# Exercise as it relates to Disease/Tai Chi & Parkinson's: Finding the balance within

This is an analysis and summary of the article "Tai Chi improves balance and mobility in people with Parkinson disease" by Madeleine Hackney and Gammon Earhart (2008).

## Parkinson's disease
### Background

Parkinson's disease (PD) is a chronic degenerative neurological disorder that affects 70,000 people in Australia. There is currently no known cause of PD, however research suggests that a combination of genetics, environmental factors, exposure to pesticides/toxins and certain medications may play a role to its development. People with PD present with symptoms such as slowness in movement, muscle rigidity, tremors, difficulty coordinating and initiating movement, decreased reaction time, low mood and reduced balance and mobility. Treatment currently includes levodopa medication that increases the amount of dopamine being absorbed by the brain, as well as physical activity and exercise to slow the progression of the disease.

### Where is the research from?

This pilot study was conducted at the Washington University School of Medicine in the:
* Department of Anatomy and Neurobiology
* Department of Neurology
* Program of Physical Therapy

### What kind of research was this?

This was a randomised control trial that aimed to determine the effects of Tai Chi on balance, gait and mobility in people with PD when compared to a control group, after identifying the lack of controls in previous research. It was a simple coin toss randomisation, single blind study with an intervention and control group. Whilst the author was not blinded, all participant assessments were recorded in order to maintain blinding of the assessor.
The study was funded by the American Parkinson's Disease Association, however the sponsor played no further role in the design of the study, collection of data, analysis or interpretation of data, writing of the manuscript, or decision to publish.

### Research Methods

The study included 33 participants based off the following inclusion and exclusion criteria in the table below:
| Inclusion Criteria | Exclusion Criteria |
| Age >40 years old Able to stand independently (with or without a gait aid) for minimum of 30 minutes Could walk independently (with or without a gait aid) for at least 3 metres Had a Hoehn & Yahr score ranging from 1.5–3 Diagnosed with idiopathic Parkinson’s disease by a neurologist | A serious medical condition History or evidence of a pre-existing neurological condition that is not related to Parkinson’s disease that could interfere with function such as a stroke or neuromuscular disorder |
After participants were recruited, they were randomly assigned to:
* Intervention group – twice weekly 1 hour lessons, completing 20 sessions within 13 weeks.
* Control group – no intervention
The intervention group was measured at baseline one week prior to commencing the Tai Chi and then again after completing 20 classes. The control group were assessed at the same time interval as the intervention group. When statistically compared, the two groups did not differ significantly in age, Unified Parkinson's Disease Rating Scale Motor Subscale 3 score, Hoehn & Yahr score, or years since diagnosis with PD. The authors use several outcome measures to assess the participants, most of which are validated for Parkinson’s disease. These include the UPDRS, Berg Balance Scale (BBS), tandem stance test, one leg stance test, Timed Up and Go (TUG), forward and backwards walking, and six-minute walk test (6MWT).

### Results

The results suggest that Tai Chi can help improve balance, gait and functional mobility in PD. The intervention group showed significant improvement on the UPDRS, BBS, TUG, tandem stance, and 6MWT. The table below shows the mean results ± S.D.
| | Tai Chi | Control |
| UPDRS | -1.5 ± 6.6 | 4.5 ± 5.6 |
| BBS | 3.3 ± 3.0 | -0.5 ± 2.1 |
| TUG | -1.0 ± 0.1 | -0.1 ± 1.1 |
| Tandem stance | 8.3 ± 14.1 | -11.6 ± 24.5 |
| 6MWT | 44.4 ± 65.9 | 0.8 ± 43.4 |
Interestingly, the results showed that the intervention group did not improve in forward walking or the one leg stance test, whereas previous research has suggested Tai Chi can improve both. This could be due to the relatively small sample size of the study, as well as the short duration of training whereas previous research trained individuals for greater than three months.
It is important to note that four participants from the intervention group and three from the control did not complete the study. In order to maintain consistency in data collection, these participants were excluded from all data analysis.

### Conclusions
#### Reduced Falls Risk

Whilst the section of the BBS that measures the reaction to a loss of balance wasn’t explicitly stated, the TUG test is a strong indicator of falls risk. As a significant improvement in this measure was noted, participants are at a lower risk of falls.

#### Improved balance

The improvement on the BBS shows that balance improved both whilst standing still and walking. This is further demonstrated in improvements in the tandem stance test.

#### Functional Mobility

The 6MWT and the TUG results show the Tai Chi improves functional mobility, as well as walking endurance in PD.

### Practical advice

Consistent with previous research, this pilot study demonstrates that Tai Chi should become a component of a long-term management plan of PD

### Further information/resources

Parkinson’s overview - http://www.parkinsons.org.au/what-is-parkinsons Signs and Symptoms of Parkinson’s - http://www.parkinson.org/understanding-parkinsons/10-early-warning-signs Tai Chi and Parkinson’s - http://www.taichiaustralia.com.au/articles/parkinsons UPDRS - http://img.medscape.com/fullsize/701/816/58977_UPDRS.pdf Berg Balance Scale - http://www.fallssa.com.au/documents/hp/Berg_Balance_Scale.pdf

### References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 Hackney, M. E., & Earhart, G. M. (2008). Tai Chi improves balance and mobility in people with Parkinson disease. Gait & posture, 28(3), 456-460.
* 1 2 3 Parkinson's NSW. (2016). Parkinson's Disease. Retrieved from http://www.parkinsonsnsw.org.au/about-parkinsons-disease/parkinsons-disease/
* 1 2 Li, F., Harmer, P., Fisher, K. J., Xu, J., Fitzgerald, K., & Vongjaturapat, N. (2007). Tai Chi-based exercise for older adults with Parkinson's disease: a pilot-program evaluation. Journal of Aging and Physical Activity, 15(2), 139.
* ↑ Klein, P. J., & Rivers, L. (2006). Taiji for individuals with Parkinson disease and their support partners: program evaluation. Journal of Neurologic Physical Therapy, 30(1), 22-27.
* 1 2 Li, F., Harmer, P., Fisher, K. J., McAuley, E., Chaumeton, N., Eckstrom, E., & Wilson, N. L. (2005). Tai Chi and fall reductions in older adults: a randomized controlled trial. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 60(2), 187-194.
* ↑ Hass, C. J., Gregor, R. J., Waddell, D. E., Oliver, A., Smith, D. W., Fleming, R. P., & Wolf, S. L. (2004). The influence of Tai Chi training on the center of pressure trajectory during gait initiation in older adults. Archives of Physical Medicine and Rehabilitation, 85(10), 1593-1598.
* ↑ Podsiadlo, D., & Richardson, S. (1991). The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142-148.