Journal of Novel Physiotherapies
Open Access

Balance; Fall; Elderly; Mental imagery; Tai chi exercises

Introduction

Fall is defined as any unintentional positional change that results in a person coming to rest on the ground floor, or other lower surface. The risk of fall increases dramatically with age [1]. Older adults, unintentional injuries are the fifth leading cause of death, and falls constitute two-thirds of these days [2]. Falls are the most serious common condition present in older adults causing injuries, social isolation, and psychological difficulties [3]. Deficiency or impairment in balance increases the risk of fall thus making it difficult to perform functional activities [4]. Decrease in balance ability resulting from aging triggers motor and gait disabilities in elderly people, which greatly affects their mobility in day-to-day life [5]. They are the serious cause of mortality and morbidity which leads to immobility and premature nursing care [5,6]. Falls occurred in more than one-third of the elderly aged 65 years and older annually [7]. The incidence of falls rises steadily from Middle age and peaks in persons older than 80 years. Approximately 30-50% of people living in long-term care institutions fall each year, and 40% of them experienced recurrent falls. Approximately 25% to 35% of people over age 65 years experiences more falls every year [7] several factors may influence the fall risk in the elderly to a great extent. Environmental hazards are the leading cause of falls, accounting for about 25 to 45 percent in most studies [8]. Major risk factors of fall among elderly population weakness, mobility impairment, balance and gait disturbance, Dizziness, vertigo, drop attacks, postural hypotension, visual impairment, and syncope are known to cause falls [9]. Lower extremity muscle weakness is a significant risk factor for falls, increasing the odds of falling fourfold. History of falls and gait or balance deficits increases the risk threefold [10]. Other high-risk situations that can cause or contribute to falls are the use of an assistive device, visual deficit, arthritis, and impaired activities of daily living, depression, cognitive impairment [11]. Use of medications has been strongly associated with an increased risk of falls. In particular, the use of psychotropic medications, have been Implicated in increasing the Effects of Yang Style Tai Chi Exercises Combined with Mental Imagery Training on Balance and Fall Prevention in Elderly Farah Naqvi1, Misbah Ghous2* and Saira Jahn2 1Physical Therapist, Railway General Hospital, Rawalpindi, Pakistan 2Faculty of Rehabilitation & Allied Health Sciences, Riphah College of Rehabilitation Sciences, Islamabad, Pakistan risk of falls. Tai chi exercises have more beneficial and health effects to maintain the good, physical, psychological conditions in older adults [12]. In previous studies have shown beneficial effects of Tai Chi on the cardiorespiratory system, flexibility, muscle strength, and body fat composition in middle-aged and elderly individuals [13,14]. Likewise, studies suggested that older adults who had been practicing Tai Chi Chuan for years had better balance and functional fitness compared to sedentary older adults [13]. Another study o mental imaginary concluded that the link between attentional demands, postural oscillations, static balance, and the prevention of falls among the elderly is of importance [15]. The reduction of attentional demands reflects the automaticity of a task [16]. It has been shown that mental imagery is an effective technique, not only in reducing anteroposterior postural oscillations but also in interpreting the postural control tasks more automatically [16,17]. Therefore, this technique may be considered effective among the elderly population, to contribute to improving their static balance and preventing falls [18]. A study was done by Page SJ, et.al with the title of a randomized efficacy and feasibility study of imagery in acute stroke. Published in 2001 and concluded that the Imagery technique is a clinically feasible intervention and Imagery, in association with therapy, appears to be a noninvasive, efficacious complement to traditional therapy. The current study was planned to fill the gap by finding out the combined effect of Yang style Tai Chi exercises with mental imagery training on balance and prevention of falls among older adults.

