know about recent falls and help assess fall risk.

Regularly review your prescription medications with a professional. Many medications come with fall risks associated with dizziness or balance issues.

Check vision and hearing regularly.

The senior centers have available copies of “Steady as You Go Fall Prevention Home Safety Checklist,” which offers a room-by-room practical guide to keeping a home safe from fall risks. Nearly half of all fall injuries of Missouri’s older adults occur at home.

Enlist family support in keeping areas free from fall risks.

To learn more about “Matter of Balance” classes, call lifestyles specialist Samantha Schnell at 1 (800) 748-7826.

To learn more about fall prevention, visit www.goaging.org or https://www.preventmofalls.org.

[GeneChing]

September 10, 2018
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
Fuzhong Li, PhD1,2; Peter Harmer, PhD, MPH3; Kathleen Fitzgerald, MD4; et al Elizabeth Eckstrom, MD, MPH5; Laura Akers, PhD1; Li-Shan Chou, PhD6; Dawna Pidgeon, PT7; Jan Voit, PT8; Kerri Winters-Stone, PhD9
Author Affiliations Article Information
JAMA Intern Med. Published online September 10, 2018. doi:10.1001/jamainternmed.2018.3915

Key Points
Question Is a fall prevention–specific tai ji quan intervention clinically more effective in reducing falls among older adults at high risk of falling than a stretching intervention (control) or a standard multimodal exercise intervention?

Findings In a randomized clinical trial involving 670 adults 70 years or older with a history of falls or impaired mobility, the therapeutic tai ji quan intervention effectively reduced falls by 58% compared with the stretching exercise (control intervention) and by 31% compared with a multimodal exercise intervention.

Meaning For older adults at high risk of falling, a therapeutically tailored tai ji quan intervention was more effective than stretching or multimodal exercises in reducing the incidence of falls.

Abstract
Importance Falls in older adults are a serious public health problem associated with irreversible health consequences and responsible for a substantial economic burden on health care systems. However, identifying optimal choices from among evidence-based fall prevention interventions is challenging as few comparative data for effectiveness are available.

Objective To determine the effectiveness of a therapeutically tailored tai ji quan intervention, Tai Ji Quan: Moving for Better Balance (TJQMBB), developed on the classic concept of tai ji (also known as tai chi), and a multimodal exercise (MME) program relative to stretching exercise in reducing falls among older adults at high risk of falling.

Design, Setting, and Participants A single-blind, 3-arm, parallel design, randomized clinical trial (February 20, 2015, to January 30, 2018), in 7 urban and suburban cities in Oregon. From 1147 community-dwelling adults 70 years or older screened for eligibility, 670 who had fallen in the preceding year or had impaired mobility consented and were enrolled. All analyses used intention-to-treat assignment.

Interventions One of 3 exercise interventions: two 60-minute classes weekly for 24 weeks of TJQMBB, entailing modified forms and therapeutic movement exercises; MME, integrating balance, aerobics, strength, and flexibility activities; or stretching exercises.

Main Outcomes and Measures The primary measure at 6 months was incidence of falls.

Results Among 670 participants randomized, mean (SD) age was 77.7 (5.6) years, 436 (65%) were women, 617 (92.1%) were white, 31 (4.6%) were African American. During the trial, there were 152 falls (85 individuals) in the TJQMBB group, 218 (112 individuals) in the MME group, and 363 (127 individuals) in the stretching exercise group. At 6 months, the incidence rate ratio (IRR) was significantly lower in the TJQMBB (IRR, 0.42; 95% CI, 0.31-0.56; P < .001) and MME groups (IRR, 0.60; 95% CI, 0.45-0.80; P = .001) compared with the stretching group. Falls were reduced by 31% for the TJQMBB group compared with the MME group (IRR, 0.69; 95% CI, 0.52-0.94; P = .01).

Conclusions and Relevance Among community-dwelling older adults at high risk for falls, a therapeutically tailored tai ji quan balance training intervention was more effective than conventional exercise approaches for reducing the incidence of falls.

