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Abstract of dissertation entitled

“An Evidence-based Program of Tai Chi Exercise for Reducing Fall Risk of

Community-dwelling Older Adults”

Submitted by

Wong Po Wai

for the degree of Master of Nursing

at The University of Hong Kong

in August 2015

In Hong Kong, falls are very common in the elderly population, around one out

of five elderly has a fall every year. Consequence of fall to elderly can range from

minor injury to severe trauma and require hospitalization, which may bring along a

great impact towards the public health service and a high economic cost. However,

many studies supported that Tai Chi exercise can improve the lower extremities

strength and balance ability as well as the gait stability, so as to reduce the risk of fall

for the elderly. Thus an evidence-based guideline for Tai Chi exercise as part of the

comprehensive fall prevention program can help to reducing the fall risk for the older

adults.

This study aims to identify the best available evidence for the Tai Chi exercise

program in reducing fall risk for community-dwelling older adults, assess the

transferability and feasibility, develop an implementation plan and evaluate the

program.

The relevant literature was searched by different electronic database. The related

literature was then retrieved, reviewed and synthesized. The quality assessment of the

studies was performed according to the methodological checklist for controlled trials

designed by the Scottish intercollegiate Guideline Network (SIGN). Evidence-based

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guideline for Tai Chi exercise program for reducing fall risk were then developed

according to the findings of the reviewed literature, while the implementation

potential being assessed in terms of transferability, feasibility and the cost-benefit

ratio.

Five studies were identified according to the criteria set. “An evidence-based

program of Tai Chi exercise for reducing fall risk of community-dwelling older adults”

was formulated based on the review of the selected studies. Six recommendations of

the evidence-based guidelines are formulated and graded according to the grading

system of SIGN. The evidence-based recommendations can offer health care

professionals a standards and strategies for implementing the proposed Tai Chi

exercise program. A communication plan for various parties with pilot test for

determining the feasibility of the innovation and an evaluation plan to determine the

effectiveness of the proposed program were then subsequently developed.

This study reviewed evidence for the effectiveness of the Tai Chi exercise

program in reducing fall risk, translated the reviewed evidence and developed

evidence-based guidelines for a Tai Chi exercise program in reducing fall risk for the

community-dwelling older adults. It is expected this evidence-based guidelines can

further ease the burden of the Hong Kong health care system

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“An Evidence-based Program of Tai Chi Exercise for Reducing Fall

Risk of Community-dwelling Older Adults”

by

WONG Po Wai

A dissertation submitted in partial fulfillment of the requirements for

the Degree of Master of Nursing

at The University of Hong Kong

August 2015

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Declarations

I declare that this dissertation represent my own work, except where due

acknowledgment is made. It has not been previously included in a dissertation, thesis,

or report submitted to this university or to any other institution for a degree, diploma,

or other qualifications.

Signed ..................................................

Wong Po Wai

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Acknowledgments

I would like to express my sincerest gratitude to my supervisor, Dr. Patsy PH

Chau, for her continuous guidance, assistance and suggestion for improvement

throughout my thesis. Her prompt response and availability despite her busy

schedules was highly appreciated.

I would also like to express my deep and sincere thanks to my family and my

fellow classmates for their support, encouragement and understanding in the past two

years. Their support was the key to the successful completion of this dissertation.

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Table of Contents

Declarations iv

Acknowledgments v

Table of Contents vi

Chapter 1: Introduction 1

1.1 Background 1

1.2 Affirming the needs 3

1.3 Objectives 4

1.4 Significances 5

Chapter 2: Critical Appraisal 6

2.1 Search and appraisal strategies 6

2.1.1 Identification of studies 6

2.1.2 Selection criteria 6

2.1.3 Appraisal strategies 6

2.2 Results 7

2.3Summary and synthesis 8

2.3.1 Study design 8

2.3.2 Subject characteristics 8

2.3.3 Intervention and control 8

2.3.4 Outcome measure 8

2.3.5 Effect size 9

2.3.6 Synthesis 9

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Chapter 3: Translation and Application 11

3.1 Implementation potential 11

3.1.1 Target setting 11

3.1.2 Target population 12

3.1.3 Philosophy of care 12

3.1.4 Timeframe 13

3.1.5 Support from the individual level 13

3.1.6 Support from the administration level 14

3.1.7 Measuring tool 16

3.1.8 Cost-benefit ratio 16

3.2 Evidence-based practice guideline/ protocol 18

Chapter 4: Implementation Plan 20

4.1 Communication plan 20

4.1.1 Identification of different stakeholders 20

4.1.2 Formation of the communication team 21

4.1.3 Communication with the stakeholders 21

4.1.3.1 Initiating phase 21

4.1.3.2 Guiding phase 22

4.1.3.3 Sustaining phase 23

4.2 Pilot study plan 23

4.3 Evaluation plan 25

4.3.1 Identification of outcome 25

4.3.1.1 Patient outcome 25

4.3.1.2 Staff outcome 25

4.3.1.3 System outcome 26

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4.3.2 Target population and sample size 26

4.3.3 Data collection and analysis 27

4.3.4 Basis for the change of practice 28

Chapter 5: Conclusion 29

Appendices 30

References 49

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Chapter 1: Introduction

1.1 Background

Following the improvement of the medicine, human is able to live longer. With

the aging process, older people usually experience decrease in physical mobility and

loss of balance, and lead to increase the chance of fall (Chu et al., 2007). Fall is

defined as an unintentional event in which an individual comes to rest inadvertently

on the floor, the ground or other lower level from a standing, sitting, or horizontal

position, to landing and hitting an object such as stair or piece of furniture (Lamb et

al., 2005). In Hong Kong, falls are very common in the elderly population, around one

out of five elderly has a fall every year (Chu et al., 2007). A research conducted by a

local university associated with Hong Kong Housing Society in 2008 to 2010 shows

that the incident rate of an elderly to fall within a year was above 15% and the rate of

repeated falling was almost 5% (Hong Kong Housing Society, 2011). The

consequence of fall to elderly can range from minor injury such as bruising, abrasions

or lacerations, to severe trauma such as internal hemorrhage or bone fracture. Falls

also bring along a great impact towards the public health service and a high economic

cost. According to the numbers reported by the Hospital Authority, it shows that there

were more than 32,000 elderly required to be admitted to the hospital due to fall in

2008, and the cost of related medical care amounts is about $2 billion Hong Kong

dollar per year (Hospital Authority, 2009). This is absolutely a great pressure on the

health care system. With the aging population in Hong Kong keeps growing, it is

foreseeable that the situation will become worse in the future and it is on top of our

most concerning list.

There are numbers of reason on elderly are more prone to fall. The risk factors

for falls can be categorized as either intrinsic person related factors or extrinsic

environment factors. The reason why elderly are more prone to fall is that they are

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more likely to experience multiple risks factors (Chu et al., 2007). For the intrinsic

factors, it is defined as clients’ basic functional and health status, especially is age

related degenerated changes in elderly. Elderly with higher level of impairment on

activity of daily living and instrumental activity of daily living are at high risk of

falling due to muscle weakness, poor balance and coordination. Certain illness with

different signs and symptoms may also contribute to increase chance of falling, such

as visual impairment, Parkinson’s disease, postural hypotension, hypoglycemia,

cardiovascular disease and certain side effects from the medication. Those with fall

history are also at higher risk to repeat falling, it is because they are lack of

confidence and fear of falling (Chu et al., 2007). Those with cognitive impairment,

such as dementia, also with increased risk of fall since they are unaware of the

potential hazards of falls (Leung et al., 2010). For the extrinsic factors, it is defined as

environmental conditions. It is found that poor lighting, slippery floor, lack of

handrails, uneven walking surface, presence of obstacles and loosen fitted clothes or

footwear are associated with fall risk (Leung et al., 2010).

