Journal of Neurological Physical Therapy 22Vol. 30 • No. � • 2006

Taiji for Individuals with Parkinson Disease and their Support Partners: Program EvaluationPenelope J. Klein, PT, EdD,1 Lynn Rivers, PT, PhD2

1 Associate Professor of Physical Therapy, D’Youville College (kleinpj@dyc.edu)2 Chairperson, Physical Therapy Department, D’Youville College

ABSTRACTBackground and Purpose: Exercise is advocated in the

management of Parkinson disease (PD), however, little is known regarding the potential benefits of complementary mind/body exercise for this clinical population. The purpose of this pilot program evaluation was to gain insight into participant and instructor perceptions of the perceived benefits and potential utility of a taiji exercise program. Program Evaluation: Program participants (N=15) included 8 individuals with PD and 7 support partners with no history of PD. Group taiji instruction was offered in 45-minute weekly sessions, for 12 weeks at a community facility. Postprogram evaluation included administration of a survey questionnaire, thematic analysis of a focus group discussion, instructor reflections, and review of attendance records. Results: Benefits were perceived by participants in physical, psychological, and social domains. Thirteen of the survey respondents, including 6 of the 8 respondents with PD reported perceiving a physical benefit attributed to taiji practice. Improved balance was reported most frequently. Instructor observations and participant testimony suggest movement capability for individuals with Parkinsons may also be improved by performing taiji. Conclusion: This preliminary research provides support for further Taiji Buddy program examination and application.

Key Words: Parkinson disease, exercise, tai chi, complementary

INTRODUCTIONParkinson disease (PD) is experienced as progressive neuromotor

debilitation characterized by akinesis, bradykinesis, and tremor.1 Health benefits of regular exercise for the management of PD are well known.2,3 The National Parkinson Foundation (NPF) supports the use of taijiquan practice for individuals with PD (http://www.parkinson.org/). Taijiquan is an ancient Eastern health-promoting, low intensity exercise that can be safely performed by individuals of varying physical abilities. While taijiquan has origins in the martial arts, it is more popularly known for health promotion.4-11 A similar exercise discipline, qigong, shares some of the movement characteristics of slower forms of taijiquan but has its origins in Traditional Chinese Medicine.12

When taijiquan is practiced for health benefit, it is a form of qigong.13 Given the known health-promoting benefits of taijiquan as qigong and increasing interest in developing novel nonpharmacological treatment modalities for people with PD,

the specific benefits of the exercise regimen for individuals with PD were considered worth exploring. The Taiji Buddies program described in this paper is an example of such an intervention.

Within the paradigm of Traditional Chinese Medicine (TCM), health is believed to be a state of natural balance achieved through regulation of the body, breathing, mind, Qi, and the spirit. ‘Qi’ refers to life energy or bioelectricity. Qigong is the gathering and storing of life energy. Qigong may be quiet or dynamic meditation combined with breathing and postures. In his text on taijiquan theory,13 Dr. Yang, Jwing-Ming, a taijiquan master, provided a comprehensive dissertation on the Eastern theoretical and philosophical foundations of this ancient art. He explained that the ultimate goal of the study of taiji, the art and philosophy, is enlightenment. In contrast, the goal of the Taiji Buddies Program is to improve physical function. Therefore, theories of Western medicine and movement science have more contextual relevance for this application.

In Western medicine and rehabilitative sciences, there is a growing body of clinical research that proves that regular practice of taijiquan can improve balance, flexibility, strength, and circulation as well as mediate pain, enhance immune response, and induce a sense of calm and well being.10,11 However, validating basic science research on how taijiquan works is, for the most part, propositional. For example, taiji-like movements are similar in pattern and rhythm to slow reversing techniques and movement patterns introduced into conventional physiotherapeutic practice by Knott and Voss.14 The slow pacing of the exercise can allow time for muscle recruitment within stabilizing muscles and slower twitch fibers of prime movers for strength training and improved coordination of movement. The dynamic quality, body-part connectedness, and mental intention of practice is similar to whole task training in motor control theory. Mediation of joint and chronic pain may be a combination of overcoming pain memory, regulation of cytokines, and improved biomechanics. The induced sense of well-being may be a result of release of serotonin. Whether or not participants in the Taiji buddies program perceived any of these benefits is a first step to exploring these propositions.

