Running head: DNP PROJECT FINAL REPORT Tai Chi for Falls Prevention: A Student-led DNP Project Graham C. Sawicki Arizona State University 1 DNP PROJECT FINAL REPORT 2 Abstract Aim: To reduce the fear of falling in an elderly population by teaching ‘Tai Chi for Falls Prevention’ classes twice a week for 12 weeks. Background & Significance: Falls continue to be the leading cause of injury-related deaths of Arizonans who are 65 years or older - well above the national average. It is predicted that by 2030, national medical spending for this population will total over $31 billion, yearly. Tai Chi is revered for being a beneficial form of simple, low-impact exercise, which the CDC endorses for its falls risk reduction benefits. Methods: The intervention consisted of 60-minute classes occurring twice a week for 12 weeks. Participants were English-speaking, between 65-85 years old, and able to ambulate independently. Appropriate pre-screening tools were used before applicants consented. Their Fear of Falling (FoF) was measured using a fall risk perception tool at the beginning, middle, and the end of the project. This ordinal data was analyzed with Friedman ANOVA using SPSS 25 Outcomes/Results: After enrolling five total participants, only three completed the project. This severely limited data analysis of their FoF, resulting in a statistical significance (p = 0.68), deeming the intervention ineffective - Despite observable downwards trending FoF scores. Conclusion: The acceptance of the null hypothesis is attributed to the low enrollment and high attrition rate. Also, the only data measured was quantifiable, subjective data. Future projects could add objective data to reinforce the benefits of Tai Chi. This might reinforce the validity of Tai Chi as a practical recommendation due to its cost-effective simple interventional design and effectiveness for prevention of accidental falls. Increased focus on improved recruitment & retainment strategies should be prioritized for similar projects in the future. Keywords: accidental falls, falls, fall risk reduction, older adults, Tai Chi, balance, exercise, DNP PROJECT FINAL REPORT 3 Tai Chi for Falls Prevention: A Student-led DNP Project Accidental falls in any age group can be devastating and have terrible consequences that can lead to outcomes with adverse long-term effects. Falls among the elderly who are 65 years of age and older can have detrimental effects physically and psychologically - both immediately and long-term. Falls are the number one cause of injury in older adults, with a third of this group of individuals falling every year, and half of them will have another fall sometime in the next year. One out of every two 80-year-olds fall every year (STEADI, 2015; Yoo, Kim, Yim, & Jeon, 2016; Gallant, Tartaglia, Hardman, & Burke, 2017; Office of Injury Prevention, 2017). Problem Statement A fall is classified as an accidental tumble downwards that is not caused by an external force or a neurological change. Falls have the potential to cause mortalities and create morbidities; morbidities that can steal away someone's independence and rob someone of their quality of life. Internationally, 28-35% of adults older than 65 years of age fall will fall each year (Yoo, Kim, Yim, & Jeon, 2016; Gallant, Tartaglia, Hardman, & Burke, 2017). Assessment and acknowledgment of other causes for falls should be mentioned. These include poor lighting which affects vision, slippery floors, lack of grab bars, etc. Environmental elements such as these contribute to roughly 41% of the risk factors that can instigate falls (Yoo, & et al., 2016). The likelihood of falls increases with age, but the frequency can vary by ethnicity and geographical location (STEADI, 2015). The National Guideline Clearinghouse adapted and released fall assessment and prevention recommendations for elderly adults (NICE, 2004). The recommendations were last updated in 2013, and cover cause and risk identification, multifactorial falls risk assessment, and multilevel interventions, and interpretation of current evidence regarding various interventional methods for preventing falls. Low-intensity exercises DNP PROJECT FINAL REPORT 4 and untargeted group exercises were not listed as a recommended intervention. Brisk walking, as it turns out, should no longer be recommended as a fall prevention measure, as it is not shown to reduce fall risk (NICE, 2013). Purpose & Rationale Falls among older adults continue to be a growing burden. The purpose of this proposed project is to highlight the importance of fall prevention in older adults who are 65 years and older while investigating implementing Tai Chi as a method of intervention to reduce the prevalence of falls in this population. In addition, there is a need for improved approaches for fall prevention and the applicability Tai Chi possess as an effective intervention for this at-risk population. The purpose of this paper is to discuss the background and significance of the problem; describe the search process; and the identification of ten research articles related to the addressing this problem. Background & Significance Population: Older Adults and Falls. Accidental falls are linked as the number one most frequent cause of falls in the elderly, which can result in both short-term and long-term injuries which can result in decreased mobility afterward, pain – both chronic or acute, loss of independence, or even death. Gait and balance disorders are the second most frequent cause of falls (Landers, Oscar, Sasaoka, Vaughn, 2016). “Delays in recovery from a fall injury, plus post-fall anxiety, further heighten the risk of subsequent falls due to deconditioning, weakness and acquisition of abnormal gait,” (Plummer & Bradley, 2017, p. 239). Fear of falling has the potential to affect individuals who have and have not fallen, and as older adults get older, their fear of falling is likely to increase with age (Stojanovic, Kocic, Balov, Milenkovic, Savic, & Ivanovic, 2015). DNP PROJECT FINAL REPORT 5 Intervention: Tai Chi Tai Chi (TC) originates from Chinese tradition over 400 years ago that has rapidly evolved beyond its original martial arts roots into a multiuse tool of diversity and utilization. It has become a popular form of exercise that is well-recognized worldwide and involves full mindbody movements that remain low-impact but high in potential benefits. The literature portrays the benefits having been shown to positively improve strength, aerobic aptitude, balance, quality of life, psychological well-being, and even affect physiological diseases (Lan, Chen, Lai, & Wong, 2013; Gallant, Tartaglia, Hardman, & Burke, 2017). It can be performed both individually, as well as in a social setting and there are different styles and forms to teach Tai Chi, but much of it incorporates the same vital principles with attention on