In the recent few years, Tai Chi, a traditional Chinese martial art and exercise

system, has been considered as an effective intervention for fall prevention among

older peoples (Liu et al., 2010). This traditional Chinese exercise has been practiced

for centuries as healthy exercise in Asia, this may help to explain why the fall rate in

eastern population is far lower than in the western population (Leung et al., 2010),

and therefore it is widely promoted to the western countries recently. Tai Chi is an

exercise which emphasizes equilibrium of mind and body, continuous but highly

choreographed movement that incorporate unilateral and bilateral weight shift as well

as trunk and extremity rotation. Through slow and repetitive movement between

extremities and body, practitioners shift their body weight from one leg to the other in

sequent smoothly in order to achieve coordination. It is conventionally believed that

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perseverance in practicing Tai Chi can regulate the flow of “Qi” in the body and

strengthen one’s health. There are many studies supported that Tai Chi is an

easy-to-learn exercise and recommended to be part of the fall prevention program.

Several research studies has been done on the effect of practicing Tai Chi exercise in

order to helps to improve the lower extremities strength and balance ability as well as

the gait stability (Liu et al., 2010). Although improvement in balance does not

necessarily lead to reduction of fall, some studies reported that improvement in

balance was highly correlated with a decrease in the incidence of fall.

1.2 Affirming the needs

Indicating that the severity and the unfavorable consequence from falling, an

effective fall prevention program in the community is important for both elderly and

nurse. Different health care professions have been fighting with this issue for many

years including physical and occupational therapist, doctor and nurse. Historically,

nurses had developed different fall prevention programs, taught the public on how to

care high risk elderly to avoid falling, involved in the environmental reconstruction to

decrease the chance of fall and so on. This is a continuous combat which nurses are

keeps looking for the best and effective measure for fall prevention. For example in

my working department, including a medical and rehabilitation ward with a day care

center, there are referral for those older adult who are functionally independent to the

day care center for different exercise training, around 250 participants annually, and

one of the purpose is for fall prevention and further prevent from injury fall which

may eventually require hospitalization. However the effectiveness is not significant

and over 60% of them are still falls. Besides, Tai Chi exercise is not involved in our

training program.

In Hong Kong, the Hospital Authority has launched a territory wide falls

prevention program in collaboration with community social centers to offer Tai Chi

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exercise classes for community elderly in 2005. Since its inception, the program had

successfully organized about 500 classes of Tai Chi training and over 3000 older

peoples and completes it. The effectiveness was greatly appreciated and shows that it

is feasible to organize different Tai Chi program for the elderly in order to increase

their lower limbs muscle strength and balance ability in Hong Kong. Besides, there

was increasing evidence demonstrated that Tai Chi exercise can reduce the incidence

of falls among elderly and it is recommended to be part of an exercise program in

order to improve older adults’ lower limbs strength, gait and balance ability. Although

the effective intensity of the Tai Chi exercise program, such as the exercise duration

or the period, was various and maybe unclear, it was suggested by different health

care association as an efficient program to prevent fall for older adults. An

evidence-based guideline for Tai Chi exercise as part of the comprehensive fall

prevention program may help to complete the service and reducing the fall risk for the

older adults and also standardize the implementation of Tai Chi program, such as

duration and frequency of the training.

1.3 Objectives

In order to bridge the research to clinical practice gap and obtain a more

comprehensive program, the aim of this study is to provide effective standard Tai Chi

exercise as fall prevention exercise for community elderly population and ultimately

reduce community fall rate.

The objectives are:

1. Review current studies finding of similar program.

2. Summarize the studies result to develop an evidence based Tai Chi exercise

program.

3. Assess the transferability and feasibility of the evidence based Tai Chi exercise

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program for community older adult for fall prevention.

4. Develop implementation plan and evaluation plan of the program.

1.4 Significance

As mentioned, fall brings large negative effect. There is considerable mortality

and morbidity in fall and related complication. According to a study, the mortality of

fallers was 4.5%, which was significantly higher than in the non fallers with only

2.3% (Chu et al., 2007). Fallers experienced a greater decrease in score for the Barthel

index for independent activities of daily living (IADL), gait speed and total mobility,

and those with repeated fall even experienced the larger declines in all four functional

measures (Chu et al., 2007). Fallers would also restrict their activities and minimize

their social life and further lead to reduce mobility and increase dependence.

Therefore, an effective fall prevention program is essential in order to prevent older

adult from falling and emphasized the needs for fall prevention. It is expected that

around 200 patients in the current setting can be benefited from the proposed program

annually. On the other hand, nursing staffs can also enrich their nursing acknowledge

and gain sense of achievement.

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Chapter 2 Critical Appraisal

2.1 Search and appraisal strategies

2.1.1 Identification of studies

The identification of relevant literature was done by searching through three

main different electronic databases via the e journals of the University of Hong Kong

library and the electronic knowledge gate (eKG) of the Hospital Authority of Hong

Kong. The three electronic database are PubMed, CINAHL and British Nursing Index.

Different keywords related to the study were used for searching, including “falls”,

“fallers”, “fall prevention”, “older”, “elderly”, “Tai Chi”, “Tai Ji”, “community” and

“community dwelling”. A combined search was performed with different combination

of keywords. A manual screening was then performed based on the titles, abstracts

and also the selection criteria in order to eliminate irrelevant articles. Duplicated

articles were excluded. The reference list of related articles and eligible articles

identified were also screened for additional sources.

2.1.2 Selection criteria

All the selected articles should be randomized controlled trials (RCTs) or

quasi-experiments, which can provide a high level of evidence. The target population

are older adults aged 60 or above who are functionally independent and intervention

include Tai Chi exercise. Studies published from 2004 onward are preferable. Studies

with non-English and without full text are excluded because of the language barrier

and the difficulty in extracting information and synthesis data.

2.1.3 Appraisal strategies

All the selected articles were evaluated according to the checklist from the Scottish

Intercollegiate Guideline Network (SIGN) and the level of evidence was graded

according to the grading system and shown in Appendix 1 (SIGN, 2011). The

methodology checklist for randomized controlled trials was used in order to evaluate

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the articles, including the internal validity and overall assessment. The details of the

quality assessment of each article are list in Appendix 2. After the appraisal, data from

each article, including citation and study design, patient characteristics, intervention,

comparison, length of study, outcome measure and effect size were extracted into the

table of evidence and the table of evidence was attached in Appendix 3.

2.2 Results

By late August 2014, a total of 115 studies were retrieved from the above

electronic databases. After screening, it finally came out five relevant randomized

controlled trials articles which are eligible for this paper. Detail of the searching

process are presented in Appendix 4.From the selected 5 articles (Li et al., 2005; Gao

et al., 2014; Tousignant et al., 2013; Taylor-Piliae et al., 2014; Zhuang et al., 2014)

their level of evidence ranged from 1+ to 1++, which represent medium to high level

of evidence. In the internal validity assessment, all selected studies clearly focused

and appropriately address the research question. All articles sufficiently cover the

randomization method. Three articles had mentioned about the concealment method

(Li et al., 2005; Tousignant et al., 2013; Taylor-Piliae et al., 2014). One article did not

mentioned whether the subjects and the researchers were kept “blind” during the

treatment process (Zhuang et al., 2014). All articles sufficiently covered the subject

characteristics for the treatment, both the intervention group and the control group

were similar, and the only different between the group were the treatment under

investigation. All the relevant outcome were measured in a standard, valid and reliable

way. The dropout rate ranged 0 to 35.9%. Only one article did not mention whether

intention to treat was adopted for the analysis or not (Zhuang et al., 2014). None of

the articles was carried out at more than one site. In conclusion, all five articles were

considered to have medium to high level of evidence and the overall effect were likely

due to study intervention and the result were directly applicable to the target group.

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2.3 Summary and Synthesis

2.3.1 Study design

The five selected articles are all randomized controlled trial (Li et al., 2005; Gao

et al., 2014; Tousignant et al., 2013; Taylor-Piliae et al., 2014; Zhuang et al., 2014).

One article each was from Portland (Li et al., 2005), Canada (Tousignant et al., 2013),

and the United States (Taylor-Piliae et al., 2014). Two articles were from China (Gao

et al., 2014; Zhuang et al., 2014). All five articles were conducted in the community

setting.

2.3.2 Subject characteristics

Both male and female subjects were recruited in five articles. The mean age

ranged from 65.9 to 79.9. All of the recruited participants were functionally

independent and live in the general community. One article focus on those who were

diagnosed as idiopathic Parkinson’s disease (Gao et al., 2014) and one article focus on

those who were stroke survivors (Taylor-Piliae et al., 2014).

