Gait, posture and transfer assessment among elderly practitioners and non-practitioners of Tai Chi Chuan

doi:10.4236/health.2013.512A016

Paper Menu >>

Journal Menu >>

Vol.5, No.12A, 117-121 (2013) Health

http://dx.doi.org/10.4236/health.2013.512A016

Gait, posture and transfer assessment among

elderly practitioners and non-practitioners of Tai Chi

Chuan

Miguel Antonio Rahal, Félix Ricardo Andrusaitis, Thuan Silva Rodrigues,

Angelica Castilho Alonso*, Julia Maria D’ Andrea Greve, Luiz Eugênio Garcez Leme

Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil; *Corresponding Author: [email protected]

Received 24 October 2013; revised 25 November 2013; accepted 15 December 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Falls may be devastating events among elderly

people. Tai Chi Chuan is a type of moderate

sports exercise that demonstrates improve-

ment s in balance, gait and postu re. The aim here

was to assess the influence of this method on

the balance, gait and posture of healthy active

elderly people. A controlled cross-sectional stu-

dy was conducted on 76 volunteers, divided into

two groups: 51 volunteers Tai Chi Chuan group

mean age 76.8 years and 25 volunteers control

group mean age 70.3 years. Both groups un-

derwent the Modified Clinical Test on Sensory

Interaction for Balance (mCTSIB), Walking Test

(WT), Sit-to-Stand Transfer Test (SSTT) and

Unipedal Assessment Test (UT), using the Neu-

rocom Balance Master system. Result: In condi-

tions Static balance tests: the mCTSIB-Tai-Chi

Group had a lower sway velocity (°/s) on a firm

surface with eyes open and medio-lateral direc-

tion, Foam Surface w ith eyes open medio-lateral

and anteroposterior direction. Unilateral Stance

Tai-Chi Group had a lower mean sway velocity

(°/s) with open eyes (right and left), but with

eyes closed. The Control Group showed a lower

sway velocity. Under Dynamic Balance: Walk

Across Test Tai-Chi Group presented a w alking

speed greater than the Control Group. In Sit to

Stand Transfer Test, Tai-Chi Group showed a

better index rising to lift up and lower oscilla-

tion in the final standing position. Conclusion:

The Tai Chi Group was shown to be a protec-

tion factor for preserving and maintaining the

static and dynamic positions of posture and

gait.

Keywords: Elderly P eo pl e; Tai Chi Chuan;

Assessment; Balance; Gait

1. INTRODUCTION

One of the main recommendations for improving

quality of life and maintaining autonomy and independ-

ence is to remain active, keep up cognitive abilities and

preserve locomotor skills.

It has been estimated that balance complaints affect

85% of the population over the age of 65 years [1,2]

thereby leading to the loss of independence and auton-

omy. These complaints may result from health problems

[1-3] such as falls, which form the main cause of frac-

tures, particularly those of the femur [4]. Prevention of

such problems is a major challenge for individuals, their

families, healthcare professionals and public policy.

Rubenstein [5] advocated programs that placed value

on physical fitness through increased cardiovascular re-

sistance, strength and flexibility and improved body

composition, thereby reducing the risks of instability and

falls. Gait and balance analysis may contribute to this

and indicate new preventive programs for this age group

of the population [6,7].

All programs involving posture and balance training

have shown reductions in the frequency of falls up to

48% over the first 16 weeks of training. The best ex-

ample of this was found using Tai Chi Chuan: in the Fit-

ness, Arthritis and Seniors Trial (FAST) [8], and this

technique demonstrated the best results relating to de-

creased risk of falls, among all the comparison groups.

Gomes et al. [9] conducted a wide-ranging review of

studies in Medline covering Tai Chi Chuan for elderly

people and how this activity might prevent falls. In a

review of papers in the Cochrane database, Verguese et

al. [10] stated that Tai Chi Chuan is a method that re-

duces the risk of falls by 47%.

M. A. Rahal et al. / Health 5 (2013) 117-1 21

118

The aim of this project was to evaluate balance, gait

and transfers postural among elderly practitioners and

non-practitioners of Tai Chi Chuan.

2. METHODS

This was a controlled cross-sectional observational

study (practice of Tai Chi Chuan versus controls). Bal-

ance and gait were analyzed at the Movement Laboratory

of the Institute of Orthopedics and Traumatology, Hospi-

tal das Clínicas, School of Medicine of the University of

São Paulo (LEM-IOT-HCFMUSP). Written consent was

mandatory for study participation. The study was per-

formed through approval granted by the Ethics Commit-

tee number nº 401/06.