breathing, slow, purposeful movements that include the entire body, and results that improve strength, balance, and flexibility (Wu, Macdonald, & Pescatello, 2016). A community-based study used Tai Chi to modify fall-risk among older adults older than 65 years but could move about without any assistive walking devices in two senior centers where two individuals were trained from each county area to become a Tai Chi instructor leading each of the classes over 12 weeks. The classes took place two or three times a week with a 45-minute requirement of at-home practice per week as well. Upon completion of the study, participants, on average, showed improvement in their strength, balance, and mobility (Gallant, Tartaglia, Hardman, & Burke, 2017). Incidence of Falls In 2016, 42,808 Arizonans 65 years and older visited the emergency department due to falls that were unintentional, costing over $344.7 million. Of that number, 14,384 of them required inpatient hospitalization, and after averaging six days in the hospital, their totaled DNP PROJECT FINAL REPORT 6 charges were over $933.6 million. Falls continue to be the leading cause of injury-related deaths of Arizonans 65 or older, and in 2016, 974 deaths occurred as a result (Office of Injury Prevention, 2017). Every second, an older adult experiences an accidental fall somewhere in America. Every 20 minutes, one of them dies as a result of it. It is estimated that by 2030, medical expenses for these older adults at risk for falls will total over $31 billion each year (STEADI, 2015). The implementation of Tai Chi for falls prevention classes could reduce this high incidence of falls among the elderly who are at an increased risk, especially in Arizona, who vastly outpaces the nation’s mortality from accidental falls (Office of Injury Prevention, 2017). Internal Evidence The Arizona Falls Prevention Coalition (AFPC) expresses the desire of implementing more ‘Tai Chi for Falls Prevention’ programs throughout the state of Arizona – of which, currently there is a very limited number available to the elderly interest in Tai Chi for falls prevention. Initiating more instructor-led ‘Tai Chi for Falls Prevention’ classes throughout the community is a 2018 goal of theirs (Dunn, 2018). In 2013, a systematic review and meta-analysis of 124 randomized controlled trials were investigated after being gathered across several major research databases. The results found that regardless of the style, form, or duration, Tai Chi exercise training is shown to be an effectual technique in significantly reducing the occurrence of falls in older adults (Hu, Chung, Yu, Chen, Yu-Chi, Tsai, & Hu, 2016). A meta-analysis from 2017 acknowledges the reduction of risk of falls and fall-related injuries due to Tai Chi’s use short-term, but questions the validity and sustainability of the benefits long-term, however (Lomas-Vega, Obrero-Gaitán, Molina-Ortega, & Del-Pino-Casado, 2017); as did an evidence map reviewing 107 systematic reviews of the evidence regarding health outcomes from Tai Chi, but still indicates promising application (Solloway, Taylor, Shekelle, Miake-Lye, Beroes, DNP PROJECT FINAL REPORT 7 Shanman, & Hempel, 2016). Adverse events mainly have included minor aches, soreness of the body, and stiffness (Wayne, Berkowitz, Litrownik, Buring, & Yeh, 2014). Current literature strongly suggests the clear benefits and higher outcomes of Tai Chi compared to other more standardized and common fall prevention measures and combined exercise prescriptions which might include brisk walking, physical therapy, and physical exercises that focused on lower limbs Stevens & Burns, 2015; Yildirim, Ofluoglu, Aydogan, & Akyuz, 2016; Bubela, Sacharko, Chan, & Brady, 2017). Despite the Center for Disease Control & Prevention’s endorsement of Tai Chi and its multiple health benefits, awareness of Tai Chi’s benefit for falls prevention in the elderly is still not commonly known among healthcare and the community. This stated problem has led to the clinically relevant PICOT question, “In older adults, how does Tai Chi compared to no tai chi affect fear of falling over time?” Search Strategy To order to effectively address this question, a comprehensive and thorough screening of the literature was implemented through the following online databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, and The Cochrane Library, OCLC Worldcat, PubMed, Science Direct, Springer Link, Cochrane Library, and ProQuest Medline, as well as being independently, handpicked by this author. The population was searched for using the following search terms: elderly, older adult, 65+ years, geriatric. The outcome was searched for using: fall or falls and accidental fall. The intervention of Tai Chi, tai ji, Tai Ji Quan, Tai Chi Chuan was searched. The intervention’s focus was used to further narrow the results using these key terms: fear of falling, fear of falls, and falls prevention. All searches were restricted using the following modifiers and limiters when DNP PROJECT FINAL REPORT 8 available: within five years “2013-2018,” limited to “Humans,” and “English” language only, and narrowed by subject age of “65+ years”. Initially, while using the modifiers listed above, searching with the only “fall OR fall prevention OR falls prevention AND tai chi” yielded 2,933 search results in CINAHL (Appendix A), 452 results with Online Computer Library Center (OCLC) WorldCat (Appendix B), 216 with PubMed (Appendix C), 290 results using ScienceDirect (Appendix D), 588 results from Springer Link (Appendix E), 1706 records in Cochrane Library (Appendix F), 464 with SAGE journals (Appendix G), and 11,261 results with ProQuest Medline (Appendix H). Final search results, revising and combining search terms resulting with refinement of the search to, “‘Tai Chi’ OR ‘Tai Ji’ OR ‘Tai Ji Quan’ OR ‘Tai Chi Chuan’ AND ‘fall’ OR falls AND ‘prevention’ AND ‘fear of falling’ OR ‘fear of falls’,” resulted in four applicable search results in CINAHL (Appendix A), 60 results with OCLC WorldCat (Appendix B), 50 with PubMed (Appendix C), 1,740 review & research articles with ScienceDirect (Appendix D), 11 results from Springer Link (Appendix E), 43 results in Cochrane Library (Appendix F), 24 with SAGE journals (Appendix G), and 939 results with ProQuest Medline (Appendix H). When unable to select population or age filters or limiters, “elderly OR ‘older adult’ OR ‘65+ years’ OR ‘geriatric’ OR ‘Aged 65+’ OR ‘65 years’,” was added to the keywords being searched. Seventy studies were selected after the searching and screening took place, found from both the database containing the search elements above and hand selected from related sources. 