Materials and Methods

This was a randomized control trial, registered in Clinical Trials. gov Identifier: NCT04766112. After taking approval from the ethics committee of Riphah College of Rehabilitation Sciences, Riphah International University Islamabad, and Basharat Hospital Rawalpindi. The sample size was calculated through an Open-Epi calculator with 95% confidence interval (CI), power 80% while using the mean and standard deviation of the primary outcome measure based on literature. Non-probability convenience sampling technique was used and the sample size for this study. According to inclusion criteria those patients with age above 60 having fall problems, or at least one history of fall in the last 6 months with Berg balance score 21 to 40, intellectually ready to take in an activity program as evaluated with the SMMSE should be greater than 24 out of 30. Subjects were excluded if they: took medications that could affect balance; had a history of frequent falling; had vision problems, and had musculoskeletal/ neuromuscular/ cardiovascular impairments that restricted exercise.

Study participants and intervention program

The following tools were used for assessment, Berg Balance scale, fall efficacy Scale (FES), Timed Up and Go test (TUG), The Movement Imagery Questionnaire (MIQ-RS). Patients reported with fall problems were randomized into 2 groups i.e. Experimental Group and the Control Group with the help of the sealed envelope method. The patients in the experimental group received Yang style Tai chi exercise combined with mental imagery training which consists of different positions and the Control group received only Yang style Tai chi exercises and the outcomes of both groups were evaluated at baseline, 4th and at 8th week.

After screening for inclusion and exclusion criteria, subjects were provided with detailed information regarding the purpose of the study, procedures and tests, and the scheduled time of the TC exercise. If the subject agreed to proceed, he/she signed the informed consent form as approved by Institutional Review Board (IRB). The patients in the experimental group received Yang-style Tai chi exercise combined with mental imagery training. The Control group received only Yang-style Tai chi exercises only (Table 1, 2). The flow of participants is shown in CONSORT Figure 1.

Table 1: Intervention protocol

Table 2: Groups, the sessions in experimental and control group

Figure 1: CONSORT showing the process of participant recruitment and experiment implementation.

Measurement

Berg Balance Scale

The BBS is a 14-item scale that quantitatively assesses balance and risk for falls in an older community. The scale requires 10 to 20 minutes to complete and measures the patient's ability to maintain static or dynamic balance. The items are scored from 0 to 4, with a score of 0 representing an inability to complete the task and a score of 4 representing independent item completion [19]. A global score is calculated out of 56 possible points. Scores of 0 to 20 represent balance impairment, 21 to 40 represent acceptable balance, and 41 to 56 represent good balance [20]. It is also best in the assessment of psychometric properties, and the scale has shown to be a valid and reliable measure of balance and reliability of BBS was high with ICC=0.92 [21].

Fall efficacy Scale

This tool measures fear of falls in older adults. FES is a selfadministered 14 item scale, where individuals are instructed to score their concern of falling during an activity on a 4point Likert scale with 1 as not concerned at all and 4 as very concerned [22]. The item scores are summed up to obtain a total, with the higher the score, the higher being the concern for falling. Excellent test-retest reliability, and validity in both community-dwelling and geriatric nursing homedwelling individuals [23].

Timed Up and Go test (TUG)

The TUG test is most obvious and frequently used for the assessment of a person's mobility. It measures the time which is needed a patient to stand up from a chair with arm supports, 3m walk, turn back or come back to the chair and sit down [24]. The reliability of the TUG test was high, with an ICC of 0.99 for within-session reliability and 0.99 for test-retest reliability [25,26].

The Movement Imagery Questionnaire (MIQ-RS)

The MIQ-RS is a 14-item questionnaire that rates one's ability to imagine. The questionnaire consists of 7 visual and 7 kinesthetic items and requires 25–30 minutes to administer [27]. Test-retest examination showed high degrees of reliability ICC range:83-0.99) [28].