2.3.3 Intervention and Control

Tai Chi was the major intervention for all articles while one article used

combined exercise with balance and muscle strength exercise (Zhuang et al., 2014).

For the Tai Chi style, three of the articles mentioned that it was in Yang style (Li et al.,

2005; Gao et al., 2014; Zhuang et al., 2014) while the other two articles did not

mention. For the duration, it ranged from twelve weeks to twenty four weeks. For the

frequency, it ranged from two to three times per week. All the intervention last for

sixty minutes each time. For the control, three of the articles mentioned as usual care

(Gao et al., 2014; Taylor-Piliae et al., 2014; Zhuang et al., 2014). One of the article

mentioned as stretching exercise (Li et al., 2005) and one mentioned as conventional

physical therapy based on a balance program (Tousignant et al., 2013).

2.3.4 Outcome measure

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Four out of five articles used incidence of fall or fall count ranged from three

months to twelve months as the primary outcome measurement (Li et al., 2005; Gao

et al., 2014; Tousignant et al., 2013; Taylor-Piliae et al., 2014). The remaining article

used four difference physical performance tests to conclude as chance of falling

(Zhuang et al., 2014). All of the articles showed positive effect in reduction in

incidence of fall or fall risk after Tai Chi exercise although only three out of five show

statistically significant (Li et al., 2005; Gao et al., 2014; Zhuang et al., 2014). Besides

number of falls, many different kinds of physical performance test were used as

secondary outcome measure for assessment. Two articles used Berg Balance Scale to

assess participants’ static and dynamic balance abilities, which is a widely used

clinical test and considered to be the golden standard (Li et al., 2005; Gao et al., 2014).

It evaluates a person’s ability to perform 14 different balance related tasks of

increasing difficulty and score from 0 to 4.

2.3.5 Effect size

All five articles (Li et al., 2005; Gao et al., 2014; Tousignant et al., 2013;

Taylor-Piliae et al., 2014; Zhuang et al., 2014) conducted hypothesis testing for the

outcome measures. Although not all of them show statistically significant result, their

positive effect from the intervention show clinically effective on reducing fall rate.

2.3.6 Synthesis

After reviewed the selected articles, all of them demonstrated that Tai Chi

exercise is an effective intervention, as they all showed a clinically positive effect in

reducing the incidence of fall or fall risk for those older adults in the community. Four

out of five studies used Yang style Tai Chi (Li et al., 2005; Gao et al., 2014;

Taylor-Piliae et al., 2014; Zhuang et al., 2014) while one did not mention which style

was used (Tousignant et al., 2013). All of selected studies suggested sixty minutes for

each training session. Four of the selected studies suggested three training sessions

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per week (Li et al., 2005; Gao et al., 2014; Taylor-Piliae et al., 2014; Zhuang et al.,

2014) while one suggested only two sessions per week (Tousignant et al., 2013). For

the duration, three of the studies suggested total twelve weeks (Gao et al., 2014;

Taylor-Piliae et al., 2014; Zhuang et al., 2014), one suggested fifteen weeks

(Tousignant et al., 2013) and the other one suggested twenty four weeks in total (Li et

al., 2005).Besides, there were additional concomitant benefits of Tai Chi showed from

the articles, including reduced fear of falling and improved functional physical

performance. However, it was mentioned that a comprehensive fall risk assessment or

evaluation is recommended in order to identify other risk factor which contribute to

fall incident such as environment factors (Li et al., 2005).

As mentioned in previous section, there was positive effect from practicing regular

Tai Chi exercise towards fall prevention, the effectiveness of regular Tai Chi exercise

training for fall prevention among the community dwelling older adults in Hong Kong

should be further investigate. Therefore, the implementation of Tai Chi exercise

intervention for fall reduction will be assessed and studied in the following chapter,

and finally to develop an applicable evidence-based program for fall reduction among

community dwelling functional independent older adults by practicing regular Tai Chi

exercise in Hong Kong.

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Chapter 3: Translation and Application

3.1 Implementation Potential

After reviewed the selected studies in the previous chapters, an evidence-based

program of Tai Chi exercise was noted to be effective in reducing fall risk of

community dwelling older adults. In order to implement this new innovation to the

clinical, the transferability, feasibility, cost-benefit ratio of the program, and the

content of the program will be discussed in the following.

3.1.1 Target setting

The current clinical setting is a sub-acute unit of a medical and rehabilitation

ward of a public hospital in Hong Kong (Ward A of Hospital A) in collaboration with

an outpatient day care center. Patients who were stabilized from their acute situation

were then admitted to Ward A for course of rehabilitation, most of these patients were

older adults, there are around 1260 patient admission annually and about 30% of the

admission cases had a fall history within the past three months. Patients discharged

from the ward will be referred to the outpatient day care center for continuous

rehabilitation. The outpatient day care center aims to provide continuous

rehabilitation program to patient who has rehab potential and ensure safe discharge to

home with regular follow up. Both the medical and rehabilitation ward and the

outpatient day care center were operated by the same team of healthcare providers,

which include doctors, nurses, and physiotherapists.

According to the reviewed studies, the Tai Chi exercise program was provided to

community dwelling older adults to reduce fall risk. The intervention was given by

Tai Chi master with the assistance from trained nurses. Based on the setting, the

transferability was high because both recruit patient who are going to be discharge

back to the community with regular follow up and exercise.

Currently, patients who admitted due to fall were mainly focus on pain

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management and for course of inpatient walking exercise. After short period of

rehabilitation, patients will then be discharged home when their pain reduced and

lower limbs power regained. However, seldom continuous and effective outpatient

rehab program was provided for them to maintain their lower limbs power or stability,

therefore patient would still complain difficulty in balancing or walking and suspected

to high risk of recurrent fall. Thus a continuous program is needed for community

older adults to reduce fall risk.

3.1.2 Target population

From the selected studies, all the participants were community dwelling older

adults who can tolerate moderate level of exercise with mental and physical condition

compatible for exercise, participants from 3 out of 5 selected studies mentioned with

fall history before the study ranged from 3 months to 12 months (Li et al., 2005; Gao

et al., 2014; Tousignant et al., 2013). Their mean age ranged from 65.9 to 79.9. Those

selected subjects include both western and eastern ethnicity. To fit the similarity, the

target population is patients who discharged from Ward A back to the community with

age 65 years old or above and functionally independent. Client who has cognitive

impairment was also excluded.

As mentioned before, around 30% of the admission cases had a fall history

within the past three months. Besides, there are many older adults encountered fall

incident out there in the community. Moreover, as the aging population is increasing,

it is estimated that the number of older adults who are at risk of fall will also be

increased. Therefore a sufficiently large number of clients, expected around 200

patients, could benefit from the proposed program.

3.1.3 Philosophy of care

As shown in previous chapter, Tai Chi exercise helps to improve the lower

extremities strength and balance ability as well as the gait stability, thus further helps

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in fall prevention. Given that patient safety is one of the most important concern from

the Hospital Authority in Hong Kong, the proposed program could achieve this

objective.

3.1.4 Timeframe

Before implement the proposed program, preparation should be made. The first

step is the formation of communication team. Then time is needed to seek approval

from management and this may take around two weeks. The frontline staffs will be

given four hourly introduction session of the proposed fall prevention program will be

provided within two weeks. After that is the recruitment of a Tai Chi master to

provide training for the staff and maintain the exercise program. There is four weeks

pilot study and four weeks analysis and modification of the pilot study is needed.

According to the selected studies, for the implementation of the proposed program, a

one hour session of Tai Chi exercise program will be provided to the patient in three

times per week for twelve weeks. There are further twenty eight weeks needed for

evaluation of the program. In conclusion, it will take sixty four weeks from

preparation to the end of the evaluation of the proposed program.

3.1.5 Support from the individual level

For the implementation of the newly introduced Tai Chi exercise program for fall

prevention, linked nurses have the autonomy to carry out and terminate the program

according to the individual situation with the evidence based guideline after complete

the training workshop. First for the recruitment of clients, nurses in the ward will have

assessment for the suitability of the clients according to the inclusion and exclusion

criteria. Besides, nurses in the day care center who provide the proposed program will

have continuous assessment of the clients in order to decide whether they were able to

continue with the proposed program or not. Moreover, fall risk assessment and

prevention is currently a routine nursing practice, nurses already have the fundamental

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knowledge and skill of it so nurses are not expected to have much difficulty about it.

