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Research Reports |
AI Greenspan, PT, MPH, DrPH, is Senior Scientist, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mailstop K-63, Atlanta, GA 30341 (USA)
SL Wolf, PT, PhD, FAPTA, is Professor, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Ga
ME Kelley, PhD, is Research Assistant Professor, Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
M O'Grady, MD, is currently in private practice. Dr O'Grady was Assistant Professor, Department of Rehabilitation Medicine, Emory University School of Medicine, at the time of the study
Address all correspondence to Dr Greenspan at: AGreenspan{at}cdc.gov
Submitted December 1, 2005;
Accepted January 9, 2007
 | Abstract |
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Subjects: Study subjects were 269 women who were 
70 years of age and who were recruited from 20 congregate independent senior living facilities.
Methods: Participants took part in a 48-week, single-blind, randomized controlled trial. They were randomly assigned to receive either TC or WE interventions. Participants were interviewed before randomization and at 1 year regarding their perceived health status and SRH. Perceived health status was measured with the Sickness Impact Profile (SIP).
Results: Compared with WE participants, TC participants reported significant improvements in the physical dimension and ambulation categories and borderline significant improvements in the body care and movement category of the SIP. Self-rated health did not change for either group.
Discussion and Conclusion: These findings suggest that older women who are transitionally frail and participate in intensive TC exercise demonstrate perceived health status benefits, most notably in ambulation.
| Introduction |
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 TopAbstract Introduction MethodResultsDiscussionConclusionReferences |
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Some studies4–6 have demonstrated the effectiveness of tai chi (TC), a type of Chinese exercise derived from a form of martial arts, in maintaining physical functioning and reducing falls among older adults. The slow, rhythmic movements that characterize TC also provide a holistic approach to exercise that combines mind and body experiences. This meditative aspect of TC could result in general improvements in health status and quality of life, in addition to improvements in physical functioning.
Several studies have demonstrated improvements in quality of life among older adults with osteoarthritis,7 patients with chronic heart failure,8 people who have had breast cancer,9 and patients with fibromyalgia10 following TC practice. Although a few studies on older adults who are at risk for falls have examined the effect of TC on physical health,6,11 the effect of TC on the multiple dimensions of health status has not been well studied. In this study, a single-blind, randomized clinical trial examining the benefits of TC, we hypothesized that a group of older women who are transitionally frail would report greater improvements in perceived health status following an intense 48-week TC program than would women taking part in a wellness education (WE) program of similar duration.
| Method |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Speechley and Tinetti defined adults as vigorous, frail, or transitionally frail on the basis of 10 attributes: age, gait and balance, walking activity for exercise, other physical activity for exercise, presence or absence of depression, use of sedatives, near-vision status, upper- and lower-extremity strength (force-generating capacity), and lower-extremity disability. Adults who are vigorous are defined as those who have at least 3 vigorous and no more than 2 frail attributes. Adults who are frail are defined as those who have at least 4 frail attributes and no more than 1 vigorous attribute. Adults who are transitionally frail are those who do not meet the criteria for the frail or vigorous group. Subjects were excluded if they had a severe or unstable medical condition, had significant cognitive impairment (Mini-Mental State Examination score of <24), or had a condition in which physical activity was contraindicated.
Of the 354 people screened, 311 (291 women and 20 men) met eligibility criteria and were enrolled in the study. Further details regarding enrollment and reasons for exclusion were previously reported.4 Because of sex differences regarding self-perceived health,14–16 we excluded the 20 men who were part of the original sample (Figure). Of the 291 women who were enrolled, 148 were randomly assigned to participate in the TC intervention and 143 were randomly assigned to participate in the WE intervention. Ten of the women who were randomly assigned to participate in the TC intervention and 11 of the women who were randomly assigned to participate in the WE intervention withdrew from the study before the start of the intervention. Of the 21 women who withdrew, 5 did not want to participate, 5 had poor health status, 3 experienced catastrophic events, 2 died, and 6 did not receive physician approval to participate. One other woman was later excluded because of previously nondiagnosed Parkinson disease. This process resulted in a total of 137 women in the TC group and 132 women in the WE group. During the course of the intervention, 34 participants in the TC group and 30 participants in the WE group discontinued their interventions. The reasons for dropping out are given in the Figure. The study analysis was based on the 269 participants who either completed or participated in the TC or WE intervention.
