Tai Chi and Perceived Health Status in Older Adults Who Are Transitionally Frail: A Randomized Controlled Trial

doi: 10.2522/ptj.20050378Originally published online April 3, 2007

2007; 87:525-535.PHYS THER. Michael O'GradyArlene I Greenspan, Steven L Wolf, Mary E Kelley andControlled TrialWho Are Transitionally Frail: A Randomized Tai Chi and Perceived Health Status in Older Adults

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Tai Chi and Perceived Health Status inOlder Adults Who Are TransitionallyFrail: A Randomized Controlled TrialArlene I Greenspan, Steven L Wolf, Mary E Kelley, Michael O’Grady

Background and PurposeTai chi, a Chinese exercise derived from martial arts, while gaining popularity as anintervention for reducing falls in older adults, also may improve health status. Thepurpose of this study was to determine whether intense tai chi (TC) exercise couldimprove perceived health status and self-rated health (SRH) more than wellnesseducation (WE) for older adults who are transitionally frail.

SubjectsStudy subjects were 269 women who were �70 years of age and who were recruitedfrom 20 congregate independent senior living facilities.

MethodsParticipants took part in a 48-week, single-blind, randomized controlled trial. Theywere randomly assigned to receive either TC or WE interventions. Participants wereinterviewed before randomization and at 1 year regarding their perceived healthstatus and SRH. Perceived health status was measured with the Sickness ImpactProfile (SIP).

ResultsCompared with WE participants, TC participants reported significant improvementsin the physical dimension and ambulation categories and borderline significantimprovements in the body care and movement category of the SIP. Self-rated healthdid not change for either group.

Discussion and ConclusionThese findings suggest that older women who are transitionally frail and participatein intensive TC exercise demonstrate perceived health status benefits, most notablyin ambulation.

AI Greenspan, PT, MPH, DrPH, isSenior Scientist, National Centerfor Injury Prevention and Control,Centers for Disease Control andPrevention, 4770 Buford Hwy NE,Mailstop K-63, Atlanta, GA 30341(USA). Address all correspondenceto Dr Greenspan at: [email protected].

SL Wolf, PT, PhD, FAPTA, is Profes-sor, Department of RehabilitationMedicine, Emory University Schoolof Medicine, Atlanta, Ga.

ME Kelley, PhD, is Research Assis-tant Professor, Department of Bio-statistics, Rollins School of PublicHealth, Emory University, Atlanta,Ga.

M O’Grady, MD, is currently inprivate practice. Dr O’Grady wasAssistant Professor, Department ofRehabilitation Medicine, EmoryUniversity School of Medicine, atthe time of the study.

[Greenspan AI, Wolf SL, Kelley ME,O’Grady M. Tai chi and perceivedhealth status in older adults whoare transitionally frail: a random-ized controlled trial. Phys Ther.2007;87:525–535.]

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About 30% of older adults livingin the community fall eachyear.1 Of those who fall, ap-

proximately 5% will sustain frac-tures, and an additional 5% to 11%will sustain other serious injuries.2

Among older adults who sustain hipfractures, 90% of these fractures oc-cur following a fall.3 Whether expe-riencing injurious or noninjuriousfalls, many older adults will neverreturn to preinjury function. The re-sulting functional limitations also areassociated with depression, fear offalling, and declines in health statusand related quality of life.

Some studies4–6 have demonstratedthe effectiveness of tai chi (TC), atype of Chinese exercise derivedfrom a form of martial arts, in main-taining physical functioning andreducing falls among older adults.The slow, rhythmic movements thatcharacterize TC also provide a holis-tic approach to exercise that com-bines mind and body experiences.This meditative aspect of TC couldresult in general improvements inhealth status and quality of life, inaddition to improvements in physi-cal functioning.

Several studies have demonstratedimprovements in quality of life amongolder adults with osteoarthritis,7 pa-tients with chronic heart failure,8 peo-ple who have had breast cancer,9 andpatients with fibromyalgia10 followingTC practice. Although a few studies onolder adults who are at risk for fallshave examined the effect of TC onphysical health,6,11 the effect of TC onthe multiple dimensions of health sta-tus has not been well studied. In thisstudy, a single-blind, randomized clin-ical trial examining the benefits ofTC, we hypothesized that a group ofolder women who are transitionallyfrail would report greater improve-ments in perceived health status fol-lowing an intense 48-week TC pro-gram than would women taking part

in a wellness education (WE) programof similar duration.