10 final studies were selected for evaluation and synthesis (Appendix I). The criteria for exclusion included studies published before 2013, published in a nonEnglish language, or unfinished studies, or reports studying a population younger than 65 years old. Reports that studied the effects of Tai Chi without mention of fall reduction or prevention DNP PROJECT FINAL REPORT 9 were further eliminated. Studies investigating the benefits of Tai Chi in patients with chronic diseases such as a deteriorating neurologic condition or diabetes were excluded. This resulted in ten final studies that were chosen for critical appraisal. Critical Appraisal & Evidence Synthesis The ten final studies were quantitative and evaluated with a rapid critical appraisal tool and are displayed in a table below (Appendix I). The strength of the studies is high, overall: five systemic reviews (SR), two SR with meta-analysis (MA), two Quasi-Experimental, and one randomized-control trial (RCT). Most of the studies did not report a theoretical framework and most studies and reviews of RCTs took place in community-based settings. The studies evaluating Tai Chi’s effectiveness for falls prevention featured samples composed of populations of older adults without chronic illnesses. A handful of studies report bias within sampling without much diversity in the characteristics of their members. Some of the systemic reviews did not mention the sample group characteristics of the studies included in their review. (Appendix J). Bubella et al. reported a moderate increase to perceived balance confidence using the self-reported balance confidence activity-specific balance confidence (ABC) scale, between pre and post scores using the activity-specific balance confidence, “(p = .022) and moderate effect size and observed power (ηp^2 = 0.217; observed power = 0.656)” (2017, p. 5). Gallant, Tartaglia, Hardman, & Burke determined that even a novice instructor for a 12 week tai chi program could have a beneficial impact, as significant pre-post improvements were reported among functional mobility and balance (Timed Up and Go (p < .001) and Functional Reach (p < .01), as well as perceived balance (ABC scores (p < .01), (2017). Hu et al. reported tai chi as having significantly reduced fall risk (OR = 0.70; 95% confidence interval, 0.59 to 0.84) during DNP PROJECT FINAL REPORT 10 its meta-analysis of ten different trials with 2850 individuals participating. They used the Physiotherapy Evidence Database (PEDro) scale to measure and determine the quality of the randomized controlled trials. Their subgroup analysis also found no evidence of differential effects from training duration or Tai Chi style used (2016). Lomas-Vega & et al. performed a meta-analysis on ten studies and reported Tai Chi as having “high-quality evidence of a medium protective effect for fall incidence over the short term (IRR = 0.57; 95% CI = 0.46, 0.70) and a small protective effect over the long term (IRR = 0.87; 95%; CI = 0.77, 0.98)” (2017, p. 2037). Yıldırım, Ofluoglu, Aydogan, & Akyuz compared changes to standing balance, ambulatory balance, fear of falling and mood between two groups - one following ‘combined exercise prescription’ and the other ‘tai chi’. Afterward, differences to pre-post evaluations between the two groups were compared after 12 weeks. Using the Survey of Activities and Fear of Falling in the Elderly (SAFFE) tool, it was determined that there was a greater and much more significant reduction to fear of falling in the group practicing tai chi (p = 0.002) (2016). Most of the studies were led by an instructor certified in Tai Chi training, and a couple of others were led by non-professionals who were volunteers or just moderately trained beforehand. On average, Tai Chi classes took place for about an hour, once or twice a week, ranging 12-16 weeks, with pre- and post- tests and evaluations. Fear of Falling changes was commonly analyzed via the SPSS program. Timed up and go and activity-specific balance scales were commonly for assessment for Tai Chi’s effects upon participant balance (Bubella & et al., 2017; Yildirim, Ofluoglu, Aydogan, & Akyuz, 2016). Attrition rates were generally low for the studies and SRs, when divulged. Strength, mobility, fall incidence, balance, and fear of falling or confidence were mainly tested for and reported. DNP PROJECT FINAL REPORT 11 Tai Chi is well-regarded as being generally very safe, due to its simple, low impact, continuous, sequential movements that doubles as a form of exercise and meditation. Concerning its safety, adverse events (AE) reported during studies using Tai Chi are rare uncommon but do include falls and fall-related injuries. Commonly reported complaints from participants of Tai Chi includes fatigue, muscle soreness, or muscle stiffness (Wayne et al., 2014). Evidence-Based Practice Model and Conceptual/Theoretical Model Plan-Do-Study-Act Model The Plan-Do-Study-Act (PDSA) model (PDSA, 2018) was chosen to guide project development, it is a simple (Appendix K) model and is commonly used as a performance improvement project because it measures a change after it has been implemented and is designed is structured well for adjustments to be made after, allowing for the process to repeat again. This method guides the process with four steps: Plan, Do, Study, Act. First, a plan must be drawn up with clear indications for what is to be done, the outcomes desired, and the steps for execution. Next, the test is carried out or executed – during this phase, the observations are recorded. After this step, the results are studied and whether or not the goal was achieved is evaluated. The final stage is the conclusion of what was learned from the conclusion of the effects, including what worked, what did not, and what could be done differently for next time? (PDSA Worksheet, 2018). The plan would involve using Tai Chi as a method for fall prevention with reducing the incidence of falls, preventing falls, and increasing the confidence of individuals who are afraid of falls. The project could be student-led and would follow much of the same structure, direction, and goals of that in the studies below. The frequency of classes per week, length of each class, and the same age of participants would be replicated. The project would take place in the DNP PROJECT FINAL REPORT 12 community, in an area that does not already have Tai Chi classes for fall prevention already in place. After the project has completed, the data will be collected and studied. Then, during the act phase, conclusions will be made so that adjustments can be made. This model easily allows for repeating of the project with adjustments made afterward. Self-Efficacy Theory The entirety of the project is built upon Bandura’s Self-Efficacy Theory which is a subtheory of his Social-Cognitive theory. The Self-Efficacy theory lends itself to what the structure of the Tai Chi for Falls Prevention classes is structured to achieve. This theory presents the notion that the observation of value or efficacy is determined