Trial Registration ClinicalTrials.gov identifier: NCT02287740

Introduction
Falls in older adults constitute a major public health problem in the United States.1,2 Annually, approximately 28% of community-dwelling adults 65 years or older report falling; an estimated 38% of these falls result in injuries2 leading to emergency department visits, hospital admissions, or death.3,4 Fall-related treatments are costly, averaging $9389 per fall for fall-related injuries among Medicare beneficiaries.5 In 2015, the total medical costs for falls in persons aged 65 years and older were more than $50 billion, 75% of which fell to Medicare/Medicaid.6

Falls, however, are largely preventable, with mounting evidence suggesting that exercise can be a safe and effective way to reduce falls.7,8 However, identifying optimal choices from among available evidence-based fall prevention interventions is challenging because few comparative effectiveness data are available, especially for older adults with high fall risk.9 With the continuing growth of the older segment of the population10 and the concomitant projected increase in the number of falls,2 high health care spending,11 and escalating health care costs,12 identifying the exercise intervention that is the most safe, effective, and easily implementable would greatly aid clinicians and health care institutions in making informed decisions about which interventions to prescribe given clinical goals and fiscal constraints.

This trial was designed to respond to this evidence gap and these clinical decision needs. We aimed to determine the comparative effectiveness of 2 proven interventions, therapeutically tailored tai ji quan exercise (Tai Ji Quan: Moving for Better Balance [TJQMBB])13-15 and multimodal exercise,16 relative to stretching exercise in reducing the incidence of falls in older adults at high risk of falling. Our primary hypothesis for this trial was that, compared with stretching or multimodal exercise programs, TJQMBB would be clinically more effective in reducing the number of falls.

Methods
Study Design
We performed a single-blind, parallel-design, randomized clinical trial with participants randomly allocated to 1 of 3 active arms: TJQMBB, entailing modified tai ji quan forms (derived from the classic framework of tai ji, also known as tai chi) and associated therapeutic movement exercises; multimodal exercise, integrating aerobic, strength, balance, and flexibility activities; or stretching exercises (the control arm) (Figure). The trial protocol (available in the Supplement) was approved by the institutional review board of Oregon Research Institute, and an independent data and safety monitoring board appointed by the National Institute on Aging oversaw the study. Written informed consent was obtained from all participants.

Population, Setting, and Recruitment
The target population was community-dwelling older adults living in 7 urban and suburban cities across 3 counties in Oregon. These counties were strategically chosen because of a moderate to high density of older adult populations and a high incidence of fall injuries.17 Eligible participants were 70 years or older and met one of the following primary criteria: (1) having fallen at least once in the preceding 12 months and having a health care practitioner’s referral indicating that the participant was at risk of falls or (2) having impaired mobility as evidenced by a Timed Up & Go (TUG)18 result greater than 13.5 seconds.19 Other inclusion criteria were as follows: (1) ability to walk 1 or 2 blocks, with or without the use of an assistive device; (2) ability to exercise safely as determined by a health care practitioner; and (3) willingness to be randomly assigned to and complete a 6-month intervention. We excluded individuals who had (1) participated in daily or structured vigorous physical activity or walking for exercise that lasted 15 minutes or longer or muscle-strengthening activities on 2 or more days a week in the previous 3 months, (2) severe cognitive impairment (Mini-Mental State Examination20 score, ≤20 on a range of 0 to 30), or (3) major medical or physical conditions determined by their health care practitioner to preclude exercise.

Recruitment strategies included promotions at local senior or community centers, senior meal sites, medical clinics, statewide senior falls prevention networks, targeted mass mailings, and local newspaper advertisements. Recruitment lasted from February 20, 2015, to August 29, 2018, with the final participant follow-up on January 30, 2018.

Randomization and Masking
Eligible older adults were randomly assigned in a 1:1:1 ratio to receive 1 of the 3 interventions via a computer-generated randomization sequence with a block size of 3 or 6 to prevent anticipation of assignment to study condition. Because this was a behavioral intervention, study participants were not blinded to intervention group allocation. Primary and secondary outcome assessors were masked to group allocation and remained separate from the intervention team, and class instructors (interventionists) were blinded to the study’s hypothesis.

Interventions and Procedures
Each of the 3 interventions involved a 60-minute exercise session twice weekly for 24 weeks. In all 3 groups, each session consisted of a 10-minute warm-up, 40 to 45 minutes of core exercises, and a 5-minute cool-down activity. Exercise intensity in each intervention group was monitored through a subjective measure of perceived exertion (Exercise Intensity section of Trial Protocol in the Supplement). Intervention classes varied in size, with a range of 9 to 21 participants, and were held in community facilities, such as senior or community centers, churches, or nonprofit organizations. All 3 interventions were conducted concurrently and delivered in 15 class sites throughout the study area. At each site, the 3 interventions were separated in time to avoid cross-contamination.

continued next post

[GeneChing]