In designing the Taiji Buddies Program, exercise adherence was considered as essential as choice of exercise regimen. Factors known to positively influence exercise adherence are perceived benefit, self-efficacy of performance and a sense of social cohesion.15 Social cohesion was identified as the important factor in the design of the Taiji Buddies program, which differs most from other health-

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promoting community taijiquan instructional programs in its intent to involve a supportive exercise partner into the exercise experience. The partner assumes the role of taiji buddy. The taiji buddy assists in transportation to and from the training site, in maintaining a safe exercise environment during home practice, and offers social support. Taiji buddies are expected to participate in classes. In doing so, they have equal opportunity to experience general health benefits as well as engage in a shared life experience with their movement-impaired partners. The purpose of the paper is to describe the Taiji Buddies program and its evaluation from the participants and the instructor’s perspectives.

METHODSThe research protocol was approved by the D’Youville College

Institutional Review Board. Pilot program participants were recruited from a regional Parkinson support group. Study subjects were recruited from program enrollees. Program enrollment preference was given to individuals with PD and their supportive exercise partners. Enrollment excluded individuals who could not (1) engage in mild exercise for a period of 45 minutes or more, (2) walk unassisted for a minimum of 100 feet, or (3) participate in large group instruction. At program inception, program enrollees self-reporting a diagnosis of PD were invited to participate in quantitative pre/postassessment. On the second to last class of the 12-week session, all program enrollees in attendance were invited to participate in a qualitative postprogram evaluation to be conducted following the last class of the session.

Seventeen individuals enrolled in the pilot course offering, 8 of which had a diagnosis of PD. At the completion of the 12-week program, all but 2 of the original participants completed qualitative postprogram evaluations (12 females and 3 males). One participant stopped attending due to an unrelated illness. Another missed the last 2 sessions due to scheduling conflicts. Each of the postprogram evaluation subjects had attended at least 8 of the 12 classes. The average postsurvey respondent’s age was 69.2 years (range 44-84). The average years since diagnosis for the 8 subjects with PD was 9.8 years. Three taiji buddies reported having arthritis including one who had a history of knee replacement. One taiji buddy reported having Multiple Sclerosis. Another had an active diagnosis of cancer. Among the individuals with PD, fatigue was the most frequently reported debilitating symptom, followed by movement or balance impairment. Three taiji buddy pairings were husband and wife. One pairing was mother and daughter. Four pairings were friends. One individual with PD signed up without a taiji buddy exercise partner.

The primary variables in the postprogram evaluation were participant perceptions of benefit and program utility. Instructor reflections were also solicited to gain additional insight into management considerations for future programming. Indicators of benefit were assessed qualitatively for all subjects, and supplemental quantitative measures were used for subjects with PD. Indicators of program utility included attendance, adherence, and home exercise adherence.

Postprogram qualitative evaluation included administration

of a self-report questionnaire, a focus group discussion, and instructor reflections. The self-report evaluation survey was a 2-part questionnaire. Part 1 surveyed subject demographics and characteristics. Part 2 surveyed perceived benefits and experiences with the exercise program. Part 2 was constructed with 4 Likert-like questions and 2 open-ended questions that addressed physical, social, and psychological domains (see Figure 1). Survey content validity was established by cross-referencing survey items to study questions. Survey construct validity was established by expert review. In the focus group discussions, pilot program participants were asked to offer comments about their experience with taiji. The focus group discussion was led by one of the program instructors. Guiding questions for the focus group were consistent with Part 2 survey questions, and the focus group was conducted immediately following the independent completion of the questionnaire survey. An independent observer recorded comments expressed during the focus group discussion. This same field observer transcribed and collated responses from the written survey. Instructor reflections were formative and summative and addressed in-class observations, program utility, and suggestions for any program revision.

