With a rapidly aging population around the world, frailty has become a major public health concern for both the older adults and society (41). As such, there is a need to provide evidence-based interventions targeting prefrail/frail older adults for community translation. The results of our feasibility study suggest that the 16-week community-delivered BDJ training program is safe has very good acceptance and adherence in the selected group and potentially effective in improving health, function and psychological outcomes among prefrail/frail older adults.
Program safety is vital for health promotion in the vulnerable population of frail older people. Our study intervention assessed BDJ exercise safety with close monitoring on health indicators such as blood pressure and blood oxygen levels before and after each training session. With no training-related adverse events, the current BDJ training program is safe for prefrail/frail older adults.
Program adherence is a significant challenge for exercise interventions in frail persons (42). Poor program adherence leads to sub-optimal intervention dosage and health benefits. Prefrail/frail older adults with physical and/or cognitive function deficit may have greater difficulties adhering to exercise training. Feasibility of this community delivered BDJ program is supported by the high average adherence rate of 88.6%, as well as result from participants’ survey. It was noted that those participants even performed BDJ at home during the 16-week intervention as well as spontaneously continued with program in the community after the completion of the study.
A systematic review showed the older people’s adherence to exercise programs was associated with the program characteristics and personal factors (43). It was also suggested that the simple and slow movement nature of BDJ made it a suitable option for older adults (44). The eight simple movements may enhance the older adults’ confidence in performing the exercise and compliance to training. Cultural identity and self-efficacy are important personal factors for adherence. Some older Chinese adults maybe keen to participate BDJ due to favourable perceptions on Chinese Traditional Medicine (TCM). Moreover, to motivate participants’ participation, the Qigong trainers employed strategies to enhance the program experience - instructing the BDJ exercise in a fun way and nominating peer models in the class, which may have promoted self-efficacy, and greater enjoyment of the program participation. Our community partner also provided snacks and drinks after each session, which encouraged social interactions that further promoted participation, as supported by the program adherence and participant survey results. This underlines the importance of community partnership and other implementation factors in community program translation (45).
Falls have significant impacts on older adults including loss of mobility and confidence to maintain daily activities, leading to frequent hospitalizations and greater need for social care (46, 47). Muscle strength and balance are two essential components of physical fitness which provide information about the older adults’ capacities to reduce fall risk. Furthermore, reduced strength and balance also restrict their performance of activities of daily living, especially among the prefrail/frail. Our results suggest that BDJ training may confer benefits to muscle strength and balance, with potential to reduce fall risk.
First of all, we have observed better hand grip strength (p = 0.013) after the 16-week BDJ training, which is consistent with other previous studies conducted among college students (20, 48, 49) as well as healthy sedentary older adults (23, 50). This allows us to add our results on hand grip strength to fill in the existing gap of knowledge among the prefrail/frail population. This potential improvement in hand grip strength may be attributed to the elements of dynamic tension particularly in the execution of exercise G, which involves thrusting of the fists. (Fig. 1)
Secondly, we also observed better lower limb strength following BDJ training, with a large effect size for knee extension strength (Cohen’s d = 0.69, p = 0.048). Only one previous study by Bao et.al in 2019 had examined the effect of BDJ on lower limb strength but showed no improvements (51). This potential difference may be due to the different styles of BDJ intervention - Bao’s study utilized the modified seated BDJ, whereas ours was the traditional standing BDJ, which involved the low horse stance to train the leg musculature. BDJ’s elements of dynamic tension in the quadriceps are apparent in the execution of low horse exercise stances in B, E and G. (Fig. 1: B, E, G) Dynamic tension is a strength training method that pits muscle against muscle via isometric contraction.
Furthermore, a number of studies have shown that BDJ consistently improved the balance of older adults (19, 50, 52, 53). Consistent with the literature, our study found that BDJ led to potential decreases in TUG (p = 0.018) and FES (p = 0.022). The possible mechanisms to explain the improvements in balance include: 1) BDJ may increase flexibility and dynamic mobility by the coordinated motions of the head, trunk, and extremities; 2) BDJ movements are performed slowly with focus placed on being conscious of where their body parts are, which may promote proprioceptive awareness (51); 3) Increased muscle strength may enhance balance function. In our study, according to the results of the individual PPA components, the significant improvement on balance was mostly attributed to lower limb strength, which contributed a medium effect size reduction on the PPA fall risk score. There was no obvious change for other components including edge contrast sensitivity, lower limb proprioception, hand reaction time, and postural sway. However, since our sample size was small, it is difficult to draw a definitive conclusion. Thus, future studies can examine the mechanisms of balance improvement from doing BDJ.