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Characteristics of the Study Population
Table 1 summarizes the baseline frailty, demographic, and selected health and functional characteristics of the study participants. The frequency of frailty characteristics ranged from 16.1% to 99.2%. Near-vision impairment (97.8% in the TC group and 99.2% in the WE group) and impaired gait or balance (92.7% in the TC group and 94.7% in the WE group) were the most common frailty characteristics; upper-extremity impairment (16.1% in the TC group and 18.9% in the WE group) was the least common. More than three quarters of the study participants were white and had completed high school, and more than one half were at least 80 years of age. Baseline Sickness Impact Profile (SIP) scores were in the moderate disability range for the TC and WE groups, although baseline SIP scores were significantly lower for the TC group, indicating better perceived health status, for subjects in the TC group.
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The control intervention consisted of a WE program. The WE classes were held for 1 hour per week and consisted of instruction on falls prevention; exercise and balance; diet and nutrition; pharmacological management; legal issues relevant to health; changes in body function; and mental health issues, such as stress, depression, and life changes. Interactive materials were provided, but there was no formal instruction in exercise. The total amounts of time for individual attention given to participants in each group by the instructors were comparable.
Variables and Measures
Perceived health status.
The SIP is a reliable and valid measure of perceived health status,18–20 has been used widely across patients with a variety of diseases and injuries,20 takes 20 to 30 minutes to administer,21–29 and has been applied extensively to older adults.23,30–32 Specifically, the reliability and validity of SIP data among older adults have been well demonstrated across a variety of older populations, including nursing home residents who are frail,33,34 older adults with chronic illnesses,35 and older veterans.36 The internal consistency of the overall SIP is .96, with individual category scores ranging from .63 to .90.37 In addition, the clinical validity of SIP data has been well established through comparisons with clinical data for a variety of situations and diagnoses, including total hip replacement, hyperthyroidism, stroke, angina pectoris, and rheumatoid arthritis.38 Finally, multiple studies have demonstrated that the SIP is responsive to changes over time.37
The SIP consists of 136 statements divided into 12 categories: sleep and rest, eating, work, home management, recreation and pastimes, ambulation, mobility, body care and movement, social interaction, alertness behavior, emotional behavior, and communication (Tab. 2). Four of the categories—social interaction, alertness behavior, emotional behavior, and communication—combine to form a psychosocial health dimension. Ambulation, mobility, and body care and movement combine to form a physical health dimension. Participants are asked whether the statements describe themselves today and whether the statements are related to their health. Categories and dimensions can be scored independently or combined to produce an overall summary score. Scores are derived by use of a weighted algorithm. Overall SIP scores and categorical scores range from 0 to 100, with higher scores indicating poorer health status. Scores of less than 4 are found in the general population and indicate no disability, scores of 4 to 9.9 indicate minor disability, scores of 10 to 19.9 indicate moderate disability, and scores of 20 indicate severe disability.39–41 Differences of 2 or 3 points indicate meaningful differences in function.42,43
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Data Analysis
Baseline characteristics were summarized by use of means and standard deviations for continuous data and frequency distributions for categorical data. Because the distribution of the SIP was significantly skewed, the data were grouped into clinically meaningful categories as described in previous studies.39–41 Repeated-measures ordinal logistic regression (proportional odds) was used to model the various domains within the SIP as the dependent variables for the evaluation of intervention x time interaction effects. The repeated measures were analyzed by use of generalized estimating equations. A significant interaction effect would indicate a larger change in function in one of the groups between baseline and follow-up. Significance was set at P=.05. Participants who did not complete the intervention were analyzed in the groups to which they initially were assigned by use of an intention-to-treat analysis. We also compared this analysis with a complete-case analysis that included only participants who completed the intervention.
| Results |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Perceived Health Status and SRH
The SIP scores at baseline and at 1 year after the intervention and the group x time interactions (intervention effects), determined by use of an intention-to-treat analysis, are summarized in Table 3. Participants in the TC group reported significantly lower SIP scores in the physical dimension (P=.016) and ambulation category (P=.013). In addition, participants in the TC group reported borderline significant scores in the physical dimension category of body care and movement (P=.051). These scores indicated improved physical functioning (group x time interaction), most notably in ambulation, following 48 weeks of TC practice relative to the findings for the WE group.
