Setting and participants
This feasibility study was designed as a single arm pre–post comparison. In partnership with a provider of senior community services (day care and community clinic), the study was implemented at a community center from September 2018 to April 2019, where the provider is based at the Whampoa housing estate in Singapore. A small convenience sample of older adults was recruited by the provider amongst the visitors of the community center, daycare center, and community clinic at the same locale near enough for participants to walk to the training venue. Wheelchair users were either assisted by their domestic helper or used a paid transport we provided. Participants were familiar with the venues since those venues were the activity centers within the communities.
Researchers did initial frailty screening. Afterwards a licensed General Practitioner (GP) screened for program eligibility and excluded participants who did not meet the medical criteria. Since there was no previous study on BDJ frail older adults, we could not estimate sample size. Based on a maximum instructor to participants ratio of 1:10, we aimed to recruit a maximum of 20 participants.
The inclusion criteria were: 1) pre-frail (score 1-2) or frail (scored 3-5) according to FRAIL scale screening questionnaire (28); 2) older adults aged 55 years and above ; 3) able to ambulate without personal assistance and has no other physical limitations which limited participation; 4) able to understand basic instructions; and 5) generally sedentary lifestyle according to Physical Activity Scale for the Elderly (PASE) questionnaire (29) (self-reported participating in sitting activities at least 5 days per week with more than 4 hours per day on average).
Exclusion criteria were as follows :1) participating in any other exercise program or interventional studies; 2) severe audio-visual impairment diagnosed by physicians (e.g., dementia, Alzheimer’s Disease); 3) diagnosed with cognitive impairment and/or history of neurological disorder (e.g., cerebral palsy, Parkinson’s Disease); 4) unable to participate for the full duration of the study; 5) diagnosed with postural hypotension. 6) unable to come to community club by himself/herself or by the help of caregivers, 7) unable to get the medical clearance from the GP.
BDJ training program
The program was designed by the local Qigong association. The entire set of BDJ exercise comprises eight sections (Fig 1). Participants underwent a group-based 16-week supervised BDJ training program with a total of 44 training sessions. Each session lasted 90 minutes including warming up, BDJ exercise, and cool down. During the first four weeks, participants practiced each section of BDJ twice a week with the training intensity gradually increased to familiarize with the training. During the following 12-week period, participants practiced the whole set of BDJ exercise for 90 minutes three times a week. Two professional Qigong trainers from the local Qigong association conducted the training in both English and Chinese as appropriate.
Fig 1. Baduanjin exercise
All participants cleared pre-exercise medical examination before recruitment into the study. Simple screening was performed by study coordinator before each training session. Participant with either one of the following did not participate for that training session: blood oxygen levels below 95% saturation; high resting heart rate (>=90 beats per minute) (30); abnormal resting blood pressure (systolic blood pressure>=130 mmHg or Diastolic blood pressure >=80 mmHg) (31); giddiness; or any form of discomfort. During training, each participant had a chair with armrests behind them so anyone who felt unstable can sit down. Two community volunteers assisted to ensure the seniors’ safety during exercise.
Measurements
Program Feasibility
To examine the feasibility of the training program, the outcomes and process evaluated were (32):
- Safety (adverse events), physical and psychological effects.
- Feasibility of recruitment, retention, adherence; recruitment efforts and any program challenges.
A survey was administered to the participants after the training program. The survey utilized a four-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree) and comprised nine questions on program acceptance, adherence satisfaction, engagement, and willingness for continued participation. Any adverse event during the program duration was recorded by a research coordinator who contacted the participants regularly. The coordinator also obtained the attendance record from the provider and is present at every training session.
Physical and psychological outcomes
To explore the potential effects of BDJ, we assessed a range of exploratory outcomes during the week before (pre) and the week after (post) the 16-week training program. All outcome measures were administered by assessors who were not involved as part of the research team nor BDJ instruction and demonstration.
Physical and functional outcomes
Physical and functional outcomes included knee extension strength, hand grip strength, 6-meter fast gait speed test, Time Up and Go test (TUG), Physiological Profile Assessment (PPA), and 30-second Sit-to-Stand (30s STS) test.
To assess muscle strength, knee extension strength and hand grip strength were measured using a spring gauge and hand-grip dynamometer respectively for the dominate leg or hand. Two trials were administered for knee extension strength, hand grip strength, and 6-meter fast gait speed test and the mean values used for analyses.
TUG, a test of basic functional mobility for frail elderly persons, required participants to stand up from a chair, walk a distance of 3 m at a comfortable pace, turn, walk back, and sit down (33). The test was performed twice, with the shorter time of two trials used for analysis.
PPA, which includes five measures of physiological functioning (postural sway, knee extension strength, reaction time, lower limb proprioception and visual contrast sensitivity), was used as a systematic approach to explore the underlying causes of balance changes (34). The five components were weighted to compute a composite PPA fall risk score, where higher composite scores indicate higher risks of falling.
For the 30s STS, the number of successful stands within 30 seconds were recorded. The performance of 30s STS has been suggested to be determined by balance, muscle strength, lower extremity endurance, as well as mobility (35).
Frailty outcomes
Frailty score of the participants was assessed using the Cardiovascular Health Study Frailty Phenotype (CHS Fried criteria).(1) The five criteria were: 1) shrinking (defined as unintentional weight loss >4.5kg and/or BMI of <18.5 kg/m2 in the last 6 months by self-report); 2) weakness, assessed by knee extension strength of the dominant leg according to cut off points stratified by gender and BMI (Asian classification) ( (a) in men: underweight: <9.5 kg, normal weight: <12.3 kg, overweight: <14.7 kg, obese: <15.0 kg; (b) in women: underweight: <9.3 kg, normal weight: <10.0 kg, overweight: <10.0 kg, obese: <10.0 kg). 3) slowness, established according to a cutoff point of <0.8m/s by 6-meter fast gait speed test; 4) exhaustion was measured with the 3 questions on vitality domain in the Medical Outcomes Study 12-Item Short-Form Health Survey (36) “Did you feel worn out?” “Did you feel tired?” “Did you have a lot of energy?” with total summed scores ranging from 3 to 15, and a score of less than 10 was used to denote exhaustion; and 5) physical inactivity, measured by Longitudinal Aging Study Amsterdam Physical Activity Questionnaire (37). One-point was assigned for the presence of each component, and based on the individual’s total score, participants were categorized as frail (3-5 points), pre-frail (1-2 points), and robust (0 point). Reduction in frailty during the study was defined as a transition to a lower frailty category from baseline to post-training program.
Psychological and other outcomes
We also measured participants’ vital exhaustion using Maastricht Questionnaire (MQ) (38), and fear of falling using Fall Efficacy Scale (FES) (39). Other outcomes also included Montreal Cognitive Assessment (MoCA) (40) for cognitive function; EQ-5D-5L (41) index score for the health-related quality of life; and the 16-item short form Geriatric Depression Scale (GDS) (42) to assess depression status.
Statistical analyses
Descriptive statistics of demographic information and outcome measurements were presented as mean and Standard Deviation (SD) for continuous variables, and frequencies and percentages for categorical variables. Results from the outcome measurements were summarized and effect size of each test was calculated using Cohen’s d. Results of the post intervention interview was reported as the percentage of responses for each question. All analyses were conducted using Stata 14.0 (StataCorp LP, College Station, TX).