Exercise as it relates to Disease/Reduce falls and balance your life: is Tia Chi the answer to Parkinson's?

This Wikibooks page is a fact sheet and analysis of the journal article “tai chi and postural stability in patients with Parkinson’s Disease” by Li et al., (2012). This has been created by 3084396.

What is the background to this research?
Parkinson's disease is second only to Alzheimer’s in the prevalence of neurological conditions. This disease results in a series of motor impairments such as tremors, decreased amplitude of movement, rigidity, decreased speed of movement, freezing of gait and poor postural stability. This postural instability causes a high risk of falls. A recent study examined the incidence of falls in neurological patients over a 12-month period. It found that Parkinson’s patients had the highest rate of falls with 62% of patients falling over the study period. Recent literature supports the idea that exercise and motor training can slow the process of degeneration in mild to moderate Parkinson’s, leading to improvements in walking, balance, functional tasks and decreased falls. However, these exercise programs often require monitoring from trained staff and are can be reliant on equipment. Tai chi is a possible alternative form of balanced-based exercise, and it has been shown to decrease falls in older adults. Tai chi involves weight shifting to move center of mass towards theoretical limit of stability. This means that a large component of tai chi is essentially balance training. Therefore, Li and colleagues designed a randomized control trial that looked at the effect of a 24 week tai chi program on postural stability in Parkinson’s.

Where is the research from?
This study was carried out by researchers from the Oregon Research Institution, and was approved by the same institution.

What kind of research was this?
This study was a randomized clinical trial to compare the effect of effect tai chi, resistance training and stretching on balance in Parkinson’s disease.

What did the research involve?
A total of 309 subjects were screened to meet the following factors.

•	Mild to moderate Parkinson’s categorized by a rating of one to four on the Hoehn and Yahr scale (see further readings).

•	40–85 years of age.

•	Stable medication use of levodopa (see further readings).

•	Able to stand unaided and walk without an assistive device.

•	Low scores on the Mini-Mental State examination were considered cognitively impaired and subjects were excluded from the study (see further reading for the Mini-Mental state examination).

195 subjects qualified for the study and were randomized into one of the following three groups; tai chi experimental group, resistance training group and a low intensity exercise stretching group. Each group participated in 60 minute classes twice a week for 24 weeks.

The primary outcomes were maximal excursion and directional control, which were measured by a computerized balance master system. Both these parameters are indicative of postural stability. Secondary outcomes included strength, number of falls, step length, walking speed and the functional reach test. All outcomes measures were assessed at baseline, at the 3 and 6-month period, and 3 months after completing the study. There was no difference between the groups at baseline.

What were the basic results?
Most significantly, the subjects in the tai chi group performed significantly better than the other experimental groups in the primary outcomes, which is indicative of improved postural stability. These improvements in balance were seen in the everyday activities with the Tai Chi group only reporting 19 falls, compared to the 31 for the resistance group and 26 for the stretching group.

The tai chi and the resistance training groups also showed improvements in walking speed, stride length, functional reach and strength. The tai chi group showed greater improvements than the resistance training group in walking speed, step length and reach, which again are indicative of improvements in balance. Unsurprisingly, the resistance group showed greater increases in strength, although the percent difference was not as large as might be expected. Importantly, these improvements were maintained three months after the intervention. The stretching group did not show any significant improvements in any of the outcome measures. The results of the study can be seen in table 2.

What conclusions can we take from this research?
The main conclusion that can be drawn from the research is that tai chi is more effective in improving balance and reducing falls when compared to resistance training and stretching. This is promising because the reason for conducting the study was to see if tai chi could offer an alternative method of training to slow the process of Parkinson’s disease. Not only does the study suggest that is effective, it actually suggests that tai chi is more effective than usual resistance training. These findings are in accordance with recent research which offers tango dancing as an alternative form of exercise. Dancing classes twice a week for a year was found to be effective in improving dual task walking speed, balance and increased participation in leisure activities

The study has a few limitations. Firstly, the study only includes mild to moderate Parkinson participants, and excludes any cognitively impaired subjects. The same can be said for the study that found tango dancing is beneficial for Parkinson’s. More than likely, this excludes the participants who need the most help. A recent study suggests more severely affected patients do not benefit from a program targeting balance strength and freezing of gait. This study showed that higher disease severity patients usually fall while trying to participate in exercise programs, and the milder participants see the training benefits.

Interestingly, resistance training in this study did not reduce falls. A recent study found that progressive resistance training along with falls education to be more effective in reducing falls when compared to movement strategy training. This study also involved mild to moderate severity patients. Another study found that a 12 week strengthening program in Parkinson patients leads to better functional performance and stability. This suggest that perhaps the resistance program in this study was not of sufficient intensity to help to decrease falls.

Practical advice
This research has shown that tai chi can be an effective alternative to standard exercise in slowing the degenerative effect of Parkinson’s disease, improving balance and increasing walking speed in mild to moderate disease severities. Exercise in more severe disease states does not appear to be helpful in reducing falls.

Further resources
For information on the Hoehn and Yahr head to http://parkinsonsresource.org/wp-content/uploads/2012/01/The-FIVE-Stages-of-Parkinsons-Disease.pdf

For information on Levadopa head to https://parkinsonsmi.org/medications/entry/the-role-of-levodopa-in-parkinsons-disease-therapy-the-present-and-the-future

For information on the Mini Mental Examination http://www.dementiatoday.com/wp-content/uploads/2012/06/MiniMentalStateExamination.pdf

For information on Parkinson's disease head to http://www.parkinsons.org.au/what-is-parkinsons

To read the presented article on the benefits of tai chi in Parkinson's head to http://www.nejm.org/doi/full/10.1056/NEJMoa1107911

To see the appendix of the article head to http://www.nejm.org/doi/suppl/10.1056/NEJMoa1107911/suppl_file/nejmoa1107911_appendix.pdf