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The majority of participants in both the TC and the WE groups rated their health as good or better, with at least 40% rating their health as very good or excellent and less than 30% rating their health as fair or poor at baseline. Self-rated health was not significantly different between the TC participants and the WE participants at baseline. In addition, SRH did not change significantly from baseline to 1 year for either the TC group or the WE group.
| Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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70 years of age. The preintervention total SIP score (
±SD) of 14.1±10.0, indicating moderate disability, lies between that of older adults who are healthy (mean SIP score=3.4)48 and that of nursing home patients who are very frail (mean SIP score=43.5).49 The major finding of this study was that adults who are transitionally frail who participated in a 48-week TC intervention reported significant improvements in perceived physical health, specifically in the category of ambulation, and borderline significance in the category of body care and movement. Significant changes in perceived health status were not observed for psychosocial health or the independent categories of home management, sleep and rest, and eating. Although we did not expect changes in eating behavior, we had hypothesized that TC would affect other areas of health status. In previous studies in which the effect of TC on perceived health status was examined, conflicting findings were reported.38,50,51 These discrepancies may be attributable to differences in the intensity of the intervention, the study population, sample size, the study methodology, or the measure used to assess perceived health status. In only 1 of 3 studies in which the Medical Outcomes Study Short-Form questionnaire38,50,51 was used to assess health status was a significant improvement in perceived health status reported. That study50 targeted older adults with balance deficits; in the other 2 studies,38,51 older adults who were healthy were recruited. In her review of TC interventions, Wu52 reported that changes in health status may be limited in studies that target older adults who are healthy, in whom baseline health status scores are already high.
The findings of Li and colleagues,6,11,53 who conducted a randomized trial of TC among physically inactive older adults, lend support to this idea. The initial findings of Li and colleagues supported the conclusion that TC improved perceived physical functioning; however, in a reanalysis stratifying their sample into high and low scores on the basis of baseline physical functioning, Li and colleagues found significant improvements among participants with low baseline physical functioning scores following 6 months of a TC intervention, whereas participants with high baseline physical functioning scores did not show any change in physical functioning, relative to the findings for control participants performing their usual daily activities.53 Our own findings of improved physical functioning among TC participants in this study and negative findings for older adults who were healthy recruited in the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) TC trial38 also support the conclusion that older adults with lower levels of functioning may be more likely to report improvements in perceived physical health than older adults who are healthy.
Within the physical function dimension, ambulation significantly contributed to improvements in physical functioning, the body care and movement category was borderline significant, whereas no significant differences were reported with mobility. Items in both the ambulation category and the body care and movement category focus on activities that require balance. For example, the ambulation category includes items such as walking up or down hills, walking up and down stairs, and getting around only by using a walker, crutches, cane, walls, or furniture. Body care and movement activities primarily include activities of daily living, many of which require balance to perform well. Such items include standing up, kneeling, stooping, bending down, getting into or out of cars or bathtubs, and maintaining balance. Several studies52,54,55 have shown improvements in balance following TC. In contrast, mobility items describe an individual's ability to move around within the community versus staying at home. Although balance certainly plays a role in an individual's ability to do so, illnesses and various chronic health conditions also may affect this area, consequently reducing the effect of TC in the area of mobility. For example, subjects may stay home most of the time because they feel too sick to leave home, irrespective of walking and balance capabilities.
Given that TC has meditative components to complement its exercise aspects and because improved physical functioning could affect other areas of health, we hypothesized that TC would result in improved psychosocial health. Previous studies support our hypothesis. Improvements in psychosocial health following TC have been demonstrated among participants with a variety of diagnoses and chronic conditions, including osteoarthritis,7 breast cancer,9 and chronic heart failure.8 Two randomized controlled studies in which the psychological effects of TC on sedentary older adults were examined revealed improvements in life satisfaction and general well-being among TC participants relative to control participants.56,57 In another randomized controlled study, Kutner et al38 examined the effects of TC on general health status among community-dwelling older adults. Although improvements in general health, mental health, and social functioning were not demonstrated, as measured with the Medical Outcomes Study Short-Form questionnaire, exit interviews revealed that TC participants were more likely than control participants to report benefits from participation and to report that the intervention (TC) had a noticeable effect on their lives. Therefore, our failure to demonstrate improvements in psychosocial health and other aspects of health status, with the exception of physical health, was surprising.
Several factors could account for our findings. First, our study participants were more frail than those in previous studies, and comorbid conditions may have exerted a greater influence on psychosocial health. Second, the SIP may not be sensitive enough to identify modest changes in psychosocial health among older adults. Third, differences in study methodology may account for conflicting results. Further research is needed with psychosocial measures that are sensitive in older adults to better understand whether TC has any direct or indirect effect on psychosocial health or whether the trends that we observed are spurious.
