Functional tness and quality of life of elderly Lian Gong, Tai Chi, and Qigong practitioners

Long-term regular physical activity, such as body practices of Traditional Chinese Medicine, seems to be an important habit for maintaining the functional tness, independence and quality of life of elderly individuals. However, scientic knowledge production concerning assessment of such practices, specically for the elderly population, focusing on functional tness and quality of life, is still modest. Moreover, there is a lack of studies with long-term follow-up and control groups. Therefore, this study aims to compare the parameters of functional tness and the dimensions of quality of life of elderly participants and non-participants in the body practices of Traditional Chinese Medicine. Longer adherence time, shorter adherence time and control group have been considered.


Background
The change in the world demographic pro le showed a signi cant increase in the proportion of elderly individuals, and it is one of the most signi cant themes of the 21st century. This trend sets up a new epidemiological reality and creates challenges for public policy makers and for the Brazilian health system in terms of ensuring comprehensive care. Thus, the focus is directed to elderly people and their needs, especially those resulting from decreased physical, cognitive, mental/emotional and social autonomy 1,2 .
Scienti c literature emphasizes the importance of actions that encourage and provide elderly individuals with adherence and maintenance of a healthy and physically active lifestyle 3 with quality of life 2 . Regular physical activity, such as the body practices of Traditional Chinese Medicine (BPTCM), seems to be an important habit for maintaining long-term functional tness, independence and quality of life 4 .
BPTCM are integrative and complementary health practices also called meditative movements, as they include, during their performance, meditation, body movement, breathing, and relaxation 5 . Studies show that such practices have contributed to promoting health and quality of life for elderly individuals [6][7][8] . There is evidence regarding the association of such practices in reducing stress, anxiety and depression 9 and in increasing self-e cacy and social support 10 . Moreover, they seem to positively assist in improving physical function, balance and consequently preventing falls 11 .
According to the Brazilian scienti c literature, assessment of these practices, speci cally for the elderly population, focusing on functional tness, quality of life, and social support, is still minimal; and it represents a gap in the production of scienti c knowledge. There is a lack of studies with long-term follow-up and control groups.
Therefore, this study aims to compare the parameters of functional tness and the dimensions of quality of life of elderly participants and non-participants in the body practices of guided BPTCM, considering longer adherence time, shorter adherence time, and control group.
The results support the development and implementation of strategies to promote healthy aging. BPTCM are associated with comprehensiveness of care, sensitivity and body awareness, and the opportunity to rede ne the ways of dealing with health-disease-care of elderly individuals.

Methods
This is an observational epidemiological case-control study carried out with 118 elderly people aged 60 years and older; Traditional Medicine Specialized Units (TMSU) of the Municipal Health O ce of São Paulo (SMS-SP) users; belonging to Eastern, Central, and Southeastern Regional Health Coordination Centers. TMSU offer a wide variety of service modalities in Integrative and Complementary Practices, including BPTCM, Lian Gong, Qigong, Tai Chi Pai Lin, Tai Chi Chuan, among others 13 .
All elderly users enrolled in one of the four TMSU, who met the eligibility requirements of the cases (a group known to have the outcome) and the controls (a group known to be free of the outcome), with conditions to respond to the research instruments, were invited to participate in the survey.
Of the 183 BPTCM participants, the case group (CA) comprised elderly people of both sexes enrolled in one of the four TMSU, practitioners of only one of the guided BPTCM (at least twice a week for at least six months without interruption) 14 . They could practice physical activity in their leisure time, but without guidance from a professional, totaling 59 participants subdivided into two groups according to their median adherence time < 24 months and ≥ 24 months.
The control group (CO) comprised 59 elderly users of both sexes enrolled in the four TMSU, not participating in guided physical activity programs or BPTCM in or out of the TMSU for at least six months. The eligibility criterion established they could practice physical activity in leisure time, but without guidance.
CA and CO were paired by sex and age, considering the 1:1 ratio between them, accepting an alpha error of 5% and power of the test (1-β = 80%).
Sociodemographic data were collected through a questionnaire designed to the objectives of the study. Lower and upper limb strength was assessed by 30-second chair stand test 15 and hand grip strength test 16 ; lower and upper limb exibility was measured by sit and reach test 17 , chair stand and reach test, and back scratch test 15 ; mobility, speed, agility, and dynamic balance were assessed by 8-foot up-and-go test 15 .
Health-related quality of life was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) 18 . The SF-36 is a multidimensional questionnaire consisting of 36 items that encompass the dimensions of physical and mental health and eight domains, namely: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. To assess the results, a score was assigned to each question, and the values were transformed into a scale from 0 to 100; zero was the least favorable score, and 100 was the most favorable score; each domain was analyzed separately 18 .
Statistical analyzes were performed using the statistical program R 3.3.2. (R Core Team, 2016) 19 , which initially performed a descriptive analysis of the dependent and independent variables using mean, median, minimum and maximum values, standard deviation and absolute and relative frequencies. Univariate Logistic Regression was used to compare CA and CO concerning quality of life and functional tests.
The Kruskal-Wallis test was used to compare CA and CO in relation to less (< 24 months), equal or greater (≥ 24 months) practice time, according to quality of life and functional tests. An alpha signi cance level of 5% was used in the inferential analyzes.