by four main aspects: mastery experience, vicarious experience, verbal persuasion, and somatic or state of emotion. The mastery experience builds upon the perceptions from previous successes that have been accomplished in the past but are similar to the newer behaviors being attempted. With the stepby-step program being followed by the participants, they are more open to each of the newer, more complicated steps because of their mastery of the earlier, similar steps prior. The vicarious experience is based upon the individual’s ability to learn by watching others be successful at completing the same actions being attempted by the individual. Being surrounded in a supportive environment that a group class setting provides creates an atmosphere that is encouraging and motivating to the participants of the tai chi classes. With verbal persuasion, reinforcement from others and instructors is both crucial and effective, which is supplied both from the fellow participants and the instructor in this project. Lastly, the somatic and emotional states of each individual must be considered constantly because their physical and emotional statuses are instigated by their perception regarding the undertaking of new behaviors (Brown, Malouff, & Schutte, 2013). By measuring the participant’s fear of falling perceptions, the instructor of the DNP PROJECT FINAL REPORT 13 Tai Chi for Falls Prevention classes can adjust the teaching stylings to better meet the needs of the participants. Project Methods After IRB After becoming a certified Tai Chi for Falls Prevention instructor through the Tai Chi for Health Institute, I designed my intervention to consist of: 60-minute classes that were held twice a week over 12 weeks in a classroom setting at a not-for-profit hospital’s medical office building in an urban Phoenix area. Participants who were considered for recruitment had to be between the ages of 65-85 years of age, English-speaking and able to ambulate without the use of assistive devices. Relevant pre-screening was utilized with reliable tools that whose validity was supported, with permission to use granted beforehand. Before interested applicants were allowed to provide consent, individuals were screened for any pre-existing mental or cognitive impairments using the Montreal Cognitive Assessment-Basic (MoCA-B) tool (Appendix L). Their physical activity readiness was determined using the 2018 Physical Activity Readiness Questionnaire (PAR-Q+) (Appendix M). The data collected was their falls risk perception, measured using the ‘Falls Efficacy Scale-International (English)’ (FES-I) (Appendix N) at the beginning, middle, and the end of the project. This ordinal data was analyzed using SPSS 25, in which Friedman ANOVA was used for data analysis. All participant-related information and data was safely stored on an encrypted, external flash drive that was only via secure methods only. After completion of the project, the information and any identifying information was properly deleted, removed, and destroyed. Total expense, excluding commute-related expenses for this project, would have been about $308 to cover the certification course and related learning materials and supplemental supplies for teaching the Tai Chi classes. No cost for classes space as they were provided via the DNP PROJECT FINAL REPORT 14 connections of the Arizona Falls Prevention Coalition. It should be mentioned that Tai Chi can occur in any public space that is flat and open, such as at a park, library, or home, therefore, additional costs for practice space should not be included in a proposed budget. Outcomes The project started on 11/27/18, after minor project delays due to poor public response to recruitment strategies utilized. There was a total enrollment of five participants, each providing their consent after passing the pre-screenings beforehand for a total inclusion into the project of five participants (n = 5). After an anticipated attrition rate of two, this project completed without any adverse events 12 weeks later on 2/14/19 with three participants. Because of this low completion rate, data analysis of their FoF was severely limited. After analyzing the three participant’s data collected from the three different intervals using Friedman ANOVA analysis, the resulting p-value indicated that the intervention’s effects were not significant (p = .68). Thus, proving the null hypothesis correct. Discussion Though, participant enrollment might have been impeded by non-ideal recruitment strategies in the beginning, the impact was of Tai Chi’s benefits was clear and apparent to the participants who completed the project after 12 weeks as indicated by the positive verbal praise that was shared at the project’s end. Poor recruitment strategies are considered to be the primary cause of low participant interest/enrollment. The attrition rate, like most long-term projects and studies, was not unexpected as this project’s requirements were demanding in its length of time and frequency of classes. As mentioned above, low enrollment that was negatively affected by the project’s attrition rate is most likely the cause for the data lacking statistical significance (p > .05), but there was an unmistakable downwards trend observed for fear of falling total scores DNP PROJECT FINAL REPORT 15 among all completing participants (Appendix O), which indicates this intervention as having clinical significance. After completing the project, the participants were encouraged to seek Tai Chi instructor certifications of their own so that additional Tai Chi for falls prevention classes can be implemented in their own communities. Nine weeks into the project, one of the participants stated as testimonial believing in the effects of the project, “Over the weekend, I tripped over my dog while trying to settle him when someone was in the yard. I felt myself falling as I instantly regretted everything I did leading up to that point. Miraculously, I maneuvered my feet in a way to recover and catch myself. I didn’t fall, and I know for certain that it is due to these Tai Chi classes.” Interested participants, upon completing the project were advised to continue taking Tai Chi classes within and were encouraged to seek instructor certification for the continued development and expansion of available Tai Chi classes throughout their communities for sustainability. Conclusion The project’s implications and benefits for falls prevention is not without merit due to its apparent clinical benefits which should not be overshadowed by the data’s lack of statistical significance. To the participants who completed the project to its entirety, there was personal benefit that was stated by all. The Tai Chi was discussed as being both beneficial, easy to perform, and fun. These subjective critiques are worth mention in reviewing the benefits to both the