Out of the 76 patients evaluated, 56 were female

(73.7%) and 20 were male (26.3%) (Ta ble 1). The mean

age of the Tai Chi Chuan practitioners (N = 51) was 76.8

years, with a maximum of 88 and minimum of 67 years.

The mean age of the non-practitioners (N = 25) was 70.3

years, with a maximum of 85 years and minimum of 60

years, The Tai Chi Chuan practitioners were significant

older than non-practitioners (P < 0.0001) and no signifi-

cant difference between the distribution of genders be-

tween groups (χ²-0.621; p = 0.431).

They were all capable of moving their body weight on

a single leg in the Biodelta leg press apparatus. The indi-

viduals were divided into two groups: Practitioners of Tai

Chi Chuan for more than two years, using the Lian-Gun

variant technique adapted for elderly people (Tai Chi

Chuan group). Independent volunteers living in the

community, over the age of 60 years. (Control group).

The inclusion criteria were as follows: 1) Falls over

the last three months; 2) Painful or insensitive feet; 3)

Neurological deficit with impairment of the lower limbs;

4) Inability to walk; 5) Amputations at any level on the

lower limbs; 6) Surgical interventions on the feet at the

time of the study; 7) Presence of amaurosis; 8) States of

dementia; 9) Use of any auxiliary means for gait, for any

reason; 10) Painful or incapacitating conditions in the

lower limbs; 11) Pathological processes in the feet, knees

and/or hips; 12) Any degree of dependence relating to

activities of daily living; m) Presence of hallux valgus

exceeding 30˚;13) Inability to go up a flight of stairs

consisting of eight steps.

2.1. Equipment

The platform used was the Balance Master System

(BMS), made by Neurocom International Inc®, Clacka-

mas, USA, accompanied by version 8.3 of the operating

software. It was 1.40 meters in length by 0.43 meters in

width and had four force sensors connected to the soft-

ware. The sensors enabled measurement of each indi-

vidual’s pressure center from the mean horizontal and

Table 1. Characterization of the sample according to sex and

group.

Group Female% Male % Total%

Tai Chi Chuan group39 76.5 12 23.5 5167.1

Control group 17 68.0 8 32.0 2532.89

Total 56 73.68 20 26.3 76100.0

vertical forces exerted by the feet [11,12].

All tests were performed by the same evaluator and

standardized in respect of positioning and testing. The

NeuroCom Balance Master® has multiple testing proto-

cols designed to examine balance. This study used for

Static balance protocol: Modified Clinical Test of Sen-

sory Interaction on Balance (mCTSIB) and Unilateral

Stance. Dynamic balance protocol: Walk Test and Sit-to-

stand transfer test. The equipment has good reliability and

reproducibility by researchers (ICC 0.53 to 0.81) [13].

2.2. Statistical Analysis

The data were entered into the Excel software (Mi-

crosoft, 2007), within the Microsoft® Office package.

The results were calculated by means of the Sigma Stat

software (Jandel Corporation, 1995).

For the association between the sexes in the Balance

and Volunteers groups, the chi-square test (2) was used.

To compare ages between the two groups, the Mann-

Whitney test was used. This test was also used for all the

comparisons between the two groups regarding the

Modified Clinical Test on Sensory Interaction for Bal-

ance (MCTSIB), Walking Test (WT), Sit-to-Stand Trans-

fer Test (SSTT) and Unipedal Assessment Test (UT).

3. RESULTS

3.1. Static Balance

Modified Clinical Test of Sensory Interactionon Bal-

ance (mCTSIB)—Tai-chi Group had a lower sway veloc-

ity in degrees per second (°/s): on a firm surface in the

medio-lateral direction with eyes open and in surface

foam with eyes closed in the mediolateral and antero-

posterior direction, on a condition eyes closed only in

surface foam in the medio-lateral direction.

Unilateral Stance Tai-chi group had a lower sway ve-

locity in degrees per second (°/s) with open eyes (right

and left), but with eyes closed, the Control Group had

lower sway velocity (Table 2).

3.2. Dynamic Balance

In Walk Across Test Group Tai-Chi presented a walk-

ing speed while greater than the Control Group.

In Sit to Stand Transfer Test Tai-Chi Group showed a

better index rising to lift up and lower oscillation in the

final position standing (Table 3).