MethodSubjects and ProcedureThe study methods have been de-scribed in detail elsewhere.12 Briefly,study subjects were recruited from20 independent senior living facili-ties in the greater Atlanta, Ga, areabetween December 1997 and August1999. Participants were at least 70years of age, reported one or morefalls during the last year, were am-bulatory (with or without an assis-tive device), and were classified astransitioning to frailty on the basis ofcriteria developed by Speechley andTinetti.13

Speechley and Tinetti defined adultsas vigorous, frail, or transitionallyfrail on the basis of 10 attributes: age,gait and balance, walking activity forexercise, other physical activity forexercise, presence or absence of de-pression, use of sedatives, near-visionstatus, upper- and lower-extremitystrength (force-generating capacity),and lower-extremity disability. Adultswho are vigorous are defined as thosewho have at least 3 vigorous and nomore than 2 frail attributes. Adultswho are frail are defined as thosewho have at least 4 frail attributes andno more than 1 vigorous attribute.Adults who are transitionally frail arethose who do not meet the criteria forthe frail or vigorous group. Subjectswere excluded if they had a severe orunstable medical condition, had signif-icant cognitive impairment (Mini-Mental State Examination score of�24), or had a condition in whichphysical activity was contraindicated.

Of the 354 people screened, 311(291 women and 20 men) met eligi-bility criteria and were enrolled inthe study. Further details regardingenrollment and reasons for exclusionwere previously reported.4 Becauseof sex differences regarding self-perceived health,14–16 we excluded

the 20 men who were part of theoriginal sample (Figure). Of the 291women who were enrolled, 148were randomly assigned to partici-pate in the TC intervention and 143were randomly assigned to partici-pate in the WE intervention. Ten ofthe women who were randomly as-signed to participate in the TC inter-vention and 11 of the women whowere randomly assigned to partici-pate in the WE intervention with-drew from the study before the startof the intervention. Of the 21 womenwho withdrew, 5 did not want to par-ticipate, 5 had poor health status, 3experienced catastrophic events, 2died, and 6 did not receive physicianapproval to participate. One otherwoman was later excluded because ofpreviously nondiagnosed Parkinsondisease. This process resulted in a totalof 137 women in the TC group and132 women in the WE group. Duringthe course of the intervention, 34 par-ticipants in the TC group and 30 par-ticipants in the WE group discontin-ued their interventions. The reasonsfor dropping out are given in the Fig-ure. The study analysis was based onthe 269 participants who either com-pleted or participated in the TC orWE intervention.

Eligible subjects who agreed to par-ticipate were interviewed and un-derwent functional assessments attheir facilities prior to randomizationand intervention. The initial inter-view was used to characterize thesubject’s health status and to obtaininformation regarding demographicand behavioral characteristics, in-cluding fear of falling. The functionalassessments consisted of perfor-mance measures designed to assessmuscle strength, range of motion,gait, and balance. Following baselineassessments, participants were ran-domly assigned to either the TCgroup or the WE group. Participantswere reassessed at 1 year, aftercompletion of the TC and WE pro-grams. A total of 103 participants in

Tai Chi and Perceived Health Status

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the TC group and 102 participants inthe WE group completed 1-yearfollow-up assessments. Study investi-gators who administered assess-ments and interviews were unawareof participant intervention groups.Written informed consent was ob-tained from all subjects beforeenrollment.

Characteristics of the StudyPopulationTable 1 summarizes the baselinefrailty, demographic, and selectedhealth and functional characteristics

of the study participants. The fre-quency of frailty characteristicsranged from 16.1% to 99.2%. Near-vision impairment (97.8% in the TCgroup and 99.2% in the WE group)and impaired gait or balance (92.7%in the TC group and 94.7% in the WEgroup) were the most commonfrailty characteristics; upper-extremity impairment (16.1% in theTC group and 18.9% in the WEgroup) was the least common. Morethan three quarters of the study par-ticipants were white and had com-pleted high school, and more than

one half were at least 80 years of age.Baseline Sickness Impact Profile(SIP) scores were in the moderatedisability range for the TC and WEgroups, although baseline SIP scoreswere significantly lower for the TCgroup, indicating better perceivedhealth status, for subjects in the TCgroup.