Quantitative pretesting for assessment of physical function and quality of life in subjects with PD occurred in the 2 weeks prior to the beginning of the 12-week program. Post-testing occurred immediately following the last class. Pretests of physical function for individuals with PD included the Berg Balance test16 and the Timed Up and Go test.17 Assessment of global function and quality of life was conducted using the SF-12 questionnaire, a standardized short form of the MOS-SF-36 test.18 Physical tests were administered on site by trained field observers. The Berg Balance test and Timed Up and Go test were not used in postprogram evaluation. Of these 3 tests, only the SF-12, administered as a confidential survey, was used in postprogram evaluation.

InterventionThe pilot curriculum was developed and implemented by

a senior taiji instructor and a physiotherapist/taiji instructor. The pilot program was structured as twelve, 45-minute classes. Instructional content included selected Temple Exercises, elements of the Yang Style 12-movement short form, and selected qigong exercises. Class size was limited to 18 participants. Tuition fees ($5/class) were either paid as self-pay or covered by third-party health insurers under health and wellness coverage, at course registration. Participant taiji buddy pairs were each given a copy of an instructional video19 to augment class instruction and to guide recommended home practice. The video was presented as a gratuity for participation in the pilot program.

Each class was organized into 4 parts: warm-up, instruction in movement patterns, form practice, closing taiji Temple Exercises, and selected qigong exercises. Typical warm-up and closing exercises included assuming taiji posture, weight shifting in place, arm swinging with rotation, unweighted knee and ankle rotation, as well as repetitions from among the following standard taiji moves4,5: ‘rising and sinking,’ ‘picking fruit,’ ‘presenting fruit,’ ‘cross-arm opening and closing,’ ‘polishing the mirror,’ ‘polishing

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the table,’ ‘wave-hands-like-clouds’ in place, and ‘prayer wheel.’ Instruction in form practice included ‘grasp birds tail,’ ‘single whip,’ ‘wave-hands-like clouds,’ ‘stork-cools-wings,’ ‘strum-the-lute,’ ‘repulse monkey,’ and a modified qigong set. Two of the exercise activities using teaching aids are shown in Figures 2 and 3. A video clip illustrating selected movements can be found in the online version of JNPT at jnpt.org.

RESULTSPrimary findings of this study relate to perceptions of perceived

benefit of the participants, reported as confidential survey responses and comments transcribed from focus group discussion.

Postprogram evaluation On the confidential questionnaire survey, 14 of the 15

respondents endorsed the value of the Taiji Buddies Program, affirming that they would recommend or highly recommend the program to others (93% affirmation). The remaining respondent expressed a neutral opinion. Twelve of the 15 respondents (80%) reported engaging in home practice during the last 2 weeks of the session. A thematic analysis of survey responses to open-ended questions found perceived program benefits in physical, psychological and social domains. Thirteen of the respondents, including 6 of the 8 respondents with PD reported perceiving a physical benefit. Improved balance was reported most frequently.

Figure 1. Postprogram self-report survey: Part 2 (provided in 14 pt. font for study).

Part 2. My Taiji experience.

6. My level of enjoyment in learning and doing Taiji over the past 12 weeks was

very good good neutral negative very negative

7. If asked by another about doing Taiji, I would …

strongly recommend be neutral not recommend strongly not recommend recommend

8.

On average, in the first 2 weeks of the 12-week exercise period, I did home Taiji practice …

daily at least 3 times, weekly 1-2 times a week a few times never

9.On average, in the last 2 weeks of the 12-week exercise period, I did home Taiji practice…

daily at least 3 times, weekly 1-2 times a week a few times never

10. List any positive and/or negative effects of your Taiji Buddies experience

Any positive effects Any negative effects

11. Offer any additional comments you would like to make regarding the quality and format of the Taiji-Buddy classes.

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(See Table 1 for examples of responses along all 3 domains.) Perceived program limitations reported as survey responses

included difficulty in remembering routines for home practice, difficulty finding time to do home practice, difficulty following instructions and seeing the instructor in the large group setting, and difficulty trying to synchronize arm and leg movements.