site at which the project took place and the organization this student partnered with. Increased focus for recruitment strategies should be better prioritized by the organization and the project site to more aptly prevent lower enrollment of participants in the future. Also, it is worth highlighting that the only data measured was quantifiable, subjective data. Despite this project’s DNP PROJECT FINAL REPORT 16 lack of interventional validation, current literary evidence does extensively support the health benefits of Tai Chi (Lan, Chen, Lai, & Wong, 2013).). Future projects could add objective data to reinforce the benefits of Tai Chi, such as: ‘Sit to Stand’ timing, Balance, Leg-Strength, & Speed of ambulation (Bubella & et al., 2017; Yildirim, Ofluoglu, Aydogan, & Akyuz, 2016). Doing so might reinforce the validity of Tai Chi as a practical recommendation due to its cost-effective, simple interventional design and effectiveness for prevention of accidental falls. Depending on who is asked, this project could still be considered a great success in its potential benefits and should be regarded as a worthwhile first step in a process advocating for more practical falls prevention options for the public. DNP PROJECT FINAL REPORT 17 References Brown, L.J., Malouff, J.M., & Schutte, N.S. (2013) Self-Efficacy Theory 89742_Ch02.indd 36 [PDF]. Retrieved from: http://samples.jbpub.com/9781449689742/Chapter2.pdf Bubela, D., Sacharko, L., Chan, J., & Brady, M. (2017). 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Falls: assessment and prevention of falls in older people (NGC:009951). Retrieved from: https://www.guideline.gov/summaries/summary/46931/falls-assessment-and-preventionof-falls-in-older-people?q=Falls+assessment+and+prevention+of+falls+in+older+people Office of Injury Prevention (2017). Unintentional falls among Arizonans 65 years and older, 2016 [PDF file]. ADHS. Retrieved from http://azdhs.gov/documents/prevention/tobaccochronic-disease/healthy-aging/reports-statistics/falls-among-older-az-residents-2016.pdf Plan-Do-Study-Act (PDSA) Worksheet. (2018). Ihi.org. Retrieved from: http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx Plummer, M., Bradley, C. (2017). Tai chi as a falls prevention strategy in older adults compared to conventional physiotherapy exercise: A review. International Journal of Therapy and Rehabilitation. 24(6). 239-247. 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Retrieved from http://onlinelibrary.wiley.com.ezproxy1.lib.asu.edu/doi/10.1111/jgs.14242/full Yang, G., Wang, L., Ren, J., Zhang, Y., Li, M., & Zhu, Y. Luo, J., Cheng, Y., Li, W., Wayne, P., & Liu, J. (2015). Evidence base of clinical studies on tai chi: A bibliometric analysis. PLOS ONE, 10(3), e0120655. doi:10.1371/journal.pone.0120655 Yildirim, P., Ofluoglu, D., Aydogan, S., & Akyuz, G. (2016). Tai Chi vs. combined exercise prescription: A comparison of their effects on factors related to falls. Journal of Back and Musculoskeletal Rehabilitation, 29(3), 493-501. doi: 10.3233/BMR-150645 Yoo, J., Kim, C., Yim, J., & Jeon, M. (2016). Factors influencing falls in the frail elderly individuals in urban and rural areas. Aging Clin Exp Res. 28(4)687-697. doi: 10.1007/s40520-015-0469-2 DNP PROJECT FINAL REPORT 21 Appendix A Figure A CINAHL Database – Search Results Screenshot: DNP PROJECT FINAL REPORT 22 Appendix B Figure B1 Online Computer Library Center WorldCat – Initial Search Results Screenshot: Figure B2 Online Computer Library Center WorldCat – Final Search Results Screenshot: DNP PROJECT FINAL REPORT 23 Appendix C Figure C PubMed.gov - Search Results screenshot: DNP PROJECT FINAL REPORT 24 Appendix D Figure D1 ScienceDirect - Initial Search Results Screenshot: Figure D2 ScienceDirect - Final Search Results Screenshot: DNP PROJECT FINAL REPORT 25 Appendix E Figure E1 Springer Link -Initial Search Results Screenshot: Figure E2 Springer Link – Final Search Results Screenshot: DNP PROJECT FINAL REPORT 26 Appendix F Figure F1 Cochrane Library – Initial Search Results Screenshot: Figure F2 Cochrane Library – Final Search Results Screenshot: DNP PROJECT FINAL REPORT 27 Appendix G Figure G1 SAGE journals – Initial Search Results Screenshot: Figure G2 SAGE journals – Final Search Results Screenshot: DNP PROJECT FINAL REPORT 28 Appendix H Figure H ProQuest: Medline – Search Results Activity Screenshot: Running head: DNP PROJECT FINAL REPORT 29 Appendix I Table 1 Quantitative Evaluation Table: Citation: Theory/ Conceptual Framework Design/Method Sample/ Setting Major Measurement/ Variables & Instrumentation Definitions Bubela, D., Sacharko, L., Chan, J., & Brady, M. (2017). Balance and functional outcomes for older communitydwelling adults who practice tai chi and those who do not. Inferred: social cognitive therapy Design: A quasiexperimental comparative preand post- test design IG: Tai Chi = 16 IG: TC Training Group AR: 100% CG: no TC n=group of 14 adults, purpose: (SD) age = This study considers 71.2 (6.1) the effects of years community-based Tai Chi programs on Sample: participants’ gross Subjects had motor ability in to be areas known to community contribute dwelling and collectively to fall Englishrisk, namely, speaking, 55 strength, balance, years or functional mobility, older, who and fear of falling. ambulated independently w/ or w/o an Pre- & post- test measures of: Data Findings/ Analysis Results (stats used) • SPSS15 with an • α level of .05 DV1: • Cohen’s d • handheld values were CG: no TC dynamometry calculated to AR:93% (HHD) determine the • knee extension effect sizes of strength changes IV1: Age • five-time sit to • Comparison stand (FTSTS) of the 2 DV1: DV2: groups over functional • Timed Up and Go the training strength [TUG] test & period DV2: Fifty-Foot Walk through Mobility Test) mixed DV3: DV3: ANOVA Balance • Functional Reach & • 2×2 mixed DV4: Fear of Berg analysis of Falling • Berg Balance Scale variance DV4: Decision for practice Age: S: (SD) age of LOE: I persons • TC significantly participating in increasing force the Tai Chi production & improves group was 80.4 functional lower (6.8) years, (P extremity strength in = .00), (SD) = older adults 71.2 (6.1) years. • The results of this study support the CDC’s Balance - Knee endorsement of Tai Chi Strength: as a means of fall IG compared to prevention in older CG, community-dwelling significant differences in the adults. right knee extension strength (P = .042) & mod es & observed power (η p 2 = W: • limitations in both sample and design. • Sample size of both groups were small – Key: α – alpha; ABC / ASBS – Activity-specific balance confidence; AE - adverse events; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF Fear of Falling; LOE – Level of Evidence; LT – Longterm ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR systematic review; ST – Shortterm; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; W