M. A. Rahal et al. / Health 5 (2013) 117-1 21

119

Tabl e 2. Comparison between Tai-Chi Group and Control Group by eyes, surface and side leg stance in terms of static balance pro-

tocol.

Tai-Chi-Chuan Group Median No-Practicant Group Median p

mCTSIB test (°/s)

Open Eyes

Firm Surface mediolateral 0.100 −0.400 0.02*

Firm Surface anteroposterior -0.300 −0.600 0.55

Foam Surface mediolateral 0.100 −0.600 0.05*

Foarm Surface anteroposterior 1.500 1.000 0.25

Closed Eyes

Firm Surface mediolateral 0.300 −0.200 0.03*

Firm Surface anteroposterior 0.200 −0.300 0.39

Foam Surface mediolateral 0.300 −0.350 0.11

Foarm Surface anteroposterior 1.300 0.500 0.25

Unilateral Stance (˚/s)

Open Eyes

Mean Right Leg Stance 1.200 1.700 0.00*

Mean Left Leg Stance 1.150 1.800 0.00*

Closed Eyes

Mean Right Leg Stance 3.400 2.400 0.00*

Mean Left Leg Stance 3.400 1.900 0.00*

Test Mann Whitney *p < 0.005. Legend: mCTSIB—Modified Clinical Test of Sensory Interaction on Balance; M—mean.

Tabl e 3. Comparison between Tai-Chi Chuan Group and No Practicant Group in terms of dynamic balance protocol (gait and trans-

fers).

Tai-chi-chuan Group

Median

No-Practicant

Group

Median

Walk across

Mean Step width (cm)

Speed (cm/s)

End sway velocity(degrees/s)

10.400

21.250

4.600

10.800

18.300

6.300

0.31

0.00*

0.10

Sit to Stand

Rising Index (%) 22.000 16.000 0.00*

COG Sway Velocity (degrees/sec) 3.600 5.200 0.01*

Test Mann-Whitney. *p < 0.005 Legend: COG = center of gravity.

4. DISCUSSION

With increasing life expectancy, increasing numbers of

elderly people in Brazil and improvements in quality of

life, studies on balance and gait abnormalities increas-

ingly involve analyses that attempt to create strategies

for recognizing and preventing incapacity and the onset

of frailness.

Activities that emphasize balance reduce the risk of

falls. They improve muscle strength in the lower limbs

and vertebral column and improve postural reaction

times. There are increases in locomotion velocity, flexi-

bility and stability when stopping a movement [14].

Regarding the tests applied, we observed that the eld-

erly people in the group undergoing balance training by

means of Tai Chi group presented a greater mean age

than that of the control group. The mean age in the bal-

ance training group was 76.8 years, versus 70.3 years in

the control group. Hence, one group was theoretically

characterized as presenting greater risk of falls and lower

capacity for balance and posture [1,14-16] However, the

battery of tests showed:

Modified Clinical Test on Sensory Interaction for

Balance (MCTSIB): This test had the aim of analyzing

posture under circumstances of suppression of visual

information and modification of somatosensory informa-

tion, separately or in association [10,17]. In our study, we

found that Thai Chi group presented quantitative advan-

tages, especially when the experimental conditions in-

volved vision and a stable surface. These Tai Chi Chuan

practitioners maintained increased reserves of balance, in

the same way as described by others authors [17-19].

The velocity of postural oscillation was lower on sta-

M. A. Rahal et al. / Health 5 (2013) 117-1 21

120

ble surfaces when vision was maintained. When vision

was suppressed, both groups were affected, but the Tai

Chi group had a greater adaptive capacity for keeping an

erect posture, in the same way reported in others studies

[17,20,21].

With wider oscillations and a capacity for recovery of

balance, better results were obtained on the unstable sur-

face. The Tai Chi group presented better performance,

but without any statistical difference.

Anteroposterior stability is lower than side-to-side sta-

bility in humans because of the support base formed by

the feet. This characteristic may explain the loss of sta-

bility at the time when movement is made in the antero-

posterior direction. The Tai Chi group showed better ad-

aptation because of its training in this situation.

Walking Test: This presented movement velocity data

consisting of the mean locomotion velocity of the center

of mass, going towards the target. In this, Tai Chi group

presented better scores than did the control group. This

was contrary to the findings from the studies of authors

like Quesada et al. [22] and Rejeski et al. [23], consider-

ing that all practitioners of physical activities should be

benefited equally, although the Tai Chi group was the

best. The movement velocity may translate anticipatory

or even compensatory adjustments in relation to the pos-

tural disorders that existed. Our study was concordant

with the findings of Thimoty [24] and Gomes et al. [9].