Therapeutic Tai Ji Quan
The training protocol, Tai Ji Quan: Moving for Better Balance (see the Supplement for detail), involved practice of a core of 8 therapeutically modified exercise forms with built-in variations and a subroutine of integrated therapeutic movement exercises.14,15,21 Aimed at stimulating and integrating musculoskeletal, sensory, and cognitive systems, the practice focused on controlled, self-initiated tai ji quan–based exercises with synchronized breathing, including center of gravity displacement using a dynamic interplay of stabilizing and self-induced destabilizing postural actions involving unilateral weight-bearing and weight-shifting movements, trunk and pelvic rotation, ankle sway, and eye-head-hand movements.21

During the initial 10 weeks, sessions focused on learning and performing the TJQMBB forms in various formats (ie, seated, standing in place, and stepping), accompanied by sets of therapeutic and functional tai ji quan–based exercises involving ankle sway, sit-to-stand, single-leg stands, turning, and stepping exercises(referred to as mini-therapeutic movements).21 At each session, participants practiced 3 to 4 sets of a tai ji quan form, with 3 to 5 repetitions in each set intermingled with 3 to 5 sets of 3 to 4 selected mini-therapeutic movements (4 to 5 repetitions in each set). After all 8 therapeutic tai ji quan forms had been learned (weeks 11 and 12), each session comprised 5 to 6 sets of variations in the 8-form routine and 3 to 4 mini-therapeutic movements in sets of 4 to 5.

Multimodal Exercise
The training protocol involved aerobic conditioning, strength, balance, and flexibility activities.16 The aerobic exercises included long strides, heel-toe walking, narrow- and wide-based walking, and sidestepping for cardiovascular fitness. Strength training included exercises for ankle dorsiflexors, knee extensors, and hip abductors. Balance training involved tandem foot-standing, heel-toe and line walking, single-leg standing, alternation of the base of support, weight transfers, and various reaching movements away from the center of gravity. Flexibility exercises included a static stretching routine of major upper- and lower-body muscle groups. At 4 months, use of gym-based equipment (hand and ankle weights, resistance tubing, and balance foams) was integrated into the strength and balance exercises.

Training was progressive, with challenges increasing with respect to movement pace, patterns and coordination, and joint range of motion. Strength training was graduated, beginning with 4 repetitions in month 1, 6 to 8 repetitions in month 2, 8 to 10 repetitions in month 3, 11 to 15 repetitions in month 4, and 25 to 30 repetitions in months 5 and 6. Resistance training involved hand weights (beginning with 0.45 kg [1 lb] for each hand in month 4 and progressing to 0.91 kg [2 lb] in months 5 and 6), tubing (beginning with extra-light resistance in month 4, moving to light resistance in month 5, and to medium resistance in month 6), and ankle weights (beginning with 0.45 kg for each limb in month 4 and progressing to 1.13 kg [2.5 lb] in month 6). These resistance exercises were implemented with 3 to 5 repetitions in month 4, increasing to a maximum of 8 to 10 repetitions in month 6.

Stretching Exercise
The training routine consisted of breathing, stretching, and relaxation activities, with most of them performed in a seated position. Each session began with a set of warm-up exercises, such as arm, neck, and leg circles; trunk rotation; and light walking. The core part of the training session consisted of a variety of combined seated and standing stretches involving the upper body (neck, arms, upper back, shoulders, and back and chest) and lower extremities (quadriceps, hamstrings, calves, and hips), along with slow and gentle trunk rotations. Also included were deep abdominal breathing exercises that emphasized inhaling and exhaling to maximum capacity as well as progressive relaxation of major muscle groups.

Baseline and Outcome Assessment
At enrollment, participants’ demographic information regarding sex, age, race/ethnicity, income, education, living arrangements, medical conditions, fall-related information, and physical activity was collected. Study outcome measures were assessed at baseline, 4 months (midpoint), and 6 months (at the end of the intervention).

The primary outcome was the incidence of falls, which was ascertained on a monthly basis. Participants were asked to use a daily “fall calendar”13 diary to record any fall event (defined as “when you land on the floor or the ground, or fall and hit objects like stairs or pieces of furniture, by accident”) and to indicate whether they sought medical attention. Information was also collected on injurious falls.13,22 Data on falls were collected starting from the date of the first intervention class and continuing until 24 weeks later (ie, the end of the intervention period) or until a participant withdrew, died, or was lost to follow-up.