Results
The study sample consisted of 118 elderly people, with 59 (50.0%) cases and 59 (50.0%) controls. Of the total number of individuals shown in Table 1, most are female (91.5% of cases and 89.8% of controls); white (35.6% of cases and 35.6% of controls); with incomplete elementary education (35.6% of cases and 55.9% of controls); married (55.9% of cases and 47.5% of controls); and unemployed (89.8% of cases and 83.1% of controls). Among the diseases mentioned, systemic hypertension (SH) prevailed in 64.4% of cases and in 72.9% of controls. There was no statistically signi cant difference between the cases and controls in relation to sociodemographic variables and reported morbidities.    Regarding quality of life, comparing CA and CO, statistically signi cant differences were found for bodily pain, vitality, role emotional, and mental health (Table 3).  The CA with longer adherence time (≥ 24 months) had a better score in bodily pain (p = 0.003), when compared to the CA with shorter adherence time (< 24 months) and the control group.
In vitality, the CA with longer adherence time (≥ 24 months) obtained a better score (p = 0.021), when compared to CO.
Concerning role emotional, CO and the CA with longer adherence time (≥ 24 months) had a better score (p = 0.034), when compared to the CA with shorter adherence time (< 24 months).
In mental health, the CA with longer adherence time (≥ 24 months) obtained a better score (p = 0.020) when compared to CO.

Discussion
The results of this study show that the CA with longer adherence time (≥ 24 months) performing BPTCM may have been a contributory factor for the improvement of lower limb strength (p = 0.006), assessed by 30-second chair stand test (SCT).
Tai Chi and Qigong practices have a broad theoretical framework [20][21][22] , and show positive results regarding increased lower limb strength. This fact was observed in a research that assessed the long-term effects (≥ 3 years) of Tai Chi on lower limb strength of elderly individuals. The survey found better results among Tai Chi practitioners compared to physically inactive elderly individuals, although the assessment methodology was different 20 .
However, in the case of Lian Gong (LG), our ndings differ from the research that compared the functional tness of elderly participants in water based exercise, hiking, and LG. Signi cant results were found for lower limb strength in relation to hiking, when compared to water based exercise and LG, indicating that LG practice generated the lowest performance result in the SCT 23 .
Another study on LG, which compared physical tness and health-related quality of life of practitioners and physically inactive elderly individuals, also found no statistically signi cant differences between the two groups for lower limb strength. Lower limb strength was assessed by the same test, although the intervention period has been smaller 24 . Such disagreement may be related to the scarcity of studies on LG practice; to the methodological quality of the research; and to the different forms of participant assessment and intervention.
Regarding health-related quality of life, long-term BPTCM, although present in fewer studies 25,26 , may indicate signi cant changes in their different domains. Pro ciency in carrying out movements was achieved over time, promoting greater bene ts 27 .
With respect to the results, it was observed that the CA with longer adherence time (≥ 24 months) obtained higher scores in bodily pain (p = 0.003), vitality (p = 0.021), role emotional (p = 0.034), and mental health (p = 0.020) (SF-36 domains).
Long-term psychosocial and health bene ts of Tai Chi and Qigong have been also found in a review study that found pain reduction and improvement in psychological well-being over time 28 . Qigong practitioners with more than ve years of adherence from a research, supporting the results of this research, attributed their permanence in practice to maintaining health and recovering from some comorbidity 29 .
Although this study has limitations regarding the causal factor of the results found, such ndings may be related to the characteristics of BPTCM. Practicing BPTCM includes synchronization of body movements, breathing, meditative mental state, and relaxation. When such components are carried out concurrently and correctly, there is a wide range of bene ts to health, quality of life, and recovery and maintenance of physiological functions. BPTCM are being increasingly used as integrative and complementary approaches to health 30 .

Conclusions
To brie y summarise, when comparing the parameters of functional tness and the dimensions of quality of life of elderly participants and non-participants of guided BPTCM, considering longer and shorter adherence to activities and CO, it was found that participation in BPTCM can contribute to improving functional tness, lower limb strength, and quality of life.