The final postural oscillation and the progression veloc-

ity can be explained by the greater difficulty in returning

to stability after locomotion. Thus, greater postural os-

cillation would be given by lower ability of the compen-

satory mechanisms. The Tai Chi group presented better

results.

Unipedal Test: This demonstrated that when one

group was trained for balance exercises, it presented

scores greater than those of the volunteers, which was in

agreement with Gomes et al. [9]. The Tai Chi Group

presented smaller oscillations when in the unipedal posi-

tion, because of controls of greater efficiency in the body

adjustment mechanisms, as also observed by others study.

[9,25-27].

Sit-to-Stand Transfer Test: The Tai Chi Group pre-

sented favorable results regarding the mean rising index

(is the amount of force exerted by the legs during the

rising phase, expressed as a percent of body weight) to

perform the task, as also shown by Condron et al. [27]

There was no pain or fear while performing the task, and

all subjects in the Tai Chi Group presented better final

oscillation results. Once center of gravity has moved

forward enough to be over the feet (new base of support),

the upper body must decelerate to stop the forward mo-

tion. The legs must extend, pushing down against the

surface to produce counterforce sufficient to raise the

body to a standing position. Insufficient force will result

in a failure to rise to a upright position. Higher scores are

good, and low scores are worse [11].

5. CONCLUSIONS

In the light of the conditions presented in this study,

we conclude the following:

Tai Chi Chuan was shown to be a protection factor for

preserving and maintaining the static and dynamic posi-

tions of posture and gait.

The locomotion capacity of the Tai Chi Chuan group

was greater in the evaluation on movement velocity. The

oscillation of the center of gravity was smaller with steps

that were more secure.

The capacity for transferring from the sitting to the

standing position was greater among the Tai Chi Chuan

practitioners.

The Tai Chi Chuan practitioners were more secure in

the tests on locomotion of the center of mass. They re-

sumed their posture when there were oscillations of

movement.

REFERENCES

[1] Tinetti, M.E. (2003) Preventing falls in elderly persons.

The New England Journal of Medicine, 348, 42-49.

http://dx.doi.org/10.1056/NEJMcp020719

[2] Hirvonen, T.P., Alto, H., Pyykko, I., Juhola, M. and Jantti,

P. (1997) Changes in vestibulo-ocular reflex of elderly

people. Acta Oto-Laryngologica, 117, 108-410.

http://dx.doi.org/10.3109/00016489709124097

[3] Telles, A.C.M. (2008) Prevalência, incidência, fatores

preditivos e impacto das quedas entre as pessoas idosas

no Município de São Paulo: Uma análise longitudinal.

Thesis, Escola de Enfermagem, Universidade de São

Paulo, São Paulo.

[4] Van Schoor, N.M., Smit, J.H., Twisk, J.W., et al. (2003)

Prevention of hip fractures by external hip protectors: A

randomized controlled trial. Journal of the American

Medical Association, 289, 1957-1962.

http://dx.doi.org/10.1001/jama.289.15.1957

[5] Rubenstein, L.Z. (2006) Falls in older people: Epide-

miology, risk factors and strategies for prevention. Age

and Ageing, 35, 37-41.

[6] Wu, G. (2002) Evaluation of the effectiveness of tai chi

for improving balance and preventing falls in the older

population: A review. Journal of the American Geriatrics

Society, 50, 746-754.

http://dx.doi.org/10.1046/j.1532-5415.2002.50173.x

[7] Tinetti, M.E. (2203) Clinical practice. Preventing falls in

elderly persons. The New England Journal of Medicine, 2,

42-49.

[8] Gillespie, L.D., Gillespie, W.J., Cummings, R., et al.

(2000) Interventions for preventing falls in the elderly

(cochrane review). The Cochrane Library, Issue 1.

Update Software, Oxford.

[9] Gomes, L., Pereira, M.M. and Assunção, L.O.T. (2204)

M. A. Rahal et al. / Health 5 (2013) 117-1 21

121

Tai chi chuan: Nova modalidade de exercícios para idosos.

Revista Brasileira de Ciência e Movimento, 12, 89-94.