Prespecified secondary outcomes were physical performance measures of (1) functional reach,23 which assessed the maximal distance a participant could reach forward, beyond arm’s length, while maintaining a fixed based of support in a standing position; (2) the Instrumented Timed Up & Go (APDM, Inc), which represents an extended version of TUG18 and assessed walking duration (in seconds) and 3 subdomain timed-based activities—sit-to-stand, turning, and turn and stand-to-sit—during a 14-m walk at normal pace (7 m toward a line, turn, and 7 m toward the chair); and (3) the Short Physical Performance Battery,24 which measured repeated chair stands, 3 increasingly challenging standing balance tasks, and a 4-m speed walk. Scores on the 3 tasks were combined to create an overall performance score of 0 (worst) to 12 (best), with higher values indicating improvement. In addition, global cognitive function was measured by the 30-item Montreal Cognitive Assessment,25 which assesses cognitive function of multiple domains (memory recall, visuospatial abilities, executive functions, attention, language, and orientation to time and place; scores range from 0 to 30, with higher scores indicating better cognitive function).

Statistical Analysis
Sample Size
The study was powered to detect a difference between 2 negative binomial rates resulting from the 6-month intervention between the 2 exercise interventions (TJQMBB and multimodal exercise) relative to stretching exercise. On the basis of data collected from previous trials,13,16 our power calculations found that a sample size of 567 participants (189 per group) would be required to detect a 35% reduction in the fall incidence rate (a respective incidence rate ratio [IRR] of 0.65) between either of the 2 intervention groups relative to stretching exercise. Although a difference was anticipated to favor the TJQMBB intervention, power was not calculated between TJQMBB and multimodal exercise owing to the lack of a priori effect size estimates. With an estimated 15% attrition, we planned to recruit a total of 666 participants.

Analyses
Baseline characteristics and unadjusted study outcome measures were summarized by intervention group using descriptive statistics such as mean (SD) or percentage and used to assess between-group equivalence at baseline. Prespecified baseline covariates in both primary and secondary outcome analyses included age, sex, health status, history of falls, and cognitive function (Mini-Mental State Examination score, ≤20).

Baseline demographic descriptors and primary and secondary outcome measures were compared across groups by using analysis of variance for continuous variables and the χ2 (or Fisher exact) test for categorical variables. The planned descriptive data on monthly falls was tabulated across the intervention groups. In our primary analysis of the falls count outcome, we used negative binomial regression to estimate absolute differences in IRRs with their corresponding 95% CIs comparing TJQMBB and multimodal exercise with stretching exercise. In a prespecified secondary analysis, we also estimated the rate differences with 95% CIs between TJQMBB and multimodal exercise. Follow-up on falls data was censored at the last visit or contact during which a complete data point was collected. Following an intention-to-treat protocol, we analyzed the secondary (continuous) outcomes with estimates and their 95% CIs generated from the linear mixed-effects models. All primary and secondary outcome analyses were conducted with and without adjustment for prespecified baseline covariates. Bonferroni correction was made to control for multiple testing of secondary outcomes, with an adjusted α value of .007 (.05 per 7 comparisons) for each test considered statistically significant. Two-sided P values of less than .05 were considered statistically significant. Analyses were conducted using SPSS version 23 (IBM Corp) or Stata (release 13; StataCorp LP).

Results
Enrollment
Of 1147 individuals screened, 670 were enrolled and randomized (224 to TJQMBB, 223 to multimodal exercise, and 223 to stretching exercise) (Figure). Of the total participants, 581 (86.7%) (194 in TJQMBB, 193 in multimodal exercise, and 194 in stretching exercise) completed their assigned interventions. At 6 months, 664 (99.1%) of the 670 participants provided full follow-up data on falls and 633 (94.5%) provided data on secondary outcomes. There were no statistically significant differences in baseline demographic variables or primary outcomes between the 581 participants who completed the intervention (defined as attending classes either regularly or irregularly without dropping out of the study) and the 89 who did not complete the intervention (defined as dropping out of the study).

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Participant Characteristics
Baseline characteristics were similar by intervention group (Table 1). The mean (SD) age was 77.7 (5.6) years (median [interquartile range (IQR)], 76 [73-81] years), 436 (65.1%) were women, 617 (92.1%) were white, 31 (4.6%) were African American. Four hundred eighty-five participants (72.4%) reported having at least 1 fall 6 months before the intervention, 355 (53.0%) reported having 3 or more chronic conditions, and 67 (10.0%) were taking 4 or more medications. The mean (SD) mobility score was 8.3 (2.2) measured on the Short Physical Performance Battery and 14.25 (5.2) seconds on TUG.