A review of focus group discussion comments provided some

insight into participant applications of their training. Transcribed comments included: • “I started doing some exercises first thing in the morning to

get going;” and • “Now, I sometimes do a few minutes of exercising during

the day if I feel I am tiring or getting stiff--especially the arm swinging and the breathing [qigong].”

Figure 2. “Taiji buddies performing ‘Prayer Wheel’ with the aid of a taiji wand.”

Figure 3. “Taiji Buddies performing ‘Wave-hands-like-clouds’ with the aid of a taiji ring.”

Table 1. Perceived program benefits in physical, psychological, and social domains submitted as postprogram evaluation survey responses, subcategorized by participant group.

Individuals with Parkinson (n=8)

Physical Psychological Social

“Balance improved” “Catch self when falling”“Better balance”“Moving a little better”“Easier to start movements”“Keeps me more mobile and supple”

“Feel more relaxed”“Found benefits of slow exercise”

“Getting out of the house”“Was good to see other people doing well too”“I enjoyed meeting the instructors”

Taiji buddies (n=7)

Physical Psychological Social

“Balance has improved”“Improved balance”“Improved balance”“More aware of my need to do exercises for balance and body control”“My balance has improved and less pain in my lower back”“Helping with my posture”“Made me feel better in movement, not always noticed but felt it was making things work some”

“Energy level somewhat improved”“Calming effect of doing tai chi”“Admiration for folks who have developed peaceful body control”“Exercising that I can do”

“I feel closer to [my spouse]”

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One respondent requested that instructors consider being more specific about instructions regarding home practice for each lesson.

Quantitative assessment of physical function and quality of lifeFour of the 8 individuals who reported a history of PD agreed to

participate in quantitative pre/post-testing as well as postprogram qualitative evaluation. The small sample size (n=4) precludes making any inferences. The testing experience did, however, provided some insight into the utility of the selected measurement tools for this context. Pretest scores for all 4 subjects tested with the Berg Balance scale achieved a score of 50/56 or greater. With a SEM of at least 6 points and a desired improvement of at least 15% to demonstrate clinical significance, this test could not be used to determine objective improvement of improved balance in these subjects. A similar phenomenon was observed in Timed Up and Go test scores. After review of these data, a decision was made by the researchers to abandon plans to administer these tests postprogram participation. The SF-12 instrument was administered pre- and postprogram participation. A descriptive review of test results detected small changes in 2 of the 4 subjects. One subject reported improved function, and one reported a decline in self-assessment of health status.

Instructor reflections In summative reflection, both instructors were sufficiently

encouraged by their observations and teaching experiences to recommend program continuation. Both the senior taiji instructor and the physiotherapist/taiji instructor noted that the warm-up exercise: arm swinging with rotation, appeared to be a key exercise for facilitating initiation of movement in at least 2 of the individuals with PD. Notably, pelvic rotation excursion and arm coordination was observed by the instructors to be improved with 8 to 12 repetitions of this exercise. Having observed this phenomenon in the first classes, arm swinging with rotation was included early in the warm-up for all subsequent classes, and sufficient repetitions were completed to achieve the desired effect of movement-freeing.

DISCUSSIONThe Taiji Buddies Program was perceived by participants and

course instructors as having physical, psychological, and social benefits as well as a sufficient level of utility for continuation and replication. Judgment of pilot program success is based on evidence of achievement of desired outcomes of (1) realization of perceived physical, psychological, and social benefits (eg, improved balance), (2) validation of self-efficacy (eg, exercises that I can perform), and (3) social cohesion (eg, I feel closer to [my spouse]).