InterventionsThe experimental intervention, TC,consists of slow, rhythmic move-ments that emphasize trunk rota-tion, weight shifting, coordination,

Figure.Flow of participants through the stages of tai chi (TC) and wellness education (WE), including randomization and withdrawals.Reasons for declining health included injuries or fractures (TC, n�3; WE, n�5), deteriorating vision (TC, n�3), cardiac problems(TC, n�3; WE, n�2), musculoskeletal impairment (TC, n�10; WE, n�4), loss of independence (TC, n�1; WE, n�6), stroke (TC, n�1;WE, n�2), cancer (TC, n�1; WE, n�2), diabetes mellitus (TC, n�1; WE, n�1), diverticulitis (TC, n�1), major surgery (TC, n�1),asthma (TC, n�1), hospitalized at time of postintervention interview (subject later died) (TC, n�1), and prolonged illness (WE, n�1).




and gradual narrowing of the lower-extremity stance. Six simplifiedforms of exercise procedures thatbest characterized these movementswere used.17 Participants were de-conditioned and were expected toprogress slowly. Thus, the goal forthe participants was to perform 2minutes of unassisted TC exercise.The facilities at which the TC inter-

vention was used were divided be-tween 2 instructors. All instructionwas standardized by having the 2 in-structors practice with one anotheruntil their execution of the move-ment forms to be taught in each classwas identical. The TC interventionconsisted of 2 sessions per week atincreasing durations starting at 60minutes of contact time and pro-

gressing to 90 minutes over thecourse of 48 weeks. Sessions in-cluded warm-up and cool-down pe-riods. Actual TC practice time, ex-cluding warm-up and cool-downperiods, progressed from approxi-mately 10 minutes to 50 minutes.However, participants were allowedto proceed at their own pace andcould sit or rest as needed. There-

Table 1.Baseline Characteristics of Study Participants (Women Only)

Characteristic Tai ChiGroup

WellnessEducationGroup

P

Age, y (%)

70–79 46.7 41.7 .411

�80 53.3 58.3

Race (%)

White 78.8 80.3 .422

African American 18.2 18.9

Other 2.9 0.8

Education (%)

Did not complete high school 21.2 22.7 .757

High school graduate 78.8 77.3

Marital status (%)

Married 6.6 4.5 .573

Widowed 75.2 76.5

Divorced or separated 10.9 14.4

Single, never married 7.3 4.5

Frailty characteristics (%)

Age of �80 y 54.0 58.3 .475

Impaired gait or balance 92.7 94.7 .501

No walking for exercise 67.2 73.5 .256

No other physical exercise 62.0 61.4 .909

Depression (treated or untreated) 33.6 40.2 .264

Use of sedatives 23.4 25.8 .647

Near vision 97.8 99.2 .332

Impaired upper-extremity strength 16.1 18.9 .534

Impaired lower-extremity strength 24.1 27.3 .550

Lower-extremity disability 37.2 40.2 .622

Sickness Impact Profile score (X�SD)

Total 12.2�8.9 16.1�10.7 .001

Physical dimension 13.1�9.1 17.0�10.6 .001

Psychosocial dimension 10.2�10.4 13.8�14.2 .018




fore, the intensity of TC practicetime varied somewhat by participantand the capability of each participanton the basis of the physiological ef-fort that she was required to exert.Individual differences could not bemonitored.

The control intervention consistedof a WE program. The WE classeswere held for 1 hour per week andconsisted of instruction on falls pre-vention; exercise and balance; dietand nutrition; pharmacological man-agement; legal issues relevant tohealth; changes in body function;and mental health issues, such asstress, depression, and life changes.Interactive materials were provided,but there was no formal instructionin exercise. The total amounts oftime for individual attention given toparticipants in each group by the in-structors were comparable.

Variables and MeasuresPerceived health status. The SIPis a reliable and valid measure of per-ceived health status,18–20 has beenused widely across patients with avariety of diseases and injuries,20

takes 20 to 30 minutes to adminis-ter,21–29 and has been applied exten-sively to older adults.23,30–32 Specifi-cally, the reliability and validity ofSIP data among older adults havebeen well demonstrated across a va-riety of older populations, includingnursing home residents who arefrail,33,34 older adults with chronicillnesses,35 and older veterans.36 Theinternal consistency of the overallSIP is .96, with individual categoryscores ranging from .63 to .90.37 Inaddition, the clinical validity of SIPdata has been well establishedthrough comparisons with clinicaldata for a variety of situations anddiagnoses, including total hip re-placement, hyperthyroidism, stroke,angina pectoris, and rheumatoidarthritis.38 Finally, multiple studieshave demonstrated that the SIP isresponsive to changes over time.37

