# Exercise as it relates to Disease/Tai Chi's Ability to Improve Postural Stability for Patients with Parkinson's Disease

This wikibook page is a critique of the journal article "Tai Chi and Postural Stability in Patients with Parkinson's Disease" by Fuzhong Li, Peter Harmer, Kathleen Fitzgerald, Elizabeth Eckstrom, Ronald Stock, Johnny Galver, Gianni Maddalozza and Sara S. Batya.

## What is the background to this research?

Parkinson’s disease is a neurological disease that is caused by a decrease in the production of dopamine in the brain As dopamine is an important neurotransmitter that transfers messages to the cells in the brain a decrease in this chemical can cause people to have difficulty controlling their movements and can impact their other body systems. While there is currently no cure it is thought that the disease can be managed using physical activity. This article explores the possibility of using Tai Chi as a means of improving postural stability and fall prevalence in patients with Parkinson’s disease. Tai Chi has been proven to improve balance, strength and physical function and was therefore expected to be effective in improving postural stability in limits-of-stability tasks.

## Where is the research from?

This study was conducted by researchers from the following institutes:
* The Oregon Research Institute
* The Oregon Medical Group
* PeaceHealth Medical Group
* Williamette University
* BPM Physical Therapy Centre
* Oregon Health and Science University
* Oregon State University
* Oregon Neurology Associates

## What kind of research was this?

This type of research was a randomised clinical trial in which participants were recruited via newspaper advertisements, referrals from neurologists or physical therapists, and information distributed to local support groups for persons with mild to moderate Parkinson’s disease (as diagnosed using the Hoehn and Yahr scale). All participants had to pass a set of eligibility criterion to be able to participate in the study.
Participants were subjected to pre-screened by telephone and those who met the criteria underwent an in-person evaluation and baseline assessment to ensure they were able to complete the assessment. Eligible patients were then randomly assigned to one of the three interventions with a ratio of 1:1:1 with the use of permuted-block randomisation once eligibility was confirmed and baseline assessments were confirmed.

## What did the research involve?

The research involved performing three exercise interventions on each of the study participant groups. One was a Tai Chi intervention which consisted of six tai chi movements integrated into an eight-form routine. The second was a resistance training intervention which focused on strengthening the muscles that are important for posture, balance and gait. The third involved a stretching intervention which was designed to provide a low-intensity exercise program without the training benefits in lower-extremity weight-bearing, strength or balance that the other two interventions had.

## What were the basic results?

Overall the tai chi group performed better and gained higher scores in both the primary secondary outcomes. The mean between-group differences in outcomes were assessed at six months. These outcomes show that in the primary outcomes of maximum excursion and directional control, the tai chi group performed significantly better than both the resistance and the stretching groups. In maximum excursion, the tai chi group had a between-group difference with the resistance group of 55.5 percentage points and an 11.98 percentage point difference with the stretching group. In directional control, the tai chi group had a between-group difference with the resistance group of 10.45 percentage points and an 11.38 percentage point difference with the stretching group.
The mean between-group differences in outcomes also show that the tai chi group had significantly better performance in all of the secondary outcomes. The results are shown below in table 1.
Table 1a :
| Secondary Outcomes | Tai Chi | Resistance | Stretching |
| Stride Length (cm) | 10.3 | 4.3 | - |
| Walking Velocity (cm/sec) | 10.4 | 10 | Decrease 4.5 |
| Knee Extension (Nm) | 13.9 | 10 | - |
| Knee Flexion (Nm) | 5.1 | 8.9 | - |
| Functional Reach (cm) | 5 | 2.2 | - |
| Up-and-go Test (secs) | Decrease 1.05 | Decrease 1 | - |
| UPDRS III (points) | Decrease 6.42 | Decrease 5.07 | Decrease 1.4 |
Overall there was a total of 381 falls in 76 of the 195 participants over the six-month period. The tai chi group had significantly fewer falls than the stretching group however, there was not a large difference between the tai chi group and the resistance group.

## What conclusions can we take from this research?

From this research, we can conclude that tai chi is more effective than resistance training and stretching in regard to improving postural stability and reducing the risk of falls in patients suffering from mild to moderate Parkinson’s disease. The tai chi training program relies on weight shifting and ankle sway to help move the individual’s centre of gravity towards the limits of stability. By alternating between a wide stance and a narrow stance the individual is continuously able to change their base of support which will in turn increase their support-leg standing time as well as their trailing-leg swing time.

## Practical advice

It has been widely acknowledged that leading an active lifestyle can improve and prevent the symptoms of Parkinson’s disease. based on the findings from the research study above clearly some forms of exercise are of more benefit than others. Patients with mild to moderate Parkinson’s disease would benefit from exercise programs that involve exercises relating to balance, postural stability and core and muscle strength. As tai chi focuses on all of these aspects it would be of great benefit for Parkinson’s disease patients to undertake a consistent tai chi program from the early stages of their disease to help improve the degenerative effect of Parkinson’s disease.

## Further information/resources

For further information on Parkinson's disease: http://www.parkinsons.org.au/what-is-parkinsons
Further information on the Hoehm and Yahr Scale http://parkinsonsresource.org/wp-content/uploads/2012/01/The-FIVE-Stages-of-Parkinsons-Disease.pdf
Further information on the UPDRS III http://img.medscape.com/fullsize/701/816/58977_UPDRS.pdf
More articles on the efficacy of tai chi in improving Parkinson's symptoms: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-0639-8 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0099377

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 Li F, Harmer P, Fitzgerald K, Eckstrom E, Stock R, Galver J, Maddalozza G, Batya S.S (2012) 'Tai Chi and Postural Stability in Patients with Parkinson's Disease' The New England Journal of Medicine;366:511-519
* 1 2 Parkinson's Australia, (2015) What is Parkinson's Disease? Available from: http://www.parkinsons.org.au/what-is-parkinsons
* ↑ Li F, Harmer P, Fisher KJ, et al. (2005) Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci;60:187-194
* ↑ Li F, Harmer P, Fisher KJ, et al. (2007) Tai Chi-based exercise for older adults with Parkinson's disease: a pilot program evaluation. J Aging Phys Act;15:139-151
* ↑ Hirsch MA, Toole T, Maitland CG, Rider RA. (2003) The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson's disease. Arch Phys Med Rehabil;84:1109-1117
* ↑ Pickering RM, Grimbergen YA, Rigney U, et al. (2007) A meta-analysis of six prospective studies of falling in Parkinson's disease. Mov Disord;22:1892-1900
* ↑ Rosenthal, Liana S. Dorsey, Ray E. (2013) The Benefits of Exercise in Parkinson Disease, JAMA Neurol:70(2):156-157