Therefore it is expected that the implementation of the proposed program will not

largely increase the workload of the staff in the daily practice and thus it will not

greatly interfere with their current duties, and the staffs will be provided time for the

training workshop. However, barriers always exist for all innovations. The potential

friction to the implementation of the proposed Tai Chi exercise program for fall

prevention maybe low acceptance to the new innovation and low motivation from the

staff to change their current practices. Staffs may perceive many barriers to the

changes in related to their lack of knowledge about the new innovation, they may felt

lack of confidence in providing the correct intervention to the clients. The extra

workload, including hiring the Tai Chi master and the paperwork are always not

welcomed by the staffs and led to the resistance of the change. Finally, the

communication between the multidisciplines is also a concern. The staffs for the

proposed program include doctors, nurses and physiotherapists, for example doctors

response to monitor the participants’ health condition and physiotherapists response to

provide assistance for the participants, they work as a team for the program but they

are having their usual duties at the same time. Hence, the estimated friction can be

resolved by providing the suggested training session for the staffs, giving them about

the details information of the proposed program and answering their question and

worries before the implementation of the program. Regular meetings will also be

conducted to facilitate the communication between the multidisciplines and remain

update on the progress of the program.

3.1.6 Support from the administration level

Patient safety is always being the highest priority of the administrative concerns.

Patient fall is one of the most common prevalent types of incident in the current

setting. All of the staffs are reinforced to taking initiatives to minimize the risk of

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patient falling and imply different fall prevention precaution. Therefore the

administrator of the department is welcome and willing to support the implementation

of the proposed Tai Chi exercise program for fall prevention in order to reduce the

risk of fall of the community dwelling older adults and further prevent them from

recurrent fall which may need to be hospitalized and require medical treatment and

rehabilitation.

In addition, evidence-based project or program was encouraged and supported by

the administrator. Regular evidence based project campaign has been conducted in the

past few years. Certain feasible evidence based projects has been imply clinically

from the campaign, for example the modification of the blood glucose monitoring

chart for easy access and monitor of the patient diabetes conditions with medication

adjustment, and the effectiveness of the use of positioning device for patient who

underwent retinal detachment and require post operation positioning. Therefore the

proposed evidence based fall prevention program would be welcomed and supported

by the administrator.

Outside the nursing department, the support and cooperation of other

departments are also necessary for the success implementation of the proposed

program so a clear introduction for them is essential is order to gain their acceptance.

As the proposed fall prevention program obtain multidiscipline, for example

physiotherapists response for the supervise of the exercise session of the proposed fall

prevention program and assist in the assessment in the evaluation phase, while doctors

response for the monitoring of clients’ medical condition and review of their

medication. Besides, regular meetings will be conducted to facilitate the

communication between the multidisciplines and remain update on the progress of the

program. Therefore conflict between different disciplines is unlikely to be occurred

within the implementation of the proposed program.

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For the manpower, facilities and equipment required for the proposed program, a

qualified experienced Tai Chi exercise mentor should firstly be recruited for the

program. This Tai Chi exercise mentor will be taking up to teach both program staffs

and the target clients of the proposed Tai Chi exercise. Facilities and equipment

required including a multi-function room for holding the exercise session, mobility

aids, teaching notes, leaflets, visual audio devices, fall assessment form and aids are

all already available or can be easily be arranged at an affordable price with the

support and sponsored by the department.

3.1.7 Measuring Tool

For the measuring tool, the incident of fall was used as the measuring tool of the

primary outcome from the selected studies. The incident of fall reported directly from

the participated clients throughout the implementation phase and the evaluation phase

is the easiest way to obtain data and for assessment. It is proposed to provide a fall

calendar for the participated clients in order to record any fall incidents and data

would be collected by the program staff in a weekly base. Further information would

be obtained such as reason of fall and outcome for any fall incident occurred. On the

other hand, an audit of the compliance of the program by the staffs and clients would

also be conducted in order to evaluate the effectiveness of the proposed program.

Feedback from staffs and clients would also be collected for better evaluate and

modify of the program in the future.

3.1.8 Cost-benefit ratio

The cost-benefit ratio of an innovation is also a factor affecting the

implementation potential. Although there are some of the barriers when implementing

the proposed program, there are numbers of potential benefits result from the

implementation of the proposed program. With the implementation of the proposed

program, clients could be trained to improve their stability and balancing function.

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Therefore their independence of activity of daily living could be increased in the

community and further minimize their risk of fall. Thus, the needs for medical

intervention or hospital admission due to fall incidents could be decreased and the

related medical burden could be reduced.

According to the own record of Ward A, there were around 1260 total patient

admission annually to the Ward A and around 30% of them were fall cases. The

average length of stay for a fall patient is around 8 days. Their treatment scheme was

mainly focus on pain management and for course of inpatient mobilization exercise.

After short period of rehabilitation, patients will then be discharged home with their

pain reduced and lower limbs power regained. Therefore the basic cost for these fall

patient for one year would be around 200 * 8 * $4,680 = $7,488,000. After

implementing the proposed program, it is estimated that the numbers of fallers will

decrease by 20%, so the potential benefit of the proposed program would be

$7,488,000 * 20% = $1,497,600.

The estimated material cost including recruitment of the qualified experienced

Tai Chi exercise mentor, training provided to the nursing and physiotherapy staffs,

teaching materials, leaflets, maintenance of the venue and visual audio devices, fall

assessment form and aids. Details of the resources needed for the implementation of

the proposed program are listed as below respectively.

Table 1

Material cost for the implementation of the program

Items $ HKD

Recruitment of Tai Chi mentor $6000/month x 12

months = $72,000

18

Nursing and physiotherapy staffs training $200 *4 hours * 24

staffs = $19,200

Printing materials (including assessment form, leaflet,

teaching notes)

$3,000

Maintenance cost of resources (including visual audio

device, venue)

$5,000

Total estimated cost $99,200

In calculation, the estimated benefit would be HKD 1,497,600 in one year. On

the other hand, the estimated cost for the first year would be HKD 99,200. Therefore

the cost-benefit ratio of the proposed program was calculated in the following

formula:

Potential benefit/ Potential cost = 1,497,600/ 99,200 = 15.1

The ratio indicates that the implementation of the proposed program in the target

setting is worthwhile.

For the estimated non-material cost, the staff morale maybe affected initially

because of the low acceptance to the new innovation and low motivation from the

staff to change their current practices. However, with the training session provided to

the staffs, giving them about the details information of the proposed program and

answering their question and worries before the implementation of the program, the

staff morale maybe improved afterward.

3.2 Evidence-Based Practice Guideline/ Protocol

Based on the review of the selected studies, an evidence-based guideline of the

program is then developed.

19

Recommendations in the evidence-based guidelines of the Tai Chi exercise for

reducing fall risk program are formulated based on the findings from the selected

studies. The Scottish Intercollegiate Guidelines Network (SIGN) is used to grade the

recommendation and state the levels of evidence in the guideline which is shown in

Appendix 1 (SIGN, 2011). Six recommendations of the program are listed in detail in

Appendix 5 with evidence supporting the recommendations stated.

These guidelines are designed to provide staffs, including nurses and other health

care providers, of the target setting a standard for the proposed Tai Chi exercise for

fall prevention program. The target population is those older adults aged 65 years old

or above who discharged from the medical and rehabilitation ward to the community

and independently in the activity of daily living. The objectives of the evidence-based

guideline are to provide staffs from the target setting with evidence-based guidelines

about the Tai Chi exercise program in order to reduce the risk of fall for the targeted

community dwelling older adults.

20

Chapter 4 Implementation Plan

The implementation of the newly innovated program involve various parties,

therefore a communication plan among different parties is necessary for better

operation. A pilot study plan for the proposed program would also benefit for the

implementation. The follow chapter will illustrate the communication plan, pilot study

plan and evaluation plan.

4.1 Communication plan

A communication plan is essential to disseminate the objectives and significance

of the proposed fall prevention program so as to promote the implementation. A

detailed schedule is shown as Appendix 6.