Chronic debilitating diseases are known to create a burden of illness not only felt by those who have been diagnosed, but also for their families.20 Programs, such as Taiji Buddies, with support partners as active participants, may have primary benefit and added utility. Relatively high rates of attendance and exercise adherence were observed in the pilot program. Perhaps, stronger evidence of

program utility is provided in the fact that Taiji Buddies session enrollments have been sustained in number since its inception. The current session, the fifth consecutive program session offering, has an enrollment of 18 and includes 4 participants from the original pilot program offering. Since the pilot, 2 administrative changes have been implemented. Complimentary coffee has been made available before and after class, and the exercise facility opens 30 minutes prior to the scheduled class time, so that participants can socialize before as well as after class. In the third and subsequent program session offerings, session lengths were reduced from 12 to 6 weeks of classes. Both delivery changes were instituted in response to requests from program participants.

Participants of succeeding Taiji Buddies session offerings have expressed perceived benefits similar to those experienced in the first offering. The following is a written comment volunteered 6 months post pilot evaluation by one of the original cohort who has maintained continuous participation in the Taiji Buddies Program.

(written communication from program participant with PD, submitted 6 months postprogram evaluation)

In weighing the value of program evaluation data, it is acknowledged that a one-group design has inherent limitations. There is a high probability of a placebo effect. There is also high probability of a positive bias among comments offered by program participants both on written survey and, even more so, in comments offered within focus group discussion. This bias may have been further influenced by the social environment that was created as part of the structure of the intervention. The use of independent field observers to assist with data collection was an attempt to minimize this potential bias. The fact that there was a balance of critical suggestions as well as positive comments allays some of this concern. The small sample size limits generalizability of findings.

A further limitation of the study was related to selection of tests of physical function. Participants with PD reported perceiving an improvement in balance. However, objective measures of balance were not able to verify and quantify this perception. This limitation is attributed to the phenomenon of ceiling effect observed in pretest scores for the Berg Balance test and the Timed Up and Go test. Based on this experience, it is recommended that in planning future studies with relatively high physically functioning adults, selection of more challenging balance and physical performance tests be explored.

“First and foremost - I have found that when my hand shakes, I can stop it by rubbing my hands together and making a small ball to find my chi [qi]. This gives me back control. Second – I breath [breathe] deeper, etc, now that I take tai chi. Third – Balance is greatly improved.”

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Implications for PracticeEvaluation of this pilot program suggests that, along with its

well-known general health benefits, taijiquan may have specific benefits for individuals with PD and their support partners. Participants perceived psychological and social benefit as well as physical benefits attributed to taiji practice. The most prevalent physical benefit perceived was improved balance. Further, the structure of the Taiji Buddies Program, one that encourages social participation and support partner involvement may have a positive influence on exercise persistence and the health and well-being of the support partner. This preliminary work provides rationale for continued clinical study and innovation in adapted taijiquan programming for individuals with PD and their support partners.

ACKNOWLEDGEMENTThe authors would like to express sincere appreciation to the

members of the Parkinson Support Group who participated in the pilot program and the support of their PT consultant, Ms. Connie Brignole-Sawicki, PT.

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VCUVirginia Commonwealth University

Department of Physical Therapy

Faculty position available for a physical therapist with expertise in pediatric assessment and intervention and motor development. Major responsibilities: teach in the entry-level doctor of physical therapy program, participate in multidisciplinary educational / training programs, develop a funded line of scholarship, contribute to curricular evaluation and development and engage in professional service.Qualifications: VA PT licensure or eligible, earned academic doctoral degree, expertise in pediatric physical therapy. Teaching experience in the physical therapy setting and evidence of scholarship preferred.Position available immediately, search will continue until the position is filled Department web site - http://www.vcu.edu/pt/ Send letter of interest, current curriculum vitiate and names, addresses and phone numbers of three references to:

Sheryl Finucane, PT, PhD Chair of Physical Therapy Search Committee

Virginia Commonwealth University Department of Physical Therapy, Box 980224

Richmond VA 23298-0224. e-mail: sfinucan@vcu.edu

Virginia Commonwealth University is an equal opportunity / affirmative action employer. Women, minorities, and persons with disabilities are encouraged to apply.

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