Statistical Analysis

Data were analyzed using IBM version SPSS 23. The demographic characteristics of the subjects were compared between the groups. The normality of data was checked at baseline to recognize the normal distribution of the data. Shapiro Wilk test indicated that data was not normally distributed for all four tests included in the study. Since the distribution of these variables was not approximately normal, the baseline scores and differences between post and pre-measures for BBS, FES, TUG, and MIQ were compared between the two groups using the Mann-Whitney U test. In each study group, comparisons between post and pre-measures after the TC exercise were assessed using the Wilcoxon Signed rank test. For the different balance tasks, changes between post and pre-measures were examined using paired t-test and between experimental and control groups using an independent t-test. The level of significance was set at p ≤ 0.05.

Results

According to above mentioned eligibility criteria, six participants were excluded due to some medical issues. A final total of sixty participants was include in the present study but two participants drop out from the experimental group due to schedule conflict (n=2), so 58 participants completed the study, mean age of experimental group was 63.94 ± 2.4 years and control group age was 63.51 ± 2.7 years. In the data, there were 36(63.3%) males and 22(36.6%) females. All females were housewives and males were enjoying retired life. At baseline there was no significant difference on all outcome measures between the experimental and control group (p>0.05)

After 8 weeks the mean Berg Balance score improved significantly in within group (p<0.01). However, there was no significant difference between the two groups (p=0.96). Similar findings were observed for the TUG test in between groups, it was non-significant (p=0.09) and in the within-group, it was significant (p<0.05). FES also showed similar findings in between groups, it was non-significant (p=0.23) and in within-group, it was significant (p<0.05). Whereas MIQ-RS showed significant improvements in within and between group analysis (p=0.001). Within groups showed balance improvements (figure 2) for the various tasks however, this improvement did not differ between groups (Table 3).

Figure 2: Mean of BBS, FES, TUG, MIQ-RS of within group (*Significant difference between pre and post exercise).

Table 3: Between group analysis for BBS, FES, TUG & MIQ-R.

Discussion

The purpose of this study was to evaluate the effects of Yang style Tai Chi exercises combined with mental imagery training on balance and fall prevention in elderly, the main findings of this study was TC exercises combined with mental imagery showed comprehensive improvement in experimental group as compared to TC exercises alone. After the 8-week of intervention participants score on BBS and TUG was significantly improved in both groups. A study was conducted, and they concluded as Tai Chi exercises have potential to decrease the prevalence of fall in older population. Tai Chi exercises shows the positive effects on balance and rapid decrease in fall related injuries. This study support the results of recent study with slightly difference in treatment plan they included only Tai Chi and recent study gives the results of Tai Chi along with mental imagery scale [1]. Literature indicated that elderly patients fall due to poor balance in this regard Tai Chi training were most suitable because they are more smooth, and slow patients feel comfortable and understanding with it [2,29]. Recent study also shows the similar results in control group patients improve their strength and balance by using Tai Chi exercise while addition of imagery training boost up the level of balance [30].

Risk of fall was measured by fall efficacy scale in both experimental and control group, the results shows that there was a significant improvement in balance and marked reduction in risk of fall in both groups with decrease of p value of 0.42 to 0.23 while within group p was <0.001. Previous study shows significant decline in risk of fall in older adults by mental imagery training [31]. So the findings of this study strongly correlate with the recent study [32]. The results indicated that after 8-weeks of training older adults demonstrated significant improvement on gait, balance and decrease fall risk [33,34]. It is worth mentioning that the value of these parameters of the older participants were consistent with those reported in a previous study and participants overall muscular strength and flexibility increased, which created positive effects on their mobility level [35]. Wingert JR, Corel CE et al. done a study in 2020 and they concluded that community based Tai Chi trainings boost up the balance in elderly population. Tai Chi also improves the sensory motor changes especially faster hip abductors muscle contraction speed, and improved hip proprioception. Results are somewhat similar to the current study as balance was improved (P=0.001) within group analysis [36].