Intervention Compliance and Adherence
The overall attrition rate was 13%, which was lower than our planned 15%. The median (IQR) time to stopping the intervention across the 3 intervention groups was 3.0 months (2.0-4.0). The intervention attendance rate across the 24-week period for all participants was 77% (78% in the TJQMBB group; 77% in the multimodal exercise group; and 77% in the stretching exercise group), and the mean (SD) number of completed sessions was 37 (10.6) (median, 40 sessions; range, 2-48 sessions) (37 [10.8] in the TJQMBB group; 37 [10.2] in the multimodal exercise group; and 37 [10.7] in the stretching exercise group; P = .82).

Safety
Serious adverse events, defined as death or medical conditions that required 1 or more days of hospitalization, were observed. Forty-seven participants reported hospital admission: 11 in the TJQMBB group (1.0 per 100 person-months), 12 in the multimodal exercise group (1.1 per 100 person-months), and 16 in the stretching exercise group (1.2 per 100 person-months) (P = .83). One death from unknown causes in the stretching exercise group was documented. None of these serious events were related to the intervention. Seven falls with no injury were documented during classes: 2 in the TJQMBB group; 3 in the multimodal exercise group; and 2 in the stretching exercise group. One participant in the TJQMBB group required an emergency department visit owing to hyponatremia during a class, but the participant recovered and completed the intervention.

Intervention Resource Use
The resources needed to conduct our intervention primarily involved costs associated with promotion, recruitment, room rental, class instruction, supplies, administrative overhead, exercise equipment (eg, weights, chairs), and participant travel expenses to and from each intervention class. The intervention cost $202 949 ($906 per person) to deliver a 24-week TJQMBB program to 224 participants, $223 849 ($1004 per person) to deliver the multimodal exercise program to 223 participants, and $201 468 ($903 per person) to deliver the stretching exercise component to 223 participants.

Primary Outcome
At 6 months, 733 falls were recorded among 324 of the 670 participants (48.4%) (85 in the TJQMBB group, 112 in the multimodal exercise group, and 127 in the stretching exercise group ). The mean (SD) follow-up on falls was 5.98 (0.21) months (median [IQR], 6.0 [6.0-6.0] months). Although both the TJQMBB and multimodal exercise groups showed a significantly lower incidence of falls (11 per 100 person-months for TJQMBB, and 16 per 100 person-months for multimodal exercise) compared with the stretching exercise group (27 per 100 person-months, P < .001), the incidence of falls was significantly lower in the TJQMBB group (total falls [mean (SD)] 152 [0.68 (1.3)]) than in the multimodal exercise group (218 [0.98 (1.8)]) (P = .04). There were no between-group differences on moderate injurious falls (TJQMBB, 88 falls [0.39 (0.9)]; multimodal exercise, 109 [0.49 (1.2)]; and stretching exercise, 156 [0.70 (1.7)]) (P = .05), but TJQMBB had a lower incidence of injurious falls than stretching exercise (TJQMBB, 8 [0.04 (0.2)]; stretching, 25 [0.11 (0.4)]) (P = .008) (Table 2).

Binominal regression of unadjusted analyses showed that both the TJQMBB and multimodal exercise groups had a lower IRR (IRR, 0.42; 95% CI, 0.31-0.56; P < .001 for TJQMBB; IRR, 0.60; 95% CI, 0.45-0.80; P = .001 for multimodal exercise) compared with the stretching exercise group. In addition, the TJQMBB group showed a significantly lower IRR than the multimodal exercise group (IRR, 0.69; 95% CI, 0.52-0.94; P = .01). The estimates of the intervention effects between TJQMBB and the stretching and multimodal exercise groups showed no change after adjusting for the prespecified covariates (data not shown).

Secondary Outcomes
At 6 months, the participants in both the TJQMBB and multimodal exercise groups performed significantly better than those in the stretching exercise group on secondary outcomes of physical performance (functional reach, Short Physical Performance Battery, and Instrumented TUG and its subdomain scores [sit-to-stand, turning, turn and stand-to-sit]) and global cognitive function measures (Table 3). Participants in the TJQMBB and multimodal exercise interventions performed significantly better than those in the stretching intervention on tests of physical and cognitive function: functional reach (TJQMBB: mean difference, 1.77; 95% CI, 1.42-2.12; P < .001; multimodal exercise: mean difference, 1.49; 95% CI, 1.15-1.83; P < .001); Short Physical Performance Battery (TJQMBB: mean difference, 1.57; 95% CI, 1.25-1.88; P < .001; multimodal exercise: mean difference, 1.59; 95% CI, 1.27-1.90; P < .001); total walking duration in the instrumented walking test (TJQMBB: mean difference, −2.42; 95% CI, −3.19 to −1.65, P < .001; multimodal exercise: mean difference, −2.20; 95% CI, −2.97 to −1.43; P < .001); and Montreal Cognitive Assessment (TJQMBB group: mean difference, 1.54; 95% CI, 1.04-2.04; P < .001; multimodal exercise group: mean difference, 1.39; 95% CI, 0.92-1.86; P < .001). There were no differences between TJQMBB and multimodal exercise on secondary outcomes. The significant effects of TJQMBB and multimodal exercise relative to stretching exercise on the secondary outcomes remained after adjustment for covariates (data not shown).