4.1.1 Identification of different stakeholders

Stakeholder is person or group who can affect or can be affected by the

innovated program. Identify and communicate with the respective stakeholders

beforehand can facilitate the implementation of the proposed fall prevention program.

In the proposed fall prevention program, stakeholders including the hospital

administrative, frontline nurses, collaborative professionals and other supporting

staffs. For the proposed fall prevention program, the hospital administrators include

the department operations manager (DOM) of the medicine and rehabilitation

department and the ward manager (WM) of the target ward and outpatient client, they

are the one who approve the implementation of the innovation and deliver the

resources. The frontline nurses, including six link nurses and two advanced practice

nurses play an important role on introducing the innovated program and monitoring

the implementation of the proposed program. Collaborative professionals, such as two

medical officers and two physiotherapists are also key members in the proposed fall

prevention program. Lastly, the target clients, approximately 200 who are directly

affected by the proposed fall prevention program are also the stakeholders.

21

4.1.2 Formation of the communication team

A communication team with different members is essential in order to facilitate

the communication between professionals and the implementation of the proposed fall

prevention program. The communication team will be established within two weeks.

First of all, the team will be led by the proposer of the proposed program. The team

then will include a medical officer and an advance practicing nurse from the target

setting who will act as adviser. It is because they are experienced in setting clinical

guideline and implementing different innovation with advance knowledge. Besides,

the link nurses, about six in total, from the target setting ward and outpatient clinic are

included for the operation of the proposed fall prevention program. Furthermore, one

physiotherapist is also included for their special aspect of advices. In the meeting of

the team, the significance, objectives and content of the proposed fall prevention

program will be presented and discussed, and modification will be made according to

any constructive suggestion from different team members.

4.1.3 Communication with the stakeholders

4.1.3.1 Initiating phase

The hospital administrator and decision maker, who are the WM of the target

ward and outpatient client and the DOM of the medicine and rehabilitation

department, will be first approached by the communication team in order to gain their

approval and obtain the resources needed for the implementation of the proposed fall

prevention program. A formal presentation will be conducted for them. In the

presentation, the current fall prevention program used in the outpatient clinic will be

reviewed with updated rate of recurrent fall which require hospitalization, and this

will lead to the need for change and newly innovated fall prevention program. Then,

evidence from the literature will be shown in order to justify the significance and

objectives of the proposed fall prevention program. Afterwards, the content of the

22

proposed fall prevention program will be explained to the administrators in details

with the feasibility, cost-benefit ration and risk or barrier. Besides, the step of

implementation of the proposed fall prevention program with minimal disturbance

and interference will also be highlighted in the presentation. After the presentation to

the administrators, the fall prevention program will be amended according to the

comments raised. It would take around two weeks in order to obtain the approval.

4.1.3.2 Guiding phase

After the proposed fall prevention program being approved, communication then

goes to the other frontline staffs. Frontline staffs include the advance practice nurses,

registered nurses, medical officers and physiotherapists from the target setting wards

and outpatient clinics who are not in the communication team. Four hourly

introduction session of the proposed fall prevention program will be provided within

two weeks for this group, ten participants each time. The content of the introduction

includes the significance and objectives of the proposed fall prevention program, a

clear explanation of the guideline, evidence supporting the proposed fall prevention

program and the potential benefits and barriers. On the other hand, to reduce the

worries from the staffs and their resistance to the changes, question and answer

session will also be included in the introduction session in order to clarify any

misunderstandings or to answer any enquiries. All comments and suggestions from

different staffs will be consolidated and help to finalize the proposed fall prevention

program. The six link nurses from the target setting wards and outpatient clinic are the

role models and troubleshooters of the proposed fall prevention program, therefore

fully understanding of the guideline is required, and they will also assist in the Tai Chi

classes. Furthermore, the whole content of the proposed fall prevention program and

detail guideline will be uploaded to the hospital intranet website for staff reference

with distribution of a pocket guideline to all hospital staffs. For the dissemination of

23

the innovation, leaflet will be distributed to eligible patients at their admission.

Further elaboration for the patient by link nurse will be provided if necessary.

4.1.3.3 Sustaining phase

It is important to ensure that the facilitation of the newly innovation is adequate

in order to sustain the change. An evaluation can demonstrate the success of the

program, as well as the limitations and barriers. Staff’s compliance with the proposed

fall prevention program can be assessed by auditing the nursing chart. Client’s

outcome can be monitored by the recurrent fall incident reported. Arrangement of

biweekly meeting within the evaluation period with the frontline staffs to discuss and

collect comments and suggestions enable ongoing revision and amendments for the

proposed fall prevention program. Moreover, sharing of successful stories by the staff

can also promote the sustainability of the newly innovated guideline.

4.2 Pilot study plan

A pilot study is a small scale and preliminary study. It is used to determine the

feasibility of the proposed change and evaluate if revisions are needed before the full

scale implementation of the innovation.

The objectives of the pilot study of the proposed fall prevention program are

determine the feasibility of the proposed program and identify the facilitations and

limitations, evaluate the integrity of the guideline and the fluency of the

implementation of the proposed program and assess the satisfaction from clients and

different staffs.

All the link nurses, advanced practice nurses and physiotherapists from the target

setting wards and outpatient clinic will be given a training workshop on the

manipulation of the proposed fall prevention program. An experienced Tai Chi master

will be recruited as the trainer. Total six sessions of training workshop will be

arranged within two weeks at the multifunction room in the outpatient center, each

24

session will last for an hour. The form of the workshop will be held with presentation

with exercise teaching and trial. Since the link nurses and physiotherapists will be the

assistance role on providing the proposed Tai Chi exercise for the fall prevention

program, their understanding and compliance on the Tai Chi exercise from the

experience Tai Chi mentor is highly important and ensures the competency of the

proposed fall prevention program with sustainability. An audit of the competency on

the Tai Chi exercise for the trained staff will be performed by the Tai Chi master after

the training and all trained staff must be passed in order to process to the next stage. A

pocket guideline will be provided during the workshop with the details and flow of

the proposed fall prevention program from identify potential client in wards, referral

to the outpatient clinic to participating the proposed fall prevention program. Example

of case will also be presented in order to show the monitoring and measuring of the

outcome of the proposed fall prevention program. On the other hand, questionnaires

will be provided to staffs for any enquires and comments of the proposed fall

prevention program ( Appendix 7).

The pilot test will run for 8 weeks, includes 4 weeks of trial run and 4 weeks of

follow up and evaluation. It can ensure that all the link nurses and physiotherapists

will have enough chance to practice the proposed innovation. All clients from the

target setting wards who meets the inclusion criteria, which are tolerate moderate

level of exercise with mental and physical condition compatible for exercise, will be

invited to join the program with informed consent. The estimated number of clients

recruited for the pilot test will be around sixty, with the estimation that around thirty

admission within a week and around 55% of them are eligible. The pilot study will be

performed according to the proposed guideline to assess the feasibility of the program.

First of all, staff compliance will be audited by the advanced practice nurse in order to

coherent to the proposed guideline. Then an evaluation form, shown as Appendix 7,

25

will be distributed to the staffs for comments of the program, including satisfactory

level, suggestion for improvement and encountered barriers. All the information will

be gathered and analyzed by the link nurses and discussed in the regular meeting of

the communication team. Eventually, a final amendment will be made after the review

of the evaluation of the pilot study so to prepare for the full scale implementation of

the proposed fall prevention program.

4.3 Evaluation Plan

The evaluation plan is used to determine the effectiveness of the proposed fall

prevention program in the target setting. The content of the evaluation plan includes

identifying the outcomes, target population and sample sizes, outcome measurement,

data collection and analysis. The result will then serve as basis for the change of the

practice. The evaluation period will take around twenty eight weeks.

4.3.1 Identification of outcome

4.3.1.1 Patient outcomes

The primary objective of the proposed fall prevention program is to reduce the

fall risk of elderly adults in the community. The incident of fall reported directly from

the client throughout the implementation phase and the evaluation phase is the easiest

way to obtain data and for assessment. It is proposed to provide a fall calendar for the

client in order to record any fall incidents and data would be collected by the link

nurses in a weekly base for twelve weeks ( Gao et al., 2014; Tousignant et al., 2013;

Taylor-Piliae et al., 2014). Hence, the evaluation period will be twenty eight weeks in

total. Further information would be obtained such as reason of fall and outcome for

any fall incident occurred.