A systemic review was done by Huang HW, Nicholson N et al. in 2019 and they concluded that Tai Chi training can diminish fall hazard in elderly population and improves dynamic equilibrium control and adaptability of people with balance and vestibular problems [36,37]. Similar results was observed in recent study and concluded that both constant pain and fear of falling can produce movement limitation and increased risk of fall among weak elderly population. Mental Imagery Training decreases the risk of fall and improves functional status of the patients [38,39]. In conclusion, an 8-week Tai chi training may change gait parameters, lower-limb flexibility, and range of motions to decrease risk of falls in older adults [39].

Study Limitations

This study has examined the mobility level, balance, and risk of fall in elderly, individual gait parameters, like step length, stride length, speed and accuracy were not measured. In future studies, it is recommended to use kinetic and kinematic data for gait assessment and functional status. As TC improves muscle flexibility and joints range of motion, it was not examined individually so future studies should also examine this.

Conclusion

Based on the findings of this study, it is concluded that both techniques have equal effects in improving mobility, and functional status of older adults. TC when combined with MI produces positive effects on balance and marked reduction in the risk of fall.

Acknowledgments

Author Contributions: Misbah Ghous and Farah Naqvi conceived and designed the experiments; performed the experiments; Sania Khawar Kiyani and Iqbal Tariq analyzed the data; Aroosa Tariq and Mehwish Butt contributed reagents/materials/analysis tools; and wrote the paper.

Conflicts of Interest:

The authors declare that they have no conflicts of interest.

Institutional Review Board: This study was approved by the research ethics committee of Riphah College of Rehabilitation Sciences, Riphah International University Islamabad, and Basharat Hospital Rawalpindi.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper.

1. Pata RW, Lord K, Lamb J (2014) The effect of Pilates based exercise on mobility, postural stability, and balance in order to decrease fall risk in older adults. J Bodyw Mov Ther 18: 361-367.

Indexed at, Google Scholar, Crossref

2. Leveille S (2019) Chronic pain, fear of falling, and restricted activity days in an older population. Innov Aging 3: 18.

Indexed at, Google Scholar, Crossref

3. Prasertsakul T, Kaimuk P, Chinjenpradit W, Limroongreungrat W, Charoensuk W (2018) The effect of virtual reality-based balance training on motor learning and postural control in healthy adults: a randomized preliminary study. Biomed Eng Online 17: 1-17.

Indexed at, Google Scholar, Crossref

4. Hosseini L, Kargozar E, Sharifi F, Negarandeh R, Memari A-H, et al. (2018) Tai Chi Chuan can improve balance and reduce fear of falling in community dwelling older adults: a randomized control trial. J Exerc Rehabil 14:1024.

Indexed at, Google Scholar, Crossref

5. Huang Z-G, Feng Y-H, Li Y-H, Lv C-S (2017) Systematic review and meta-analysis: Tai Chi for preventing falls in older adults. BMJ open 7: 013661.

Indexed at, Google Scholar, Crossref

6. Schleicher MM, Wedam L, Wu G (2012) Review of Tai Chi as an effective exercise on falls prevention in elderly. Res Sports Med 20: 37-58.

Indexed at, Google Scholar, Crossref

7. Hu Y-N, Chung Y-J, Yu H-K, Chen Y-C, Tsai C-T, et al. (2016) Effect of Tai Chi exercise on fall prevention in older adults: systematic review and meta-analysis of randomized controlled trials. Int J Gerontol 10: 131-136.

Google Scholar, Crossref

8. Kim H-D (2009) Effects of Tai Chi exercise on the center of pressure trace during obstacle crossing in older adults who are at a risk of falling. J Phys Ther Sci 21: 49-54.

Google Scholar, Crossref

9. Park M, Song R (2013) Effects of Tai Chi on fall risk factors: A meta-analysis. J Korean Acad Nurs 43: 341-351.

Indexed at, Google Scholar, Crossref

10. Wu G, Keyes L, Callas P, Ren X, Bookchin B (2010) Comparison of telecommunication, community, and home-based Tai Chi exercise programs on compliance and effectiveness in elders at risk for falls. Arch Phys Med Rehabil 91: 849-856.