The SIP consists of 136 statementsdivided into 12 categories: sleep andrest, eating, work, home manage-ment, recreation and pastimes, am-bulation, mobility, body care andmovement, social interaction, alert-ness behavior, emotional behavior,and communication (Tab. 2). Four ofthe categories—social interaction,alertness behavior, emotional be-havior, and communication—com-bine to form a psychosocial healthdimension. Ambulation, mobility, andbody care and movement combine toform a physical health dimension. Par-ticipants are asked whether the state-ments describe themselves today andwhether the statements are related totheir health. Categories and dimen-sions can be scored independently orcombined to produce an overall sum-mary score. Scores are derived by useof a weighted algorithm. Overall SIPscores and categorical scores rangefrom 0 to 100, with higher scores in-dicating poorer health status. Scores ofless than 4 are found in the generalpopulation and indicate no disability,scores of 4 to 9.9 indicate minor dis-ability, scores of 10 to 19.9 indicatemoderate disability, and scores of �20indicate severe disability.39–41 Differ-ences of 2 or 3 points indicate mean-ingful differences in function.42,43

Self-rated health (SRH). Partici-pants also were asked to rate theirhealth as excellent, very good, good,fair, or poor at baseline and 1-yearinterviews. Self-rated health as a sin-gle indicator has been shown to beassociated with mortality44,45 andwith future health and disability.46,47

Data AnalysisBaseline characteristics were sum-marized by use of means and stan-dard deviations for continuous dataand frequency distributions for cate-gorical data. Because the distributionof the SIP was significantly skewed,the data were grouped into clinicallymeaningful categories as describedin previous studies.39–41 Repeated-

measures ordinal logistic regression(proportional odds) was used tomodel the various domains withinthe SIP as the dependent variablesfor the evaluation of intervention �time interaction effects. The re-peated measures were analyzed byuse of generalized estimating equa-tions. A significant interaction effectwould indicate a larger change infunction in one of the groups be-tween baseline and follow-up. Signif-icance was set at P�.05. Participantswho did not complete the interven-tion were analyzed in the groups towhich they initially were assigned byuse of an intention-to-treat analysis.We also compared this analysis witha complete-case analysis that in-cluded only participants who com-pleted the intervention.

ResultsAttendance and DropoutsAttendance did not differ betweenthe TC participants and the WEparticipants. The mean attendancefor the TC participants was 86%(SD�10.4), and the mean atten-dance for the WE participants was82% (SD�10.4). Dropouts were de-fined as participants who missedmore than 8 consecutive weeks ofthe intervention; dropping out usu-ally was attributable to a decline inhealth. Beyond this interval, learningTC movement forms or WE materialsalready covered by the classes wouldhave impeded the progress of thoseclasses.

Perceived Health Status and SRHThe SIP scores at baseline and at 1year after the intervention and thegroup � time interactions (inter-vention effects), determined by useof an intention-to-treat analysis, aresummarized in Table 3. Participantsin the TC group reported signifi-cantly lower SIP scores in the physicaldimension (P�.016) and ambulationcategory (P�.013). In addition, partic-ipants in the TC group reportedborderline significant scores in the




physical dimension category of bodycare and movement (P�.051). Thesescores indicated improved physicalfunctioning (group � time interac-tion), most notably in ambulation,following 48 weeks of TC practicerelative to the findings for the WEgroup.

No significant intervention effectswere observed in the psychosocial

dimension or other categorical scores.Because most of the participants wereretired, there was little variation inthe work subcategory, and although itwas used to calculate total SIP scores,it was omitted from categorical ana-lyses. In addition, there were no statis-tically significant differences within in-tervention groups over time orbetween groups at baseline and attimes after intervention, except for

between-group differences in thephysical dimension indicating betterphysical functioning among the TCparticipants than among the WE par-ticipants (P�.005). The data were re-analyzed after participants who didnot complete the TC or WE interven-tion were excluded. As determinedwith a complete-case analysis, TC par-ticipants had lower scores in the fol-lowing SIP dimensions and categories:

Table 2.Sickness Impact Profile: Dimensions, Categories, and Sample Items

Dimension Category Selected Items

Physical Body care and movement I stand up only with someone’s help

I get dressed only with someone’s help

Mobility I stay home most of the time

I am not now using public transportation

Ambulation I get around only by using a walker,crutches, cane, walls, or furniture