4.3.1.2 Staff outcomes

The satisfaction level to the proposed fall prevention program by the program

staff is also important to determine its effectiveness. An evaluation form, which

26

shown as Appendix 7, will be provided to the staffs as well on self-rated satisfaction

level in applying the proposed fall prevention program at the end of the pilot test and

implementation period. The form consists of four questions with 5-point Likert scale,

which 1 means very disagree and 5 means very agree. The total marks will be

calculated and scored from 4 to 20, with score 13 or higher is defined as satisfaction.

4.3.1.3 System outcome

For the sustainability of the proposed fall prevention program, the cost benefit

ratio of the program is an important concern for the administration level. With the

implementation of the proposed fall prevention program, clients could be trained to

improve their stability and balancing function. Therefore their independence of

activity of daily living could be increased in the community and further minimize

their risk of fall. Thus, the need for medical intervention or hospital admission due to

fall incidents could be decreased and the related medical burden could be reduced.

The cost of the implementation of the proposed program will be recorded accordingly

including recruitment fee for the Tai Chi mentor, training cost to the related staffs and

others resources. With the number of fall incidents reduced during the implementation

period of the proposed program, the cost benefit ratio will be calculated within the

twenty eight weeks evaluation period.

4.3.2 Target population and sample size

The proposed fall prevention program will be implemented in the medical and

rehabilitation department wards and outpatient clinic of Hospital A.

The target population to be involved are clients who aged 65 or above and

independently in the activity of daily living. They are going to discharge from the

ward of the medical and rehabilitation and referred to the outpatient clinic under the

same unit in Hospital A.

An online software from Lenth, Java applet, is used to calculation of the sample

27

size by using one-tailed z-test of one proportion for the proportion of patient with a

fall history within the past three months (Lenth, 2006-2009). The fall rate in the target

setting was 30% according to the statistical record from Hospital A, and the program

targets is to reduce the proportion by around 20%. While based on the findings from

the table of evidence, the estimated effect size of the proposed fall prevention

program ranged from 9.4% to 15.2% (Li et al., 2005; Tousignant et al., 2013;

Taylor-Piliae et al., 2014), we use a conservative assumption that the fall rate will be

about 15.2%. The power of the study is set at 80% with the level of significance at

0.05. The final calculated sample size needed for the proposed program is 131.

According to the own record of Hospital A, there were around thirty admission within

a week and around 55% of them are eligible, about eight weeks are needed to recruit

the patients.

4.3.3 Data collection and analysis

The incident of fall is the primary outcome of the proposed program. A fall

calendar will be provide to the client in order to record any fall incidents and data

would be collected by the link nurses in a weekly base within the twenty eight weeks

evaluation period. One-tailed z-test of one proportion will be used to test if the fall

incident rate after the proposed fall prevention program implemented drops by 20% or

not, with the level of significance being 0.05, cost-benefit ratios will be calculated.

Further information would be obtained such as reason of fall and outcome for any fall

incident occurred. Other information such as socio-demographic data, age and

medical history will also be described which can be obtained from the clients’

admission record. For the staffs’ satisfaction rate, the evaluation form will be provided

at the end of the implementation period. The total marks will be calculated and scored

from 4 to 20, with score 13 or higher is defined as satisfaction. The 95% confidence

intervals for the mean satisfaction score will be calculated. For the system outcome,

28

cost-benefit ratio will be calculated within the twenty eight weeks evaluation period.

4.3.4 Basis for the change of practice

The determination of the effectiveness of the proposed fall prevention program is

depends on the achievement of the identified outcome. The primary outcome of the

innovation should be the patient outcome, which is decreased by around 20% fall

incident rate in the target setting, and this is also the most important goal of the

proposed program. Besides, the staff and system outcome identified are also

important. Staff understanding and compliance on the Tai Chi exercise can ensure the

competency of the proposed fall prevention program with sustainability and better

cost benefit ratio can proof the proposed program is worth continuing. It is aimed to

have over 70% collected evaluation form with score 13 or higher in satisfaction. For

the cost-benefit ratio, it is aimed to be over 12. With decreased clients fall rate, high

staff satisfaction level and high cost-benefit ratio, the proposed program can be

regarded as effective and therefore the implementation of the proposed program can

be sustained or further develop in other setting.

29

Chapter 5: Conclusion

Falls are very common in the elderly population in the community in Hong Kong.

Innovative exercise program can reduce fall risk and thus benefit the community older

adults. This study reviewed evidence for the effectiveness of the Tai Chi exercise

program in reducing fall risk, translated the reviewed evidence and develop

evidence-based guidelines for the Tai Chi exercise program. Moreover, an

implementation plan and evaluation plan were developed to ensure the effective

implementation of the guidelines. Hence, the proposed Tai Chi exercise program is

recommended to be implemented in target clinical setting in the future so as to reduce

fall risk for the community older adults.

30

Appendix 1: Grading system of level of evidence by The Scottish

Intercollegiate Guidelines Network (SIGN)

Level of evidence

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a

very low risk of bias.

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk

of bias.

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias.

2++ High quality systematic reviews of case control or cohort or studies.

High quality case control or cohort studies with a very low risk of

confounding or bias and a high probability that the relationship is causal

2+ Well-conducted case control or cohort studies with a low risk of confounding

or bias and a moderate probability that the relationship is causal.

2- Case control or cohort studies with a high risk of confounding or bias and a

significant risk that the relationship is not causal.

3 Non-analytic studies, e.g. case reports, case series.

4 Expert opinion.

Grade of recommendations

A At least one meta-analysis, systematic review, or RCT rated as 1++, and

directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly

applicable to the target population, and demonstrating overall consistency

of results.

B A body of evidence including studies rated as 2++, directly applicable to the

target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to the

target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

31

Appendix 2: Table of quality assessment of the reviewed studies (1)

Citation : Li et al., 2005

Internal validity Comments

1. Appropriate and clearly focused the

question

Yes

2. randomization done to assignment of

subjects

Yes

3. Adequate concealment Yes

4. ”Blinding” between subjects and

assessors

Yes

5. Similarity between the treatment group

and control group

Yes

6. Treatment under investigation is the

only difference between group

Yes

7 Outcome measured in standard, valid

and reliable way

Yes

8. Dropout rate Intervention: 27.2%

Control: 35.9%

9. Intention to treat analysis Yes

10. Comparability of sites for study with

multi—sites involved

Not applicable

Overall assessment of the study

1. Rate of quality of the study ++

2. Certainty of overall effect due to the

study intervention

Significantly fewer fall occurred in the

intervention group

3. Applicability of the result to the target

patient group

Result is applicable to functionally

independent older adult

32


Citation : Gao et al., 2014



question

Yes


subjects

Yes

3. Adequate concealment Not covered


assessors

Yes


and control group

Yes



Yes


and reliable way

Yes


Control: 2.5%




Not applicable


1. Rate of quality of the study +


study intervention

Significantly decrease the incidence of

fall in the intervention group


patient group

Result is applicable to community

dwelling older adult, especially Chinese

33


Citation : Tousignant et al., 2013



question

Yes


subjects

Yes



assessors

Yes


and control group

Yes



Yes


and reliable way

Yes

8. Dropout rate Intervention: 32%

Control: 34.2%




Not applicable


1. Rate of quality of the study ++


study intervention

The relative risk of fall incidence was in

favour of the intervention group


patient group


dwelling older adult

34


Citation : Taylor-Piliae et al., 2014



question

Yes


subjects

Yes



assessors

Yes


and control group

Yes



Yes


and reliable way

Yes


Control 1: 10.4%

Control 2: 13.6%




Not applicable




study intervention

Intervention group had significantly

fewer falls than control group


patient group



35


Citation : Zhuang et al., 2014



question

Yes


subjects

Yes

3. Adequate concealment Not covered


assessors

Not covered


and control group

Yes



Yes


and reliable way

Yes


Control 1: 0%

9. Intention to treat analysis Not covered



Not applicable




study intervention

Significantly increase balance test score

in intervention group


patient group



Wong Po Wai 2011941431

36

Appendix 3: Table of evidence of review article (1)

Citation &

Study Design Patient Characteristics Intervention Comparison

Length of

Study Outcome Measure

Effect Size

(Intervention - control)

Li et al., 2005

Randomized

Control Trial

Community dwelling older

adult with mean age=77.48

from the pool of patients

enrolled in the Legacy

Health System in Portland

n=256

Tai Chi exercise

(TC) in Yang

style, 1 hour

class, 3 times per

week for 6

months

n=125

Stretching

exercise control

n=131

6 months Primary:

Fall counts in 6 months

Secondary:

1. Berg Balance Scale

2. Dynamic Gait Index

3. Functional Reach

4. Single-leg standing test

I. Right, eye open

II. Left, eye open

III. Right, eye close

IV. Left, eye close

5. 50 foot walk

6. Time up and go

7. Fear of fall score

Primary:

38-73=-35 (P=.007)

Secondary:

1. +2.13 (P<.001)

2. +1.31 (P<.001)

3. +2.04 (P<.001)

4.