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Discussion
In this study of community-dwelling older adults at high risk of falling, we found that a 6-month TJQMBB intervention, when compared with a conventional stretching exercise control, was effective in reducing the incidence of falls. In addition, our study also showed for the first time, to our knowledge, that TJQMBB was effective in reducing the incidence of falls compared with a well-known conventional, evidence-based multimodal exercise program.9,16 Thus, of the 3 exercise interventions, TJQMBB yielded the greatest reduction in number of falls, whereas both TJQMBB and multimodal exercise significantly improved physical function and global cognitive function compared with the stretching exercise control.

The findings from this study are aligned with systematic review and meta-analyses on the effect of exercise on reducing the incidence of falls7,26 and are commensurate with the results from a meta-analysis27 and previous controlled tai ji quan studies involving community-dwelling older adults13,28,29 and persons with Parkinson disease.30 This clinically oriented and functionally driven tai ji quan–based program,21 however, is shown to be more efficacious in the magnitude of reduction in the incidence of falls compared with earlier trial or meta-analysis results.13,27-29

Our study also extends the current literature by comparing, head-to-head, 2 evidence-based interventions,13,16 with the results showing 31% fewer falls in TJQMBB compared with multimodal exercise, thus adding new clinical knowledge on the effectiveness of a therapeutically tailored tai ji quan intervention strategy for preventing falls among older adults. The findings that TJQMBB was more effective than a multimodal exercise program are of considerable practical importance because they suggest the utility of an equipment-free, low-cost, non–space-constrained exercise intervention in addressing the clinical problem of falls and balance deficits in the older population.

To our knowledge, our intervention is the only tai ji quan–based program uniquely designed to facilitate therapeutic training of balance and postural control for older adults with balance deficits,14,15,21 with the specific focus of targeting reductions in falls and tailoring implementation for clinical practice. A previous study has shown that the intervention is readily implementable in clinical practice with a high rate of adoption among health care practitioners, including internal medicine physicians, and that it is sustainable.14 Experience from that study indicated that proactive steps, such as communicating frequently with clinicians, offering educational outreach workshops, and even providing training to clinicians, can facilitate the referral process. Thus, although substantial communication gaps exist between clinicians and community service providers,9 we have shown that this program can be accessible to clinicians and implementable in the context of geriatric clinics or medical centers.

The TJQMBB intervention evaluated in this study has been the model program for multiple successful research-to-practice implementation efforts in both community and clinical settings as well as program delivery evaluation by public health organizations or senior service agencies by public health organizations or senior service agencies.14,15,31-35 The program is also currently listed as one of the highest-tier evidence-based health-promoting and disease prevention programs under Title IIID of the Older Americans Act.36 With increasing evidence of community adoption and implementation14,15,31-35 and information from cost-benefit and cost-effectiveness analyses,15,37 the intervention program represents a promising approach to low-cost and easily implementable fall prevention programs. Its demonstrated generalizability and scalability can facilitate nationwide adoption of this effective fall prevention program to benefit community-dwelling older adults.

Limitations
The study findings should be interpreted in the context of trial limitations. Falls data were collected via falls calendars kept by participants. Although such calendars remain the criterion standard for ascertaining best available evidence on falls in the field,13,16,22,38 self-reports are known to be subject to recall bias. However, to ensure that self-reporting bias was minimized, we used multiple methods, including monthly telephone calls, confirmations during follow-up assessments, proxies, and medical records, to ensure data accuracy. Participation in the study classes required traveling. Therefore, the results are most likely to be generalizable to persons who are able to travel regularly to exercise class sites. The relatively low representation of African American participants was noted given this group has high rates of falls and of injurious falls.2 However, there is no indication in the results that these participants responded differently to the interventions than did other participants. Finally, this trial was conducted in a single state. Although Oregon has one of the nation’s highest death rates from falls,39 generalizability of the findings could be enhanced by a multicenter trial involving multiple states.

