Faculty Disclosures


Frank Domino, MD

Domino Disclosure




Resources


  1. Li F et al. Effectiveness of a therapeutic tai ji quan intervention vs a multimodal exercise intervention to prevent falls among older adults at high risk of falling: A randomized clinical trial. JAMA Intern Med 2018 Sep 10; [e-pub]. (https://doi.org/10.1001/jamainternmed.2018.3915)
  2. Li F. Transforming traditional tai ji quan techniques into integrative movement therapy—Tai Ji Quan: Moving for Better Balance. J Sport Health Sci. 2014;3(1):9-15. doi:10.1016/j.jshs.2013.11.002



Transcript

Dr. Frank Domino:

Margaret is a 72-year-old retired elementary school teacher, she comes in today for her yearly wellness visit. Her past medical history is significant for open angle glaucoma under good control, osteoarthritis of her wrists and knees, and osteoporosis. Her current medications include eye drops for her glaucoma, acetaminophen on a PRN basis and a bisphosphonate as well as daily calcium. She has no complaints today, but some questions. Her friends have all joined a tai chi class at the local YMCA. She's been walking daily with her friends, which she knows is good for her bones but she wasn't sure about this new exercise. She was thinking about joining the class at the Senior Center, would it be better than walking for her?

Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School, and joining me today, to talk about exercise, fall risk, and tai chi is Susan Feeney, Assistant Professor and Coordinator of the Family Nurse Practitioner Track at the University of Massachusetts Medical School, Graduate School of Nursing.

Susan Feeney:

Hi, Frank.

Dr. Domino:

So, we worry a lots about all sorts of diseases in our senior patients, we sometimes forget the obvious things like falls. Can you tell us a little bit about the risk of falls in the elderly and who's at greatest risk?

Susan Feeney:

Yeah. Well, falls is a pretty significant risk for people. In community dwellers, 20% of folks who are 65 years and older fall in this country and about 40% of those folks go on to have serious injury, hospitalization or death. So, it's pretty significant. And from a cost standpoint, 2015, said that greater than $50 billion was spent on treating people who had fallen and 75% of that came out of Medicare. So this is not a trivial thing, both for the function, and then you think about the families and the people who care for these folks. It's a significant issue. So we know the things that can cause falls and it's usually lack of function and mobility, obstacles in the house, stairs and pets and throw rugs and poor lighting. But we are not, I think as astute, at really assessing this, even though we give it a lot of lip service.

Dr. Domino:

I think you're probably right. So it raises the question then what can we as clinicians do to help prevent falls in these patients?

Susan Feeney:

Well, first of all, we really need to do some... Ask what's going on and do these assessments in our patients when they're in the office and I know that a lot of the Medicare quality improvement metrics we have to do this. But the evidence tells us that exercise is probably the best way to prevent falls. Keeping people strong, balanced, keeping their bones strong, and that kind of thing is the best prevention and encouraging that and that also means not just telling people to do exercise at home, is finding out what's in your community to help your patients get that great exercise.

Dr. Domino:

I think you're absolutely right. So you talk about what's in the community. Can you tell us a little bit about the research on tai chi in particular for the prevention of falls?

Susan Feeney:

It's really interesting, there has been actually a lot of research on tai chi in the elderly and how it's helped to prevent falls. But there was a recent study that actually looked at, there hasn't been a lot of comparative studies. In this study that was recently published, looked at 670 elders in the community who were at risk, they had either fallen in the last six months... Excuse me, in last 12 months... Or they had decreased function. So they had a delayed timed get up and go test, and they found that tai chi was actually superior to sort of a standard exercise program and better than just plain strengthening exercises for folks and they prevented falls pretty significantly in that group.

Dr. Domino:

Wow, so I've typically referred patients to physical therapy or exercise classes. So the tai chi had a better impact on reducing the risk of falls?

Susan Feeney:

Yes and it seems to be... It also had as a secondary outcome as well as the multi-modal exercise that it helped with cognitive function as well. So, when you dive into the literature on tai chi, it seems because it works on stability, so they have to fix themselves in one place and then move another part of the body, they refer to it as the Yin-Yang kind of concept, but it appears to really work on balance and strengthening muscles throughout the core as opposed to when we would do isolated strength exercises. So it does seem to have a significant improvement on balance and reducing falls.

Dr. Domino:

So the tai chi was more effective than what they called multimodal exercise?

Susan Feeney:

Right, multimodal exercise which is standard exercise of aerobics and flexibility and strength, a strength training.

Dr. Domino:

And both of those it appeared from the study did better than just doing plain old strengthening?

Susan Feeney:

Absolutely, the plain old strengthening exercises was the control and both multimodal exercise and tai chi were better, but tai chi was superior to multimodal.

Dr. Domino:

Well, how available are tai chi classes for seniors in the community?

Susan Feeney:

They are pretty available. Most senior centers have some type of tai chi and some of the assisted livings have it. Some of the hospitals and their community outreach will have tai chi. And the thing about tai chi is that it's also a social kind of activity, so people, there's the added benefit of not just going to work with a physical therapist or doing something in your home, you're actually out with a group of people doing this activity. So it really has a lot of benefit.

Dr. Domino:

I really like the fact that it also seems to improve cognition.

Susan Feeney:

Yes, and when I did a little deep dive into the tai chi, they really talk about it being... Because of the nature of the exercise, it is muscle-skeletal, it is sensory because they have to tie into how they're feeling as they're standing and paying attention to various parts of their body, and they also have to follow a complex set of directions that it does seem to help with cognition.

Dr. Domino:

And it does seem that there's a meditative component to tai chi that probably helps with being centered, being less anxious and more focused.

Susan Feeney:

Exactly. Yeah. And they talk about the fact that it's 400 years old or more, and it's really a martial arts modality. But there are different agency... Different groups that have made sort of therapeutic tai chi where they have 8 to 16 different poses. And so you spend some time teaching the person what these different poses are and then they can practice those at home as well. And it's really about paying attention, feeling, understanding the sensation in your body, right positioning and keeping one part tense and still another part moving. So it's a fascinating exercise, and I believe everyone should be doing tai chi after reading this.

Dr. Domino:

I think so. So what do we tell Margaret?

Susan Feeney:

So I'm gonna tell Margaret absolutely. If you're interested in this, go for it, because she's not fallen before. I haven't done a time to get up and go test on her, but she's got osteoporosis, she has osteoarthritis, she's at risk if she were to fall, this could be really devastating to her, and I would tell her that if you're going to class anyway, if they have tai chi, we have some evidence that that can really help keep you strong, possibly prevent a fall and keep you sharp.

Dr. Domino:

Excellent Susan. Well, I'll see you out on the tai chi court soon. And thank you very much for discussing these new findings on how to reduce falls in senior citizens.

Susan Feeney:

My pleasure.

Dr. Domino:

Practice pointer, consider tai chi as an effective tool to prevent falls and maintain independence for senior citizen patients. Join us next time when we discuss the role alcohol plays in newly diagnosed heart failure.