I. +6.11 (P<.001)

II. +5.81 (P<.001)

III. +1.76 (P<.001)

IV. +1.52 (P<.001)

5. -1.75 (P<.001)

6. -1.04 (P<.001)

7. -0.24 (P<.001)


37


Citation &


Length of


Effect Size

(intervention - control)

Gao et al.,

2014

Randomized

Control Trial

Independent older adult

with idiopathic

Parkinson’s disease at

mean age=68.91 from the

pool of patients who had

admitted to the West China

Hospital in Sichuan and

had fall history in the past

12 months

n=76

Tai Chi exercise

in 24 form Yang

style, total 36

sessions, 60

minutes each

time, 3 times a

week for 12

weeks

n=37

Usual care

n=39

6 months 1. Incident of fall in 6

months

2. Berg balance scale

3. Unified Parkinson’s

disease rating scale

4. Time up and go

1. 21.6 – 48.7 =-27.1

(P=0.014)

2. +3.78 (P=0.002)

3. +6.15 (P=0.845)

4. -1.41 (P=0.525)


38

Appendix 3: Table of evidence or review article (3)

Citation &


Length of


Effect Size

(intervention - control)

Tousignant et al.,

2013

Randomized

Control Trial

Community older adult

who referred to day

hospital program at the

University Institute of

Geriatrics of Sherbrooke

in Quebec, Canada with

mean age=79.9 for a fall

problem

n=152

Supervised Tai

Chi exercise,

total 36 sessions,

60 minutes each

time, 2 times a

week for 15

weeks

n=76

Conventional

physical therapy

based on a

balance program

which consisted

of weight

transfer,

strengthening,

and walking

exercise, same

intensity with the

intervention

group

n=76

12 months Primary :

Fall incident in 12

months (mean number of

fall per participant)

Secondary :

1. Fall severity (need to

consult medical after

fall)

2. Time between the end

of intervention and

the first incident fall

Primary :

3.3-3.8=-0.5 (P=0.059)

Secondary :

1. 27%-27.5%=-0.005

(P=0.98)

2. 10-5=5 months

difference


39


Citation &


Length of


Effect Size

(intervention-control)

Taylor-Piliae et

al., 2013

Randomized

Control Trial

Community dwelling

older adult who live in the

greater Tucson, Arizona

with mean 37.2 months

post-stoke and with mean

age=69.9

n=145

Yang style

24-posture short

form Tai Chi

exercise , 60

minutes each

time, 3 times a

week for 12

weeks (TC)

n=53

1. Usual care

(UC)

n=48

2. Strength and

range of

movement

exercise called

SilverSneaker

s, 60 minutes

each time, 3

times a week

for 12 weeks

(SS)

n=44

12 weeks 1. Participant reported

fall rate in 12 weeks

2. Short physical

performance battery

(SPPB)

3. 2 minutes step test

3. TC-UC=5-15=-9

(P=0.06)

TC-SS=5-14=-10

(P=0.06)

2. All group had

substantial

improvements in

SPPB (F=85.29,

P<0.01)

3. Significant group by

time interaction for

the 2 minutes step

test, which both TC

(t=2.45, P=0.02) and

SS (t=4.63, P<0.01)

had significantly

better result


40


Citation &


Length of


Effect Size

(group by time)

Zhuang et al.,

2014

Randomized

Control Trial

Community dwelling older

adult who live in the

Kongjiang (Shanghai) with

mean age=65.9

n=56

Combined

exercise with

balance exercise

and muscle

strength training

and Yang style Tai

Chi, 60 minutes

each time, 3 times

a week for 12

weeks

n=28

1. Usual physical

activity

n=28

12 weeks 1. 30 second chair stand

test (CS-30)

2. Timed up and go test

(TUG)

3. Functional reach test

(FR)

4. star excursion

balance test (SEBTs)

1. 15.3% improvement

between group,

F(1,21)=21.617,

P<0.001

2. 17.6% improvement

between group,

F(1,21)=79.286,

P<0.001

3. no statistically

significant different

4. F(1,21)=8.816,

P=0.004


41

Appendix 4: Searching flowchart

Records identified

through PubMed

(n = 70)

Records identified

through CINAHL

(n = 38)

Records after duplicates removed

(n = 78)

Records screened for

titles and abstracts

(n = 57) Records excluded

(n = 21)

Full-text articles assessed

for eligibility

(n = 46)

Full-text articles excluded,

with reasons

Non-RCT (n = 22)

Non Tai Chi intervention

(n = 12)

Target age group below

age 65 (n = 7) Studies included in

qualitative synthesis

(n = 5)

Records identified

through British

Nursing Index

(n = 7)

Records identified

through other

sources

(n = 0)


42

Appendix 5: Evidence based recommendation of the Tai Chi exercise

for reducing fall risk program

An Evidence-based Program of Tai Chi Exercise for Reducing Fall Risk of

Community-dwelling Older Adults

Introduction:

Falls are very common in the elderly population in Hong Kong. It will cause injury to

the elderly and may subsequently need hospitalization, which may bring along a great

impact towards the public health care system. However, many studies supported that

Tai Chi exercise can reduce the risk of fall for the elderly.

The Scottish Intercollegiate Guidelines Network’s (SIGN) guidelines were used to

grade the recommendation and the levels of evidence in this guideline (SIGN, 2011),

which A grade recommendation means based on high quality evidence from well

conducted studies and also directly applicable to the target population.

Aims & objectives:

Provide a transferable and feasible evidence-based guideline on implementing Tai Chi

exercise program in order to reduce the fall risk of the elderly who live in the

community.

Target group:

Elderly who is age 65 years old or above, functionally independent and live in the

general community.

Recommendation 1:


43

Appropriate screening for the high risk of falling for the older adults should be done

before the Tai Chi exercise is prescribed. (Grade of recommendation: A)

Evidence:

Tai Chi exercise obtains continuous but highly choreographed movement that

incorporate unilateral and bilateral weight shift as well as trunk and extremity rotation.