Conclusions
Among older adults with high risk of falling, a 24-week therapeutically developed tai ji quan balance training intervention resulted in a significant reduction in the incidence of falls compared with a stretching exercise modality and a multicomponent exercise program.

Accepted for Publication: June 21, 2018.

Published Online: September 10, 2018. doi:10.1001/jamainternmed.2018.3915

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Li F et al. JAMA Internal Medicine.

Corresponding Author: Fuzhong Li, PhD, School of Kinesiology, Shanghai University of Sport, 200 Changhai Rd, Shanghai, China, 200438 (fuzhongl@sus.edu.cn).

Author Contributions: Drs Li and Harmer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Li, Harmer, Voit.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Li, Harmer.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Li, Akers.

Obtained funding: Li, Harmer.

Administrative, technical, or material support: Li, Voit.

Supervision: Li, Fitzgerald.

Conflict of Interest Disclosures: Dr Li, reported that he is the founder and owner of Exercise Alternatives, LLC, a consulting company, and that a licensing fee for Tai Ji Quan: Moving for Better Balance is paid directly to this company. No other disclosures were reported.

Funding/Support: This work was supported by grant AG045094 from the National Institute on Aging.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the intervention instructors and the research staff for their dedication to this study. Appreciation is also extended to all the volunteers who participated in this project.

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THREADS:
Tai Chi as medicine
Tai Ji Quan: Moving for Better Balance® (TJQMBB)
Fall prevention

[GeneChing]

Adding Tai Chi Helps Seniors Avoid Dangerous Falls
By Sonya Collins



Oct. 2, 2018 -- Duane Partain was 71 years old when he took a couple of spills in his flower garden in Eugene, OR. He has vertigo and sometimes feels lightheaded and wobbly, but he hadn’t fallen before. So, after he went crashing into the bushes, he stopped spending as much time in the garden, worried he’d take a tumble again.

When older adults fall, fear of falling again often keeps them from getting back to their usual activities. The lack of exercise then takes its toll on balance and strength, which only makes a person more vulnerable to another, more serious spill. Poor vision, slower reflexes, and medications or conditions that make you dizzy also make falls more likely.

More than one in four adults age 65 or older fall every year, and falls are the leading cause of injury-related deaths in that age group, the CDC says. Once you fall, your risk of going down again doubles. When a bone breaks -- particularly a hip -- falls can harm your quality of life, make you more disabled, and raise your risk of death. More than 95% of broken hips are the result of a fall. When an adult between the ages of 65 and 84 breaks a hip, their risk of dying in the next 2 years triples.

“I’ve had friends, acquaintances, and neighbors who’ve fallen, and when they broke something, that started a serious decline in their activities. I wanted to avoid that as long as possible,” Partain said.

In fact, most falls can be avoided. But while many people try to get rid of things that can make them fall in their homes, they don’t consider the risks within their own bodies.

“Picking up throw rugs and installing grab-bars is a great start, but if you don’t have a balance impairment, you can catch yourself when you trip over a rug,” says Lori Schrodt, PhD, a physical therapist at Western Carolina University’s Balance and Fall Prevention Clinic. “It’s that environmental hazard combined with some other risk factor, such as balance impairment, that is the real recipe for disaster.”

But how do you restore lost balance -- and confidence -- after age 65? Studies show it is possible.

Moving for Better Balance: Tai Chi and Other Proven Programs
The National Council on Aging (NCOA) recognizes 14 programs for their proven record to lessen falls. One of the most effective is Tai Ji Quan: Moving for Better Balance, a course that researchers adapted from traditional tai chi (short for tai ji quan or tai chi chuan). Tai chi, an ancient Chinese practice, includes slow, focused, fluid movement along with deep breathing.

FALL PREVENTION PROGRAMS
The National Council on Aging recommends these evidence-based programs to help older adults reduce the risk of falling.

For more information
Go to this website to find contact information and course descriptions.

A Matter of Balance
CAPABLE, or Community Aging in Place
Enhance Fitness
FallsTalk
Fit & Strong!
Healthy Steps for Older Adults
Healthy Steps in Motion
The Otago Exercise Program
Stay Active and Independent for Life (SAIL)
Stepping On
Tai Chi for Arthritis
Tai Ji Quan
YMCA Moving for Better Balance

Part of the benefit of many fall prevention programs is the exercise they provide. But not all exercise is equal. In a study of 670 adults age 70 or older who had fallen at least once in the last year, tai chi adapted for fall prevention was more effective than a generic exercise program or a stretching routine. Adults who practiced tai chi 2 hours per week for 6 months were 31% less likely than those in the exercise group to fall again and 58% less likely to fall than those in the stretching group.

