Background Patients with Parkinson's disease have substantially impaired balance, leading to diminished functional ability and an increased risk of falling. Although exercise is routinely encouraged by health care providers, few programs have been proven effective. Methods We conducted a randomized, controlled trial to determine whether a tailored tai chi program could improve postural control in patients with idiopathic Parkinson's disease. We randomly assigned 195 patients with stage 1 to 4 disease on the Hoehn and Yahr staging scale (which ranges from 1 to 5, with higher stages indicating more severe disease) to one of three groups: tai chi, resistance training, or stretching. The patients participated in 60-minute exercise sessions twice weekly for 24 weeks. The primary outcomes were changes from baseline in the limits-of-stability test (maximum excursion and directional control; range, 0 to 100%). Secondary outcomes included measures of gait and strength, scores on functional-reach and timed up-and-go tests, motor scores on the Unified Parkinson's Disease Rating Scale, and number of falls. Results The tai chi group performed consistently better than the resistance-training and stretching groups in maximum excursion (between-group difference in the change from baseline, 5.55 percentage points; 95% confidence interval [CI], 1.12 to 9.97; and 11.98 percentage points; 95% CI, 7.21 to 16.74, respectively) and in directional control (10.45 percentage points; 95% CI, 3.89 to 17.00; and 11.38 percentage points; 95% CI, 5.50 to 17.27, respectively). The tai chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance-training group in stride length and functional reach. Tai chi lowered the incidence of falls as compared with stretching but not as compared with resistance training. The effects of tai chi training were maintained at 3 months after the intervention. No serious adverse events were observed. Conclusions Tai chi training appears to reduce balance impairments in patients with mild-to-moderate Parkinson's disease, with additional benefits of improved functional capacity and reduced falls. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00611481.)
Results suggest that if activation is increased, a variety of improved behaviors will follow. The question still remains, however, as to what interventions will improve activation.
Objectives Few evidence-based fall prevention programs have been evaluated for adoption in clinical settings. This study investigated the dissemination potential of a Tai Ji Quan-based program, previously shown efficacious for reducing risk of falls in older adults, through outpatient clinical settings. Design A single-group pre-post design in which participants attended a twice weekly Tai Ji Quan training program for 24 weeks. Setting Communities in Lane County, Oregon. Participants Referral patients (N = 379) aged 65 and older living independently. Measurements Using the RE-AIM framework, the primary outcome was the proportion of participating healthcare providers who made referrals. Secondary outcomes were the proportion of referred patients agreeing to participate and enrolling in the program, and measures of program implementation, maintenance, and effectiveness (on measures of falls, balance, gait, physical performance, and balance efficacy). Results Of the 252 providers invited to participate, 157 made referrals (62% adoption rate). Of 564 patients referred, 379 (67% reach) enrolled in the program, which was successfully implemented in senior/community centers with good fidelity. Of the total number of participants, 283 completed the program (75% retention) and 212 of these attended ≥75% of the total (48) sessions. Participants reported a reduction in falls with an incidence rate of 0.13 falls per person-month and showed significant improvement from baseline in all outcome measures. A 3-month post-intervention follow-up indicated encouraging levels of program maintenance among providers, patients, and community centers. Conclusion A protocol to refer patients at increased risk of falling to a Tai Ji Quan-based program was successfully implemented among healthcare providers. The evidence-based program appears readily scalable and exportable with potential for substantial clinical and public health impact.
A previous randomized, controlled trial of tai chi showed improvements in objectively measured balance and other motor-related outcomes in patients with Parkinson's disease. This study evaluated whether patient-reported outcomes could be improved through exercise interventions and whether improvements were associated with clinical outcomes and exercise adherence. In a secondary analysis of the tai chi trial, patient-reported and clinical outcomes and exercise adherence measures were compared between tai chi and resistance training and between tai chi and stretching exercise. Patient-reported outcome measures were perceptions of health-related benefits resulting from participation, assessed by the Parkinson's Disease Questionnaire (PDQ-8) and Vitality Plus Scale (VPS). Clinical outcome measures included motor symptoms, assessed by a modified Unified Parkinson's Disease Rating Scale–Motor Examination (UPDRS-ME) and a 50-foot speed walk. Information on continuing exercise after the structured interventions were terminated was obtained at a 3-month postintervention follow-up. Tai chi participants reported significantly better improvement in the PDQ-8 (−5.77 points, P = 0.014) than did resistance training participants and in PDQ-8 (−9.56 points, P < 0.001) and VPS (2.80 points, P = 0.003) than did stretching participants. For tai chi, patient-reported improvement in the PDQ-8 and VPS was significantly correlated with their clinical outcomes of UPDRS-ME and a 50-foot walk, but these correlations were not statistically different from those shown for resistance training or stretching. However, patient-reported outcomes from tai chi training were associated with greater probability of continued exercise behavior than were either clinical outcomes or patient-reported outcomes from resistance training or stretching. Tai chi improved patient-reported perceptions of health-related benefits, which were found to be associated with a greater probability of exercise adherence. The findings indicate the potential of patient perceptions to drive exercise behavior after structured exercise programs are completed and the value of strengthening such perceptions in any behavioral intervention.
The PeaceHealth Senior Health and Wellness Center (SHWC) provides primary care coordinated by geriatricians and an interdisciplinary office practice team that addresses the multiple needs of geriatric patients. The SHWC is a hospital outpatient clinic operated as a component of an integrated health system and is focused on the care of frail elders with multiple interacting chronic conditions and management of chronic disease in the healthier older population. Based on the Chronic Care Model, the SHWC strives to enhance coordination and continuity along the continuum of care, including outpatient, inpatient, skilled nursing, long-term care, and home care services. During its development, a patient-centered approach was used to identify senior service needs. The model emphasizes team development, integration of evidence-based geriatric care, site-based care coordination, longer appointment times, "high touch" service qualities, utilization of an electronic medical record across care settings, and a prevention/wellness orientation. This collection of services addresses the interrelationships of all senior issues, including nutrition, social support, spiritual support, caregiver support, physical activity, medications, and chronic disease. The SHWC provides access in an environment sensitive to the special needs of seniors, with a staff trained to meet those needs. The SHWC business model attempts to improve access and quality of care to seniors in a mostly noncapitated healthcare setting, while also attempting to remain financially viable.
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