I walk shorter distances or stop to rest often

Psychosocial Emotional behavior I talk about the future in a hopeless way

I laugh or cry suddenly

Social interaction I am going out less to visit people

I stay alone much of the time

Alertness behavior I do not keep my attention on any activityfor long

I am confused and start several actions at atime

Communication I am having trouble writing or typing

I do not speak clearly when I am understress

Independent categories Sleep and rest I sit around half asleep

I sleep less at night, for example, wake uptoo early, do not fall asleep for a longtime, or awaken frequently

Home management I am not doing heavy work around thehouse

I am not doing any of the shopping that Iwould usually do

Recreation and pastimes I am going out for entertainment less often

I do my hobbies and recreation for shorterperiods of time

Eating I feed myself with help from someone else

I am drinking less fluid

Work I am working shorter hours

I am doing only light work




physical dimension (P�.010), am-bulation category (P�.013), and bodycare and movement category(P�.018).

The majority of participants in boththe TC and the WE groups rated theirhealth as good or better, with at least40% rating their health as very goodor excellent and less than 30% ratingtheir health as fair or poor at base-line. Self-rated health was not signif-icantly different between the TC par-ticipants and the WE participants atbaseline. In addition, SRH did notchange significantly from baseline to1 year for either the TC group or theWE group.

DiscussionIn this study, we examined the effectof TC exercise on perceived health

status and SRH in a group of womenwho were transitionally frail and�70 years of age. The preinterven-tion total SIP score (X�SD) of14.1�10.0, indicating moderate dis-ability, lies between that of olderadults who are healthy (mean SIPscore�3.4)48 and that of nursinghome patients who are very frail(mean SIP score�43.5).49 The majorfinding of this study was that adultswho are transitionally frail who par-ticipated in a 48-week TC interven-tion reported significant improve-ments in perceived physical health,specifically in the category of ambu-lation, and borderline significance inthe category of body care and move-ment. Significant changes in per-ceived health status were not ob-served for psychosocial health or theindependent categories of home

management, sleep and rest, andeating. Although we did not expectchanges in eating behavior, we hadhypothesized that TC would affectother areas of health status.

In previous studies in which theeffect of TC on perceived healthstatus was examined, conflictingfindings were reported.38,50,51 Thesediscrepancies may be attributable todifferences in the intensity of the in-tervention, the study population,sample size, the study methodology,or the measure used to assess per-ceived health status. In only 1 of 3studies in which the Medical Out-comes Study Short-Form question-naire38,50,51 was used to assess healthstatus was a significant improvementin perceived health status reported.That study50 targeted older adults

Table 3.Perceived Physical Health (Sickness Impact Profile Scores) at Baseline and at 1 Year by Intervention Type and Level of Disabilitya

Dimension or Category Score for: Group �TimeInteractionbTai Chi Group Wellness Education

Group

Baseline(n�137)

1 y(n�103)

Baseline(n�132)

1 y(n�102)

Physical dimension .016

No or minor disability 40.9 56.3 29.5 27.4

Moderate disability 42.3 28.2 37.1 35.3

Severe disability 16.8 15.5 33.3 37.3

Body care and movement .051




Mobility .224




Ambulation .013




a No or minor disability�0–9.9, moderate disability�10–19.9, severe disability��20.b Group � time interaction indicates a treatment effect of tai chi relative to wellness education between baseline and 1 year.




with balance deficits; in the other 2studies,38,51 older adults who werehealthy were recruited. In her re-view of TC interventions, Wu52 re-ported that changes in health statusmay be limited in studies that targetolder adults who are healthy, inwhom baseline health status scoresare already high.

The findings of Li and colleagues,6,11,53

who conducted a randomized trial ofTC among physically inactive olderadults, lend support to this idea. Theinitial findings of Li and colleaguessupported the conclusion that TCimproved perceived physical func-tioning; however, in a reanalysisstratifying their sample into highand low scores on the basis of base-line physical functioning, Li and col-leagues found significant improve-ments among participants with lowbaseline physical functioning scoresfollowing 6 months of a TC interven-tion, whereas participants with highbaseline physical functioning scoresdid not show any change in physicalfunctioning, relative to the findingsfor control participants performingtheir usual daily activities.53 Our ownfindings of improved physical func-tioning among TC participants in thisstudy and negative findings for olderadults who were healthy recruited inthe Frailty and Injuries: CooperativeStudies of Intervention Techniques(FICSIT) TC trial38 also support theconclusion that older adults withlower levels of functioning may bemore likely to report improvementsin perceived physical health thanolder adults who are healthy.