“[Tai Ji Quan: Moving for Better Balance] starts to reactivate the neuromuscular pathways that underpin your ability to control your body as it falls through space,” says Peter Harmer, PhD, a professor of exercise science at Willamette University in Salem, OR. Harmer and program creator Fuzhong Li have collaborated for nearly 3 decades to develop and refine Moving for Better Balance. They are co-authors of the study of 670 older adults.

Duane Partain was one of them. He responded to an ad recruiting people for the study at Oregon Research Institute 3 years ago, and he’s been practicing tai chi ever since. “It helps prevent falls because your body seems to become more aware,” Partain says. “The fall doesn’t catch you unawares. It doesn’t just come out of the blue. You can tell what is going on, and you can be proactive to stop it.”

That’s because, Harmer says, the class provides exercises that mimic balance challenges people face in everyday life.

Since Partain started tai chi, he hasn’t fallen, his bouts of vertigo are less frequent and less severe, and he’s gotten back into the garden. “After I started the classes, I felt more confident, so the garden isn’t a problem anymore.”

Talk It Out
Structured fall prevention courses aren’t only about exercise. They offer education and problem-solving, too. “It’s not just about learning a tai chi move,” says Schrodt. “It’s about learning your risks and how to manage them.”

A Matter of Balance, another of the 14 programs recognized by the NCOA, helps people face their fear of falling, support-group style. “We talk about situations in which you might be invited to do something, but you are afraid you could fall, so we discuss what you could do so that you could go to this particular activity,” says Diane Frankel, RN, a population health navigator at the YMCA of Western North Carolina. She helps older adults with multiple health issues -- such as diabetes, arthritis, and the risk of falling -- find programs at the Y that can help them improve their condition.

Frankel, 64, got involved with fall prevention at the Y after she fell herself. Only 60 at the time, she lost her footing in a parking lot while carrying several bags. “I stepped into a tiny hole, so I can’t really blame the hole. I fell, and I wasn’t injured badly, but it shocked me.” She was physically fit, had done yoga for a long time, and didn’t expect that she would be at risk for a fall. After completing the tai chi course at the Y, she found that her balance was better in yoga, too.

Learning to Fall
Some experimental approaches to fall prevention include practicing not falling when you lose your balance.

“Regardless of age, we are capable of learning,” says Clive Pai, a retired professor and director of the department of physical therapy at the University of Illinois-Chicago. “You can quickly learn how to adjust and not fall in the future.”

That was the basis for a fall prevention study Pai conducted. In the experiment, older adults walked on a treadmill at their preferred speed. They were warned that something could cause them to fall, and they wore safety harnesses to prevent them from hitting the ground. The treadmills tripped the elders 24 times. “It doesn’t take many times -- only once or twice -- before you are fully capable of making an adjustment, controlling your stability, and not falling.”

People in a control group spent the same amount of time on the treadmill, but researchers tripped them only once.

In the year after the study, those in the control group were more than twice as likely to fall as they had been the year before. Those who had intensive fall practice were 50% less likely to fall. What’s more, the training had lasting effects. When elders returned to the treadmill 3, 6, and 12 months after the initial session, they kept their balance when the treadmill tripped them.

In a Dutch program, seniors face numerous fall hazards, including uneven and unstable surfaces, set up in a school gym. The seniors practice staying stable as they get to each hazard, and they learn how to fall when they do. The program gives elders confidence to keep moving without fear of falling.

Next Steps
When the study ended at Oregon Research Institute, Partain wasted no time finding a tai chi class at the local parks department. “I go three times a week now,” he says. “It’s very beneficial.” You can find fall prevention programs at parks departments, senior centers, health care facilities, and the YMCA (which does not always require membership if you want to take part).

While there are many types of programs to choose from, they have a few things in common: movement, education, and a social environment. These seem to work together to give older adults the balance and the confidence to get moving again without fear of falling. “People just light up. They feel like they can manage better,” says Schrodt, the Western Carolina University physical therapist. “It’s like they get more spring in their step.”

WebMD Article Reviewed by Hansa D. Bhargava, MD on October 02, 2018

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Tai Ji Quan: Moving for Better Balance® (TJQMBB)
Fall prevention