Several factors could account for why our results failed to demonstrate an effect of TC or WE on SRH. First, three quarters of all participants rated their health at baseline as good or better, a finding that supports the positive perceptions of SRH among older adults in previous studies.58–60 Older adults tend to view their health in context with their peers and may perceive declining functional status as part of the normal aging process. Thus, high baseline scores may have limited our ability to detect changes in SRH. Second, individuals’ perceptions of SRH not only may be a reflection of their current health status but also may reflect a more lasting self-concept based on preexisting beliefs regarding their own health.61 Therefore, an improvement in physical health may have been only one of several factors that could have influenced participants’ assessments of SRH at 1 year. Finally, Bailis and colleagues61 found that a change in SRH is more likely to be influenced by health status changes that are most important to an individual. To demonstrate changes in SRH, we may have needed to identify a priori those individuals who had a specific goal of improving their physical functioning.
We used an intention-to-treat analysis because it minimizes bias62 and may provide a more realistic estimate of clinical relevance. Excluding dropouts and participants who do not adhere to a study protocol weakens the unbiased estimate that is gained from randomization. Participants who drop out tend to fare worse that those who complete an intervention, even after controlling for known predictive factors.62 Thus, the remaining participants would be expected to have a better outcome than those who dropped out. Such a scenario may account for the greater significance in physical health and in body care and movement that we observed with the complete-case analysis. Thus, the use of a complete-case analysis instead of an intention-to-treat analysis may result in an outcome suggesting greater success than is warranted. Finally, an intention-to-treat analysis gives the clinician a more realistic representation of the likely success of an intervention. In reality, not every individual will fully adhere to or complete a treatment regimen. Thus, an intention-to-treat model takes into account issues of nonadherence.
The interpretation of data from this study has some limitations. First, on the basis of the definition developed by Speechley and Tinetti,13 we classified older adults who met neither the frailty criterion nor the vigorous criterion as transitioning to frailty. This definition included older adults with a broad range of health characteristics and functional abilities. Although mean SIP scores ranked in the moderate level of disability, individual scores varied widely, ranging from no disability to severe disability, suggesting that our definition of transitional frailty may have been imprecise. Recently, Fried and colleagues63 presented more simplified definitions of frailty and vigor that include a transitional group that they define as "intermediate" frailty. Although this classification system has appeal because of its simplicity, further research is needed to demonstrate its sensitivity and specificity for classifying older adults, especially those who are transitioning to frailty.
Second, participants were recruited from congregate living facilities for a clinical intervention trial and may not be representative of older adults who are transitionally frail and live in the community or those who would not volunteer for an exercise intervention. Third, although the instructor gradually increased work time from 10 minutes to 50 minutes over the 48-week intervention, participants were allowed to rest as needed. Although participants generally increased their work time, with an instructor ratio of 1:15, the instructor was unable to monitor individual changes. Fourth, older adults with cognitive deficits (Mini-Mental State Examination score of <24) were excluded because participants needed to have sufficient cognitive skills to be able to answer interview questions. Fifth, few African- American women were enrolled in the study, despite attempts to enroll greater numbers. Low enrollment may have been primarily attributable to the composition of the congregate living facilities, which was primarily female and white, with the exception of 4 primarily minority facilities. Only women were included in our analysis; therefore, the findings cannot be extended to older men.
Finally, although our analyses of intervention effects took into account baseline differences in SIP scores, the higher baseline SIP scores among the TC participants could have created some unintended biases. Because TC participants had better perceived health, they may have had more optimistic views about their health and may have been more likely to perceive their health as improved after an intervention. On the other hand, previous research53 suggested a greater benefit among TC participants with lower baseline physical functioning scores, which could have reduced the treatment effects for TC participants relative to WE participants.
| Conclusion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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In summary, the results of this study suggest that an intense program of TC targeting older women who are transitionally frail can have a positive effect on their self-perceived physical health, primarily in the areas of ambulation and self-care. Ambulation, self-care, and movement activities are important functions for maintaining independent lifestyles. More community-based studies are needed to determine whether these improvements are sustained and result in older adults adopting more active lifestyles that have a broader impact on their overall health status and quality of life.
| Footnotes |
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This study was approved by the Emory University Human Investigation Committee.
This research was supported by National Institutes of Health grant AG14767 from the National Institute on Aging and coupons for redeemable products from Kroger Corporation and CVS Pharmacies for each participant upon completion of participation.
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding agency.
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