Through slow and repetitive movement between extremities and body, clients shift

their body weight from one leg to the other in sequent smoothly in order to achieve

coordination. Therefore it requires certain extent of independence and exercise

tolerance for the proposed exercise and assessment for the suitability for the exercise

should be obtained. (Li et al., 2005)(1++)

Recommendation 2:

Yang style Tai Chi is recommended for the exercise program. (Grade of

recommendation: A)

Evidence:

There are numbers of style of Tai Chi exercise, one of them is the Yang style. The

Yang style Tai Chi is recommended because this kind of Tai Chi is the most popular

Tai Chi in China and it is easy to learn. (Li et al., 2005; Gao et al., 2014; Taylor-Piliae

et al., 2013; Zhuang et al., 2014)(1++; 1+; 1+; 1-)

Recommendation 3:

The proposed Tai Chi exercise session should be taught and supervised by an

experienced Tai Chi instructor. (Grade of recommendation: A)

Evidence:

The Tai Chi instructor would taught and demonstrate the exercises to the client and

clients were then asked to replicate motions, posture, and speed of the instructors. The


44

supervision by the instructor allows individually adapted each movement to ensure

that clients reached a significant level of instability. Even if the same movement

sequence was taught to all clients, the Tai Chi instructor could made individual

adjustments in the gradient of difficulty over time. (Li et al., 2005; Gao et al., 2014;

Tousignant et al., 2013; Taylor-Piliae et al., 2013)(1++; 1+; 1++; 1+)

Recommendation 4:

The intensity of the Tai Chi exercise is recommended in 60 minutes each time and

three times per week. (Grade of recommendation: A)

Evidence:

Each Tai Chi exercise session is recommended to include 10 minutes of warm up at

the beginning and 10 minutes of cool down at the end of the session. This kind of

warm up and cool down exercise prevent client from injury during the Tai Chi

exercise. Besides, total 60 minutes session allow time for the instructor to cover

learning new movement and review movements learned in previous sessions. On the

other hand, three times per week session was studied to be an optimal intensity

considering clients’ tolerance and acceptance. (Li et al., 2005; Gao et al., 2014;

Taylor-Piliae et al., 2013; Zhuang et al., 2014)(1++; 1+; 1+; 1-)

Recommendation 5:

A total twelve weeks of intervention is recommended for a whole course of the Tai

Chi fall prevention program. (Grade of recommendation: A)

Evidence:

Results from the selected studies showed that there are significantly decreased in fall

after three months of the proposed intervention. Besides, the Tai Chi exercise may

have a latent effect in reducing falls. It was given the continued downward trend in


45

fall incidence observed, further decreases in fall incidence may be excepted through

sustained and frequent daily practice. (Li et al., 2005; Gao et al., 2014; Tousignant et

al., 2013; Taylor-Piliae et al., 2013; Zhuang et al., 2014)(1++; 1+; 1++; 1+; 1-)

Recommendation 6:

twenty four weeks follow up period for the self reporting fall incident system. (Grade

of recommendation: A)

Evidence:

The incident of fall reported directly from the participated clients throughout the

implementation phase and the evaluation phase. It is proposed to provide a fall

calendar for the participated clients in order to record any fall incidents and data

would be collected by the program staff in a weekly base for twenty four weeks (Li et

al., 2005; Gao et al., 2014). Further information would be obtained such as reason of

fall and outcome for any fall incident occurred. (Li et al., 2005; Gao et al., 2014;

Tousignant et al., 2013; Taylor-Piliae et al., 2013)(1++; 1+; 1++; 1+)

References:

Gao, Q., Leung, A., Yang, Y., Wei, Q., Guan, M., Jia, C. & He, C. (2014). Effects of

tai chi on balance and fall prevention in parkinson’s disease: a randomized

controlled trial. Clinical Rehabilitation, 28 (8), 748-753.

Li, F., Harmer, P., Fisher, K.J., McAuley, E., Chaumeton, N., Eckstrom, E. & Wilson,

N.L. (2005). Tai Chi and fall reductions in older adults: a randomized controlled

trial. Journal of Gerontology: Medical Science, 60(2), 187-194.

Scottish Intercollegiate Guidelines Network (2011). SIGN 50: A guideline developer’s

handbook. Revised Edition 2012. Retrieved from

http://ww.sign.ac.uk/guidelines/fulltext/50/annexoldb.html


46

Taylor-Piliae, R.E., Hoke, T.M., Hepworth, J.T., Latt, L.D., Najafi, B. & Coull, B.M.

(2014). Effect of tai chi on physical function, fall rates and quality of life among

older stroke survivors. Archives of Physical Medicine and Rehabilitation, 1-9

Tousihnant, M., Corriveau, H., Roy, P.M., Desrosiers, J., Dubuc, N. & Hebert, R.

(2013). Efficacy of supervised tai chi exercise versus conventional physical

therapy exercise in fall prevention for frail older adults: a randomized controlled

trial. Disability & Rehabilitation, 35 (17), 1429-1435

Zhuang, J., Huang, L., Wu, Y. & Zhang, Y. (2014). The effectiveness of a combined

exercise intervention on physical fitness factors related to falls in

community-dwelling older adults, Clinical Intervention in Aging, 9, 131-140.


47

Appendix 6: Timeline of the proposed program

Time (weeks) 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64

Formation of

communication team

Obtain approval

Introduction session

Training workshop

Pilot test

Recruitment of

patients

Implementation period

Evaluation period


48

Appendix 7: Staff evaluation form of the program

Rank :

Reference

1 2 3 4 5

Very disagree disagree neutral agree Very agree

1) It is easy for you to learn the proposed Tai Chi exercise.

1 2 3 4 5

○ ○ ○ ○ ○

2) It is easy for you provide assistance for the participants.

1 2 3 4 5

○ ○ ○ ○ ○

3) The proposed program is easy handle within your routine.

1 2 3 4 5

○ ○ ○ ○ ○

4) The proposed Tai Chi exercise can reduce the fall rate for the participants.

1 2 3 4 5

○ ○ ○ ○ ○

Suggestions:


49

References

Chu, L.W., Chi, I. & Chiu, A.Y.Y. (2007). Falls and fall related injuries in community

dwelling elderly persons in Hong Kong: a study on risk factors, functional

decline, and health services utilization after falls. Hong Kong Med J, 13 (1), 8-12.

Chu, L.W., Chi, I. & Chiu, A.Y.Y. (2008). Falls and subsequent health service

utilization in community dwelling Chinese older adults. Archives of Gerontology

and Geriatrics, 46 (2008), 125-135.

Gao, Q., Leung, A., Yang, Y., Wei, Q., Guan, M., Jia, C. & He, C. (2014). Effects of

tai chi on balance and fall prevention in parkinson’s disease: a randomized

controlled trial. Clinical Rehabilitation, 28 (8), 748-753.

Hong Kong Housing Society. (January 24, 2011). “Result of the Community Elderly

Domestic Accident Factors Study. Retrieved 2014.

http://www.hkhselderly.com/tc/house/life/18

Hospital Authority. (2009). Statistical report (2008-2009). Hong Kong

Lamb, S.E., Jorstad-Stein, E.C., Hauer, K. & Becker, C. (2005). Development of a

common outcome data set for fall injury prevention trials: the prevention of falls

network Europe consensus. Journal of the American Geriatrics Society, 53 (9),

1618-1622.

Lenth, R. V. (2006-9). Java Applets for Power and Sample Size [Computer software].

Retrieved June 4, 2015, from http://www.stat.uiowa.edu/~rlenth/Power

Leung, A.Y.M., Lou, W.Q., Chan, K.S., Yung, A. & Chi, I. (2010). Care management

service and falls prevention: a case control study in a Chinese population. Journal

of Aging and Health, 22 (3), 348-361.

Li, F., Harmer, P., Fisher, K.J., McAuley, E., Chaumeton, N., Eckstrom, E. & Wilson,

N.L. (2005). Tai Chi and fall reductions in older adults: a randomized controlled

trial. Journal of Gerontology: Medical Science, 60(2), 187-194.


50

Liu, H. & Frank, A. (2010). Tai Chi as a Balance Improvement Exercise for Older

Adults: A Systematic Review. Journal of Geriatric Physical Therapy, 33 (3),

103-109.

Scottish Intercollegiate Guidelines Network (2011). SIGN 50: A guideline developer’s

handbook. Revised Edition 2012. Retrieved from

http://ww.sign.ac.uk/guidelines/fulltext/50/annexoldb.html

Taylor-Piliae, R.E., Hoke, T.M., Hepworth, J.T., Latt, L.D., Najafi, B. & Coull, B.M.

(2014). Effect of tai chi on physical function, fall rates and quality of life among

older stroke survivors. Archives of Physical Medicine and Rehabilitation, 1-9

Tousihnant, M., Corriveau, H., Roy, P., Desrosiers, J., Dubuc, N. & Hebert, R. (2013).

Efficacy of supervised tai chi exercise versus conventional physical therapy

exercise in fall prevention for frail older adults: a randomized controlled trial.

Disability & Rehabilitation, 35 (17), 1429-1435

Zhuang, J., Huang, L., Wu, Y. & Zhang, Y. (2014). The effectiveness of a combined

exercise intervention on physical fitness factors related to falls in

community-dwelling older adults, Clinical Intervention in Aging, 9, 131-140.

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