weaknesses DNP PROJECT FINAL REPORT Citation: Theory/ Conceptual Framework Design/Method 30 Sample/ Setting Major Measurement/ Variables & Instrumentation Definitions assistive device. • ABC Data Findings/ Analysis Results (stats used) 0.183; observed power = 0.543). Setting: local senior citizen center Gallant, M., Inferred: Tartaglia, descriptiv M., e theory Hardman, S., & Burke, K. (2017). Using Tai Chi to Reduce Fall Risk Factors Among Older Adults: An evaluation of a communitybased Design: A quasiexperimental comparative preand post- test design Purpose: to examine the effectiveness of the shorter 12-week TCMBB program when taught by trained community members, instead of experienced instructors. N= 131 individuals n= 126 completed Evaluated pre&post: 97 AR= 92.3% Sample: community dwelling adults aged 65 and above, who could walk with ease with or without IV1: age • IV1-5: self-report IV2: sex • IV6: Health IV3: race/ background ethnicity IV4: Ed. DV1: IV5: Income • self-reported fall IV6: history Chronic • FoF Conditions • Monthly Falls DV1: • Recent falls (w/i 6 Fall-related mo’s) Measures DV2: Functional mobility & Balance DV2 • TUG • Functional reach • Activities-specific balance scale scores • SPSS:23 • Chi-square and twotailed t-tests • Cronbach’s alpha: .04 • Wilcoxon signed rank test Confidence: IG vs CG: (P = .022) & mod es and observed power (η p 2 = 0.217; observed power = 0.656). • Timed Up and Go (p < .001) • Functional Reach (p < .01) • ABC scores (p < .01) Decision for practice lack of randomization and use of convenience sampling led to the creation of groups with characteristics S: LOE: • There were significant pre–post improvements in all outcome variables. • W: • There was not a significant difference of fall rates between the before and after groups. • FoF: ______?? Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: implementa tion. Theory/ Conceptual Framework Design/Method 31 Sample/ Setting Major Measurement/ Variables & Instrumentation Definitions assistive devices. DV3: Confidence Data Findings/ Analysis Results (stats used) Decision for practice DV3: ABC scale Of the total group of 131 participants, 126 (96%) participated in the evaluation procedures, and complete pre–post data were obtained from 97 (77%) of these participants. Setting: nine programs were held in two senior centers, two community/r ecreation centers, and Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: Theory/ Conceptual Framework Design/Method 32 Sample/ Setting two assisted living/senior housing facilities in three counties across New York state. Design: SR and N= 10 MTA studies n= 2850 total Purpose: participants IGs= 1540 To synthesize the CGs= 1310 latest trial reports with the older data, *sample we have performed sizes ranging this systematic from 59 to review and meta684 analysis of all participants. randomized * mean age controlled trials of of all the effectiveness of participants: Tai Chi on the risk 68-84 years. of falls among older adults. IC: (1) the type of trial was a randomized Major Measurement/ Variables & Instrumentation Definitions Data Findings/ Analysis Results (stats used) Decision for practice Hu, Y.N., Inferred: IV1: DI Forest Plots • In the two S: • PEDro Scale: Chung, predictive <6mo subgroups, the LOE: I • Physio-therapy Y.J., Yu, theory IV2: DI effect of Tai • TC has a significant Evidence Database Random H.K., Chen, effects meta>6mo protective effect on fall Chi exercise scale. Y.C., Tsai, IV3: TC analysis risk among older on prevention C.T., & Hu, style: Sun adults. of fall risks G.C. IV4: TC were 0.80 • (2016). style: Yang (95% CI, 0.66 Effect of tai to 0.96; <6 chi exercise DV1: effect months) and W: on fall of Tai Chi 0.52 (95% CI, • potential prevention exercise on 0.38 to 0.71; 6 incompleteness of the in older the risk of months). evidence reviewed. adults: falls in older Then, the • data for outcome Systematic adults trials were measures were selfreview and grouped reported [subj. to bias] DV2: risk of metaaccording to • lack of training falls analysis of the Tai Chi variables as a subgroup (portrayed randomized style used. by odds controlled The effect of trials ratio) Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: Theory/ Conceptual Framework Design/Method 33 Sample/ Setting controlled trial (2) participants were older adults (age >/= 65 yrs); (3) one of the interventions was a form of Tai Chi exercise training (4) the outcomes included falls EC: <6 on PEDro score was cutoff for highquality studies Major Measurement/ Variables & Instrumentation Definitions Data Findings/ Analysis Results (stats used) Decision for practice Tai Chi exercise on the prevention of fall risks was measured as 0.57 (95% CI, 0.33 to 0.99) for the Yang style, 0.79 (95% CI, 0.62 to 0.99) for the Sun style, and 0.68 (95% CI, 0.50 to 0.93) for the modified or unspecified style • TC showed a significant reduced risk of falls (odds ratio ¼ 0.70; 95% confidence interval, 0.59 to 0.84). Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT 34 Citation: Theory/ Conceptual Framework Design/Method Sample/ Setting Major Measurement/ Variables & Instrumentation Definitions Lomas‐ Vega, R., Obrero‐ Gaitán, E., Molina‐ Ortega, F. J., & Del‐ Pino‐ Casado, R. (2017). Tai chi for risk of falls. A meta‐ analysis Inferred: predictive theory Design: SR and MTA N= 10 RCTs IV: time points Purpose: To analyze the effectiveness of tai chi for falls prevention PC: Older adult population and at-risk adults. The age of participants ranged from 56 to 98 years old. IC: (1) randomized controlled trials (RCTs) (2) analyzing the effect of tai chi (not combined with other intervention) (3) on incidence of falls, incidence of injurious Data Findings/ Analysis Results (stats used) random• fall incidence effects model ST: for (IRR = 0.57; DV1: estimating 95% CI = incidence of DV: pooled 0.46, 0.70) falls, short • incidence rate ratio effects • Small term (IRR) for falls protective Publication (<12mo) incidence effect over the DV2: long term • hazard ratio (HR) bias was assessed incidence of (IRR = 0.87; for time to first using a falls, long95% CI = fall. funnel plot term 0.77, 0.98) (>12mo) The Q test DV3: was used for incidence of heterogeneity injurious analysis and falls, shortwas term completed by DV4: calculating incidence of the degree of injurious inconsistency falls, long(I^2) term DV5: Time Comprehensi to first fall ve Metaanalysis Software 3.3.070 • GRADE – measured quality of evid. Decision for practice S: LOE: I • • In at-risk adults and older adults, tai chi practice may reduce the rate of falls and injuryrelated falls over the short term (<12 months) by approximately 43% and 50% W: • Tai chi practice may not influence time to first fall in these populations. • Low quality evidence used • The most relevant shortcoming in this evaluation was a high risk of attrition bias in two studies and in the long-term follow-up of one study. Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: Theory/ Conceptual Framework Design/Method 35 Sample/ Setting Major Measurement/ Variables & Instrumentation Definitions falls or time to first fall (4) compared to usual care or other therapies different from tai chi EC: Plummer, M., Bradley, C. (2017). Tai chi as a falls prevention strategy in older adults compared to conventiona l physiothera py exercise: A review “The PICOS framewor k (Populati on, Interventi on, Comparis on, Outcome and Study) was used” Design: SR and MTA Purpose: 1. To clarify for which population Tai Chi is most effective N= 4 RCTs included in MTA IC: ■ Published between 2005 and 2015 ■ Published 2. To identify the worldwide optimal type, but written in the English duration and intensity of Tai language Chi for falls ■ prevention Randomised controlled 3. To confirm trials (RCTs) whether Tai Data Findings/ Analysis Results (stats used) Decision for practice pooled effect was estimated using the trim and fill method IV1: Population IV2: tai chi type IV3: duration IV4: intensity DV1: falls incidences DV2: mobility DV3: balance DV4: functional status/disabi lity • DV1: incidence rate ratio (IRR) • DV2: Performance Orientated Mobility Assessment Scores (POMA) • DV3: Berg Balance Score • DV4: - Groningen Activity Restriction Scale (GARS) - Physical Performance Scores (PPS) DV5: The Only ¼ of the methodologic studies produced sig al quality of effects in the four favor of Tai papers Chi for fall included in prevention. this review was assessed Variation in falls using the incidences CASP tool across RCTs for RCTs. may be due to Tai Chi style/delivery methods, with all authors using a different form of Tai Chi. S: LOE: I • There is some evidence for positive effects in pre-frail individuals; however, more research is needed to confirm this W: although Tai Chi is effective for reducing falls in the population aged 65 and over, the body of evidence does not conclude this effect to be significant. Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: Theory/ Conceptual Framework Design/Method Chi is more effective in falls prevention than current physiotherapy programmes and therefore become a more inherent aspect of falls prevention programmes. Solloway, M., Taylor, S., Shekelle, P., MiakeLye, I., Beroes, J., Shanman, R., & Hempel, S. (2016). An Inferred: explanato ry theory Design: SR of SRs Purpose: In order to provide a broad overview of the research evidence that has been published to date, we conducted a systematic review of systematic 36 Sample/ Setting Major Measurement/ Variables & Instrumentation Definitions ■ Male and female participants aged 65 years and over ■ Compares Tai Chi to conventional physiotherap y ■ Measures a reduction in falls as an outcome. DV5: methodologi cal Quality Appraisal N= 107 SRs N=5 SRs focused on BC/FOF IV: healthcarerelated settings IC: * Systematic reviews of the effects of Tai Chi for any clinical DV1: patient health outcomes DV2: duration and • DV5: Critical Appraisal Skills Programme (CASP) tool Data Findings/ Analysis Results (stats used) • hazard ratio (HR) for time to first fall. • Evidence Map • MetaAnalysis • Bubbleplot • PRISM checklist • 15/107 SRs were regarding Fall prevention • 27/107 SRs were regarding balance • 42 % reported on the presence or Decision for practice ■ Although a worldwide search was conducted, only articles written in English language were included in the search criteria, limiting the body of evidence to be appraised ■ A search of unpublished research was not conducted, which again may limit the validity of this review. S: LOE: I? W: • 42% reported on the presence or absence of adverse events • firm conclusions cannot be drawn due to Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: evidence map of the effect of Tai Chi on health outcomes Theory/ Conceptual Framework Design/Method 37 Sample/ Setting reviews of the indication effects of Tai Chi were eligible on health outcomes for inclusion. *Systematic reviews of adult participants or unspecified age groups regardless of their health status were eligible for inclusion in the review EC: -systematic reviews exclusively focusing on children and adolescents - Systematic reviews of provider outcomes, Major Measurement/ Variables & Instrumentation Definitions follow-up point DV3: Data Findings/ Analysis Results (stats used) Decision for practice absence of methodological adverse events limitations in the original studies and/or • “Five an insufficient number systematic of existing research reviews studies. focused on balance confidence/fea • evidence maps cannot provide definitive r of falling and the largest answers about the effectiveness of an included six intervention. RCTs. One reported a positive effect for Tai Chi compared to usual care, exercise, or education (SMD 0.47; 95 % CI 0.30, 0.63; 4 RCTs)” Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: Theory/ Conceptual Framework Design/Method 38 Sample/ Setting acceptance, prevalence, use, costs, study design features, or intervention features not reporting patient health outcomes N= 50 RCTs n= Major Measurement/ Variables & Instrumentation Definitions Data Findings/ Analysis Results (stats used) Decision for practice Wayne, P., Inferred: Design: IV1: Study Descriptive • 18/50 reported S: • AE reporting Berkowitz, Prescripti SR Focus stat’s LOE: I protocol: detailed D., ve theory IV2: • Based on a small CONSORT synthesis of Litrownik, Purpose: PC: avg. age Intervention number of less-biased Extension safety evaluate the D., Buring, of study type studies, TC is unlikely checklist of 10 • 0/50 reported J., & Yeh, frequency and type participants to result in serious AEs, rec’s when serious AEs of AE occurrences was 65 years G. (2014). reporting harms in • 15/50 minor • Reported AEs were in randomized What do we old (median DV1: AEs RCTs typically minor and aches/pains of controlled trials really know 69 y; range, reported expected and primarily • Systematic lower ext’s (RCTs) of TC for about the 11-102y) DV2: AEs musculoskeletal related searching by the 2 • 6/50 reported all populations. safety of tai not reported (eg, knee and back authors back/spine chi?: A IC: RCTs DV3: AE pain, of which pain) A secondary aim is that were systematic monitoring one was severe • no intervention-related to evaluate the review of published in protocol serious AEs were consistency and adverse English and reported • 100 (65%) quality of AE event used TC as included no monitoring reports in an mention of protocols used in randomized intervention. W: either AE trials the included trials. Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: Theory/ Conceptual Framework Design/Method 39 Sample/ Setting Major Measurement/ Variables & Instrumentation Definitions EC: no monitoring protocol or adverse events listed Wu, Y., Macdonald, H., & Inferred: Predictive Theory Design: SR N= 26 RCTs n= 3247 participants IV1: Ex Rx Methods • IV1: Ex Rx Methods Data Findings/ Analysis Results (stats used) • Downs & Black checklist Decision for practice monitoring • only included trials protocols or AE published in the reports, English language. • additional 3 • study only used studies only descriptive statistics mentioned an and narrative AE protocol summaries of AE but no AE reports d/t the small report. number of studies and • Of the 50 the heterogeneity of eligible studies both interventions & that included an controls explicit AE report • only 18 trials included an explicit monitoring protocol, which provides a more reliable framework for interpreting the validity of AE reports. • Reporting rate S: LOE: I of mov’t principles Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: Pescatello, L. (2016). Evaluating Exercise Prescription and Instructiona l Methods Used in Tai Chi Studies Aimed at Improving Balance in Older Adults: A Systematic Review Theory/ Conceptual Framework Design/Method 40 Sample/ Setting Purpose: (mostly To develop an women) evaluation instrument to 27 determine to what interventions extent Tai Chi identified/rev interventions aimed iewed at imp. the balance CG: 1613 of older adults disclosed their IG: 1634 PC: exercise participants prescription (Ex aged 60 and Rx) and older w/o instructional debilitating methods and met disease best-practice EC: exercise recommendations • not RCTs for balance imp. (n=23) • Participant s had severe debilitatin g disease (n=8) • Article was not published Major Measurement/ Variables & Instrumentation Definitions Data Findings/ Analysis Results (stats used) Decision for practice IV1 1. Freq. of Tai (augmented marginally • Balance was Defined: chi practice version): correlated w/ significantly improv. In (sessions/week) used for balance imp’s Integration 19/27 interventions 2. Time or methodologic s/p TC of the (r=0.35, duration of components al study P=.08) each TC of freq., quality session intensity, assessment • The mean W: 3. Length of TC time, type, • SPSS 21 reporting rate • Intervention features intervention volume, & for the IV1 specific to IV2 were • 2-tailed sig. (weeks) progression was (92.6+/poorly reported and level was principle for 19.2%) weren’t customized for (P 0.05). After training, only Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses DNP PROJECT FINAL REPORT Citation: Theory/ Conceptual Framework Design/Method 46 Sample/ Setting Major Measurement/ Variables & Instrumentation Definitions Data Findings/ Analysis Results (stats used) Decision for practice mild improv’s in Group 1 – but not statistically significant (p > 0.05). • Group Comparison of balance control, fear of falling, & mood parameters: a sig. difference observed in Group 1 for SLS-EO (p < 0.05) & SAFFE scores (p < 0.05) • There were no serious adverse events reported Key: α – alpha; ABC – Activity-specific balance confidence; AE - adverse events; BC – balance confidence; CBS - community-based setting; CEP – Combined Exercise Prescription; CCT - clinically controlled trial; CG - control group; DI - duration of intervention; DV - dependent variable; EC - exclusion criteria; ES – effect size; IG - intervention group; IC - inclusion criteria; IV - independent variable; FoF - Fear of Falling; LOE – Level of Evidence; LT – Long-term ; mo - month(s); MTA - meta analysis; N - number of studies; n - number of participants; PC - population characteristics; RCT - randomized control trial; S - strengths; SD – standard deviation SR - systematic review; ST – Short-term; TC Tai Chi; TCMBB -Tai Chi: Moving for Better Balance; TUG – Timed Up & Go test; Tx – treatment; W - weaknesses Running head: DNP PROJECT FINAL REPORT 47 Appendix J Table 2 Bubela, D., et al. Gallant, M., et al. Hu, Y. N., et al. Lomas‐Vega, R., et al. Plummer, M., et al. Solloway, M., et al. Wayne, P., et al. Wu, Y., et al. Yang, G., et al. Yildirim, P., et al. Synthesis Table: Year LOE 2017 IV 2017 IV 2016 2017 2017 2016 2014 2016 2015 2016 I I I I? I I I II Design QuasiXP quasiXP SR & MTA SR & MTA SR SR SR SR? RCT Studies Reviewed Length (weeks) n/a 10 10 4 rcts 12-26 n/a ~12 12 Length of Class (hrs) Freq/week Communitybased Measured AEs Bias n/a n/a 612mo n/a 26 RCTs 19.7 n/a 12 153 RCTs 6-52 507 16 Eviden ce Map of SRs 107 SRs n/a 1 n/a n/a n/a n/a x 1-3 x n/a n/a n/a n/a 56.5 min. 2.8 x ~1-2 n/a 20-120 min 1-5 x X Poss. x x 3.4% n/a n/a n/a 33% - Sample Size 16/14 131 2850 1432 Mean Age (years) Neg. Events 80.4/71. 2 68-84 56 to 98 ASBCS x BBS X Sample Study Design Studies 0 1383 n/a n/a n/a 3 x x 3247 60 65 0.8% 62.37/6 3 0 x x x BDS Measured n/a ~2-3 X Fall Incidence Fear of Falling X FFWT x x x Key: 0 – No change; ASBCS – Activity-Specific Balance Confidence Scale; BBS – Balance Berg Scale; BDS – Beck Depression Scale; FFWT – Fifty-Foot Walk Test; GARS - Groningen Activity Restriction Scale; GDS - Geriatric Depression Scale; LOE - Level of evidence; PPS - Physical Performance Scores; “/” - indicates that study did not mention; SLS-EC – Single leg stance eyes closed; SLS-EO - Single Leg-Stance-Eyes Open; POMA - Performance Orientated Mobility Assessment Scores; SAFFE - Survey of Activities and Fear of Falling in the elderly; TC – Tai Chi; TCMBB - TC Moving for Better Balance TUG – Timed up & go; X - Indicates yes; DNP PROJECT FINAL REPORT Five-time Sit to Stand x Functional Reach GARS X 48 x X x GDS Knee Extension Strength PPS x X SAFFE x SLS-EC x SLS-EO Time to first fall TUG x x X x X x Balance Outcomes Confidence Inc. Inc. Fall Rate 0 Mobility Inc Strength Inc. Inc - x inc x Inc. - Inc x Other… X X Sig. Adverse Events reported 0 0 X X 0 0 Key: 0 – No change; ASBCS – Activity-Specific Balance Confidence Scale; BBS – Balance Berg Scale; BDS – Beck Depression Scale; FFWT – Fifty-Foot Walk Test; GARS - Groningen Activity Restriction Scale; GDS - Geriatric Depression Scale; LOE - Level of evidence; PPS - Physical Performance Scores; “/” - indicates that study did not mention; SLS-EC – Single leg stance eyes closed; SLS-EO - Single Leg-Stance-Eyes Open; POMA - Performance Orientated Mobility Assessment Scores; SAFFE - Survey of Activities and Fear of Falling in the elderly; TC – Tai Chi; TCMBB - TC Moving for Better Balance TUG – Timed up & go; X - Indicates yes; Running head: DNP PROJECT FINAL REPORT 49 Appendix K Fig. 1. Walter Stewart’s PDSA Cycle – Contains 4 stages: Plan, Do, Study, Act (Crawford, 2018). DNP PROJECT FINAL REPORT 50 Appendix L Fig. 2. MoCA-B Page (1 of 2). DNP PROJECT FINAL REPORT 51 Appendix M Figure 3. 2018 PAR-Q+ (Page 1). DNP PROJECT FINAL REPORT 52 Appendix N Figure 4. Fear of Falling measurement tool: Falls Efficacy Scale-International DNP PROJECT FINAL REPORT 53 Appendix O Figure 5. Participant Fear of Falling Total Scores.