Indexed at, Google Scholar, Crossref

11. Tousignant M, Corriveau H, Roy P-M, Desrosiers J, Dubuc N, et al. (2012) The effect of supervised Tai Chi intervention compared to a physiotherapy program on fall-related clinical outcomes: a randomized clinical trial. Disabil Rehabil 34: 196-201.

Indexed at, Google Scholar, Crossref

12. Wu Y, MacDonald HV, Pescatello LS (2016) Evaluating exercise prescription and instructional methods used in tai chi studies aimed at improving balance in older adults: a systematic review. J Am Geriatr Soc 64: 2074-2080.

Indexed at, Google Scholar, Crossref

13. Wayne PM, Hausdorff JM, Lough M, Gow BJ, Lipsitz L, et al. (2015) Tai chi training may reduce dual task gait variability, a potential mediator of fall risk, in healthy older adults: cross-sectional and randomized trial studies. Front Hum Neurosci 9: 332.

Indexed at, Google Scholar, Crossref

14. Penn I-W, Sung W-H, Lin C-H, Chuang E, Chuang T-Y (2019) Effects of individualized Tai-Chi on balance and lower-limb strength in older adults. BMC Geriatr 19: 1-8.

Indexed at, Google Scholar, Crossref

15. Leung DP, Chan CK, Tsang HW, Tsang WW, Jones AY (2011) Tai chi as an intervention to improve balance and reduce falls in older adults: A systematic and meta-analytical review. Altern Ther Health Med 17.

Indexed at, Google Scholar

16. Mirelman A, Maidan I, Deutsch JE (2013) Virtual reality and motor imagery: promising tools for assessment and therapy in Parkinson's disease. Mov Disord 28: 1597-1608.

Indexed at, Google Scholar, Crossref

17. Alsubiheen A, Petrofsky J, Daher N, Lohman E, Balbas E (2015) Effect of tai chi exercise combined with mental imagery theory in improving balance in a diabetic and elderly population. Med Sci Monit 21: 3054.

Indexed at, Google Scholar, Crossref

18. Lu X, Siu K-C, Fu SN, Hui-Chan CW, Tsang WW (2013) Tai Chi practitioners have better postural control and selective attention in stepping down with and without a concurrent auditory response task. Eur J Appl Physiol 113: 1939-1945.

Indexed at, Google Scholar, Crossref

19. Santos GM, Souza A, Virtuoso JF, Tavares G, Mazo GZ (2011) Predictive values at risk of falling in physically active and no active elderly with Berg Balance Scale. Rev Bras Fisioter 15: 95-101.

Indexed at, Google Scholar, Crossref

20. Neuls PD, Clark TL, Van Heuklon NC, Proctor JE, Kilker BJ, et al. (2011) Usefulness of the Berg Balance Scale to predict falls in the elderly. J Geriatr Phys Ther 34: 3-10.

Indexed at, Google Scholar, Crossref

21. Ferraz H, Babaei-Ghazani A (2014) Sensitivity and specificity of individual Berg balance items compared with the total score to predict falls in community dwelling elderly individuals. Int J Physiother 1: 58-65.

Google Scholar                     

22. Jeon B-J (2013) The effects of obesity on fall efficacy in elderly people. J Phys Ther Sci 25: 1485-1489.

Indexed at, Google Scholar, Crossref

23. Kwak C-J, Kim YL, Lee SM (2016) Effects of elastic-band resistance exercise on balance, mobility and gait function, flexibility and fall efficacy in elderly people. J Phys Ther Sci 28: 3189-3196.

Indexed at, Google Scholar, Crossref

24. Muhla F, Clanché F, Duclos K, Meyer P, Maïaux S, et al. (2020) Impact of using immersive virtual reality over time and steps in the Timed Up and Go test in elderly people. Plos one 15(3):e0229594.