Within the physical function dimen-sion, ambulation significantly con-tributed to improvements in physicalfunctioning, the body care andmovement category was borderlinesignificant, whereas no significantdifferences were reported with mo-bility. Items in both the ambulationcategory and the body care andmovement category focus on activi-

ties that require balance. For exam-ple, the ambulation category in-cludes items such as walking up ordown hills, walking up and downstairs, and getting around only byusing a walker, crutches, cane, walls,or furniture. Body care and move-ment activities primarily include ac-tivities of daily living, many of whichrequire balance to perform well.Such items include standing up,kneeling, stooping, bending down,getting into or out of cars or bath-tubs, and maintaining balance. Sev-eral studies52,54,55 have shown im-provements in balance following TC.In contrast, mobility items describean individual’s ability to movearound within the community versusstaying at home. Although balancecertainly plays a role in an individu-al’s ability to do so, illnesses and var-ious chronic health conditions alsomay affect this area, consequently re-ducing the effect of TC in the area ofmobility. For example, subjects maystay home most of the time becausethey feel too sick to leave home, ir-respective of walking and balancecapabilities.

Given that TC has meditative compo-nents to complement its exercise as-pects and because improved physi-cal functioning could affect otherareas of health, we hypothesized thatTC would result in improved psycho-social health. Previous studies sup-port our hypothesis. Improvementsin psychosocial health following TChave been demonstrated among par-ticipants with a variety of diagnosesand chronic conditions, includingosteoarthritis,7 breast cancer,9 andchronic heart failure.8 Two random-ized controlled studies in which thepsychological effects of TC on sed-entary older adults were examinedrevealed improvements in life satis-faction and general well-being amongTC participants relative to control par-ticipants.56,57 In another randomizedcontrolled study, Kutner et al38 ex-amined the effects of TC on general

health status among community-dwelling older adults. Although im-provements in general health, mentalhealth, and social functioning werenot demonstrated, as measured withthe Medical Outcomes Study Short-Form questionnaire, exit interviews re-vealed that TC participants were morelikely than control participants to re-port benefits from participation and toreport that the intervention (TC) had anoticeable effect on their lives. There-fore, our failure to demonstrate im-provements in psychosocial healthand other aspects of health status,with the exception of physical health,was surprising.

Several factors could account forour findings. First, our study partici-pants were more frail than those inprevious studies, and comorbid con-ditions may have exerted a greaterinfluence on psychosocial health.Second, the SIP may not be sensitiveenough to identify modest changesin psychosocial health among olderadults. Third, differences in studymethodology may account for con-flicting results. Further research isneeded with psychosocial measuresthat are sensitive in older adults tobetter understand whether TC hasany direct or indirect effect on psycho-social health or whether the trendsthat we observed are spurious.

Several factors could account forwhy our results failed to demon-strate an effect of TC or WE on SRH.First, three quarters of all partici-pants rated their health at baseline asgood or better, a finding that sup-ports the positive perceptions ofSRH among older adults in previousstudies.58–60 Older adults tend toview their health in context withtheir peers and may perceive declin-ing functional status as part of thenormal aging process. Thus, highbaseline scores may have limited ourability to detect changes in SRH. Sec-ond, individuals’ perceptions of SRHnot only may be a reflection of their




current health status but also mayreflect a more lasting self-conceptbased on preexisting beliefs regard-ing their own health.61 Therefore,an improvement in physical healthmay have been only one of severalfactors that could have influencedparticipants’ assessments of SRH at 1year. Finally, Bailis and colleagues61

found that a change in SRH is morelikely to be influenced by health sta-tus changes that are most importantto an individual. To demonstratechanges in SRH, we may have neededto identify a priori those individualswho had a specific goal of improvingtheir physical functioning.