Recent review showed emerging studies have explored the different exercises as interventions for frailty (11). In our study, after 16-week BDJ intervention, frailty scores resulted in a marginal significant reduction of medium effect size (p = 0.052, Cohen’s d=-0.59). Meanwhile, two frail participants at baseline converted to prefrail, suggesting that BDJ could be a potential exercise for frailty reversal. It is worth noting that both of the frail participants were wheelchair users. This may indicate that older adults with lower functional capacity are more likely to benefit from slow movement exercise such as BDJ. The Asian-Pacific Clinical Practice Guidelines recommended physical activity with a resistance training component as a prescription for frailty management (54). Potential of BDJ training for frailty reduction should be examined in a controlled study.
Apart from its benefits on physical functions, the 16-week BDJ training also seemed to result in better cognitive function (MoCA, p = 0.014), psychological well-being (GDS, p = 0.028), and quality of life (EQ-5D-5L index score, p = 0.029) compared to baseline. These results are consistent with previous studies (23, 25, 55–57), which affirms that BDJ provided a holistic health benefit for older adults. This is in accordance with the TCM theory that BDJ typically involves a mind–body integration to cultivate Qi (vital energy in TCM theory) for maximizing both physical and mental well-being (58). Moreover, our study also used MQ, a validated tool, to explore the effects of Qi. The reduction of MQ score (p = 0.001) may indicate the improvement of vital energy after BDJ training. Future studies can employ the use of biochemical energetics to confirm the training effect of BDJ on Qi.
On the other hand, we noticed that our study did not result in any change in 30 s STS and 6-meter fast gait speed test. However, a BDJ randomised control trial (RCT) by Chun at.el. (59) resulted in significant improvements on those two outcomes (p = 0.041, p = 0.045 respectively) in older adults with type 2 diabetes mellitus. Compared to our study, their BDJ intervention frequency was four times a week for 6-months. As 30 s STS and 6-meter fast gait speed test are outcomes associated more with aerobic endurance rather than balance, the inconsistent findings may suggest the improvement in endurance may be achieved with a BDJ intervention of higher frequency and longer duration.
This study is the first to demonstrate that a community based BDJ intervention is safe, feasible, and acceptable among prefrail/frail older persons. The high adherence rate is important for the implementation of such a program in the real-world setting. The strength of the study is the implementation in a “real-world” housing site setting where the participants reside, close partnership with local community providers to engage participation and adherence and using simple equipment such as chairs. To explore the potential effects of BDJ, we assessed a broad range of explorative outcomes including physical and cognitive functions as well as psychological outcomes. As fall risk is an important concern for prefrail/frail seniors, both FES, a subjective assessment, and objective assessments such as TUG and PPA, were conducted to measure the improvements from different perspectives. Furthermore, we explored the Qi component of BDJ exercise using the validated MQ instrument. The results of these explorative outcomes provide information to design a RCT on the effectiveness of BDJ to reduce frailty and improve function. Based on an effect size of 0.7 for within-subject improvement in knee extension strength, with a power of 90% and a 10% drop-out rate, the sample size for a two-arm RCT will be 60 participants.
As a single-arm feasibility study, we could not make any assumptions on the effectiveness of the BDJ training program. The community provider also did not manage to recruit participants of other races than Chinese (78% of population in Singapore are Chinese). Although not a subject of investigation in this study, it is possible that BDJ is more welcomed by the Chinese than Malay and Indians in Singapore.
The results provide some support to BDJ’s potential to be implemented as part of low-cost community health promotion program. As BDJ is an exercise which is easy-to-learn without any restrictions from specialised equipment or spaces, older adults can practise it at home, community activity centres or nursing homes, through both group-based and self-practiced training. Furthermore, BDJ is a traditional Chinese exercise which is popular among Asian Chinese populations. However, to translate the research intervention into a real-world routine community program, efforts from service providers and community partners who have a good intervention fidelity are necessary for a successful implementation. More strategies are needed to maximize the program adherence and achieve the desirable outcomes.