Indexed at, Google Scholar, Crossref

25. Rydwik E, Bergland A, Forsén L, Frändin K (2011) Psychometric properties of Timed Up and Go in elderly people: a systematic review. Phys Occup Ther Geriatr 29: 102-125.

Google Scholar, Crossref

26. Nightingale CJ, Mitchell SN, Butterfield SA (2019) Validation of the timed up and go test for assessing balance variables in adults aged 65 and older. J Aging Phys Act 27: 230-233.

Indexed at, Google Scholar, Crossref

27. Roberts R, Callow N, Hardy L, Markland D, Bringer J (2008) Movement imagery ability: development and assessment of a revised version of the vividness of movement imagery questionnaire. J Sport Exerc Psychol 30:200-221.

Indexed at, Google Scholar, Crossref

28. Collet C, Guillot A, Lebon F, MacIntyre T, Moran A (2011) Measuring motor imagery using psychometric, behavioral, and psychophysiological tools. Exerc Sport Sci Rev 39: 85-92.

Indexed at, Google Scholar, Crossref

29. Tousignant M, Corriveau H, Roy P-M, Desrosiers J, Dubuc N, Hebert R (2013) Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial. Disability and rehabilitation 35: 1429-1435.

Indexed at, Google Scholar, Crossref

30. Abdoli B, Shams A, Shamsipour Dehkordi P (2020) The effect of practice type on static and dynamic balance in elderly 60-75 year old women with no history of falling. Daneshvar Medicine: Basic Clin Res J 19: 43-50.

Google Scholar

31. Ruffino C, Bourrelier J, Papaxanthis C, Mourey F, Lebon F (2019) The use of motor imagery training to retain the performance improvement following physical practice in the elderly. Exp Brain Res 237: 1375-1382.

Indexed at, Google Scholar, Crossref

32. Zhuang M, Li J, Chen H, Yang Y, Song X, et al. (2021) Research Progress on Risk Factors and Prevention Strategies of Falls in Elderly Inpatients. Int J Clin Exp Med 5: 101-105.

Google Scholar

33. Kawasaki T, Tozawa R, Aramaki H (2018) Effectiveness of using an unskilled model in action observation combined with motor imagery training for early motor learning in elderly people: A preliminary study. Somatosens Mot Res 35: 204-211.

Indexed at, Google Scholar, Crossref

34. Gabbard C, Fox A (2013) Using motor imagery therapy to improve movement efficiency and reduce fall injury risk. J Nov Physiother 3: 186.

Google Scholar, Crossref

35. Sakurai R, Fujiwara Y, Yasunaga M, Suzuki H, Sakuma N, et al. (2017) Older adults with fear of falling show deficits in motor imagery of gait. J Nutr Health Aging 21: 721-726.

Indexed at, Google Scholar, Crossref

36. Beaudoin M, Barra J, Dupraz L, Mollier-Sabet P, Guerraz M (2020) The impact of embodying an “elderly” body avatar on motor imagery. Exp Brain Res 238: 1467-1478.

Indexed at, Google Scholar, Crossref

37. Huang H-W, Nicholson N, Thomas S (2019) Impact of Tai Chi exercise on balance disorders: a systematic review. Am J Audiol 28: 391-404.

Indexed at, Google Scholar, Crossref

38. Gomez-Pilar J, Corralejo R, Nicolas-Alonso LF, Alvarez D, Hornero R (2016) Neurofeedback training with a motor imagery-based BCI: neurocognitive improvements and EEG changes in the elderly. Med Biol Eng Comput 54(11): 1655-1666.

Indexed at, Google Scholar, Crossref

39. Maciaszek J, Osiński W (2010) The effects of Tai Chi on body balance in elderly people-a review of studies from the early 21st century. Am J Chin Med 38: 219-229.

Indexed at, Google Scholar, Crossref