[10] Verghese, J., Buschke, H. and Viola, L. (2002) Validity of

divided attention tasks in predicting falls in older indi-

viduals: A preliminary study. Journal of the American

Geriatrics Society, 50, 1572-1576.

http://dx.doi.org/10.1046/j.1532-5415.2002.50415.x

[11] Brech, G.C., Alonso, A.C., Luna, N.M. and Greve, J.M.

(2013) Correlation of postural balance and knee muscle

strength in the sit-to-stand test among women with and

without postmenopausal osteoporosis. Osteoporosis

International, 24, 2007-2013.

[12] Gil, J., Allum, J.H., Carpenter, M.G., Adkin, A.L. and

Pierchala, K. (2001) Trunk sway measures of postural

stability during clinical balance tests: Effects of age. The

Journals of Gerontology, 56, 438-447.

[13] Loughran, S., Tennant, N., Kishore, A. and Swan, I.R.

(2005) Interobserver reliability in evaluating postural

stability between clinicians and posturography. Clinical

Otolaryngology, 30, 255-257.

http://dx.doi.org/10.1111/j.1365-2273.2005.00988.x

[14] Tinetti, ME. (2001) Guideline for the prevention of falls

in older persons. Journal of the American Geriatrics So-

ciety, 49, 666.

[15] Bruce, D.G., Devine, A., Prince, R.L., et al. (2002) Rec-

reational physical activity levels in healthy older women.

The importance of fear of falling. Journal of the Ameri-

can Geriatrics Society, 50, 84-89.

http://dx.doi.org/10.1046/j.1532-5415.2002.50012.x

[16] Tinetti, M.E., Speechey, M. and Ginter, S.F. (1988) Risk

factors for falls among elderly person living in the com-

munity. The New England Journal of Medicine, 319,

1701-1707.

http://dx.doi.org/10.1056/NEJM198812293192604

[17] Tomomitsu, M.S., Alonso, A.C., Morimoto, E., Bobbio,

T.G. and Greve, J.M. (2013) Static and dynamic postural

control in low-vision and normal-vision adults. Clinics,

68, 517-521. http://dx.doi.org/10.6061/clinics/2013(04)13

[18] Baloh, R., Fife, T., Zwerling, L., et al. (1994) Comparison

of static and dynamic posturography in young and older

normal people. Journal of the American Geriatrics Soci-

ety, 42, 405-412.

[19] Bernhardt, J., Hill, K., Ellis, P., et al. (1998) Changes in

balance and locomotion measures during rehabilitation

after stroke. Physiotherapy Research International, 3,

109-122. http://dx.doi.org/10.1002/pri.130

[20] Woollacott, M.H. (1987) Neuromuscular control of pos-

ture in the child: Is vision dominant? Journal of Motor

Behavior, 19, 167-182.

http://dx.doi.org/10.1080/00222895.1987.10735406

[21] Barela, J.A. (1995) The use of somatosensory information

of balance control in humans. Human Movement Science,

14, 13-43.

http://dx.doi.org/10.1016/0167-9457(94)00048-J

[22] Quesada, P.M. and Rash, G.S. (2000) Quantitative as-

sessment of simultaneous capacitive and resistive plantar

pressure measurements during walking. Foot & Ankle In-

ternational, 21, 928-934.

[23] Rejeski, W.J., Brawley, L.R., et al. (1997) Compliance to

exercise therapy in older participants with knee os-

teoarthritis: Implications for treating disability. Medicine

& Science in Sports & Exercise, 29, 977.

http://dx.doi.org/10.1097/00005768-199708000-00001

[24] Thimoty, C.H. (1999) Effects of tai-chi on balance. Ar-

chives of Otolaryngology—Head and Neck Surgery, 125,

1191-1195.

http://dx.doi.org/10.1001/archotol.125.11.1191

[25] Era, P., Sainio, P. and koskinen, S.(2006) Postural Bal-

ance in a random sample of 7979 subjects aged 30 years

and over. Gerontology, 52, 204-213.

http://dx.doi.org/10.1159/000093652

[26] Baloh, R., Fife, T., Zwerling, L., et al. (1994) Comparison

of static and dynamic posturography in young and older

normal people. Journal of the American Geriatrics Soci-

ety, 42, 405-412.

[27] Condron, J.E., Hill, K.D. and Dip, G. (2002) Reliability

and validity of a dual-task force platform assessment of

balance performance: Effect of age, balance. Journal of

the American Geriatrics Society, 50, 157-162.

http://dx.doi.org/10.1046/j.1532-5415.2002.50022.x