We used an intention-to-treat an-alysis because it minimizes bias62

and may provide a more realistic es-timate of clinical relevance. Exclud-ing dropouts and participants whodo not adhere to a study protocolweakens the unbiased estimate thatis gained from randomization. Par-ticipants who drop out tend to fareworse that those who complete anintervention, even after controllingfor known predictive factors.62 Thus,the remaining participants would beexpected to have a better outcomethan those who dropped out. Such ascenario may account for the greatersignificance in physical health and inbody care and movement that weobserved with the complete-case anal-ysis. Thus, the use of a complete-caseanalysis instead of an intention-to-treatanalysis may result in an outcomesuggesting greater success than iswarranted. Finally, an intention-to-treatanalysis gives the clinician a morerealistic representation of the likelysuccess of an intervention. In reality,not every individual will fully ad-here to or complete a treatment reg-imen. Thus, an intention-to-treatmodel takes into account issues ofnonadherence.

The interpretation of data from thisstudy has some limitations. First, onthe basis of the definition developed

by Speechley and Tinetti,13 we clas-sified older adults who met neitherthe frailty criterion nor the vigorouscriterion as transitioning to frailty.This definition included older adultswith a broad range of health charac-teristics and functional abilities. Al-though mean SIP scores ranked inthe moderate level of disability, indi-vidual scores varied widely, rangingfrom no disability to severe disabil-ity, suggesting that our definition oftransitional frailty may have beenimprecise. Recently, Fried and col-leagues63 presented more simplifieddefinitions of frailty and vigor thatinclude a transitional group that theydefine as “intermediate” frailty. Al-though this classification system hasappeal because of its simplicity, fur-ther research is needed to demon-strate its sensitivity and specificityfor classifying older adults, especiallythose who are transitioning to frailty.

Second, participants were recruitedfrom congregate living facilities for aclinical intervention trial and maynot be representative of older adultswho are transitionally frail and live inthe community or those who wouldnot volunteer for an exercise inter-vention. Third, although the instruc-tor gradually increased work timefrom 10 minutes to 50 minutes overthe 48-week intervention, partici-pants were allowed to rest asneeded. Although participants gen-erally increased their work time,with an instructor ratio of 1:15, theinstructor was unable to monitor in-dividual changes. Fourth, olderadults with cognitive deficits (Mini-Mental State Examination score of�24) were excluded because partic-ipants needed to have sufficient cog-nitive skills to be able to answer in-terview questions. Fifth, few African-American women were enrolled inthe study, despite attempts to enrollgreater numbers. Low enrollmentmay have been primarily attributableto the composition of the congregateliving facilities, which was primarily

female and white, with the excep-tion of 4 primarily minority facilities.Only women were included in ouranalysis; therefore, the findings can-not be extended to older men.

Finally, although our analyses of in-tervention effects took into accountbaseline differences in SIP scores,the higher baseline SIP scores amongthe TC participants could have cre-ated some unintended biases. Be-cause TC participants had better per-ceived health, they may have hadmore optimistic views about theirhealth and may have been morelikely to perceive their health as im-proved after an intervention. On theother hand, previous research53 sug-gested a greater benefit among TCparticipants with lower baselinephysical functioning scores, whichcould have reduced the treatment ef-fects for TC participants relative toWE participants.

ConclusionPerceived health status measures,such as the SIP, provide a profile ofpatient-reported dysfunction that en-compasses not only physical func-tioning but also psychosocial healthand various aspects of daily func-tion. The SIP is easy to administerand can be an important adjunct toperformance measures by providingadditional information that is notclinically assessed. Although perfor-mance and self-perceived health arehighly correlated, the correlation isby no means perfect.30 Perceivedhealth and performance may be in-fluenced differently by external fac-tors, such as depression and cogni-tive status. Thus, an assessment ofperceived health can provide a morecomplete representation of function-ality for both the researcher and theclinician. Finally, the SIP can provideuseful clinical information not onlyabout the quality of performance,such as “I walk more slowly,” butalso about the level of mobility, such




as “I am getting around only within 1building.”

In summary, the results of this studysuggest that an intense program ofTC targeting older women who aretransitionally frail can have a positiveeffect on their self-perceived physi-cal health, primarily in the areas ofambulation and self-care. Ambula-tion, self-care, and movement activi-ties are important functions for main-taining independent lifestyles. Morecommunity-based studies are neededto determine whether these im-provements are sustained and resultin older adults adopting more activelifestyles that have a broader impacton their overall health status andquality of life.

Dr Greenspan, Dr Wolf, and Dr O’Grady pro-vided concept/idea/project design and datacollection. Dr Greenspan and Dr Wolf pro-vided writing. Dr Greenspan, Dr Wolf, andDr Kelley provided data analysis. Dr Green-span, Dr Wolf, and Dr O’Grady providedfund procurement. Dr Wolf and Dr O’Gradyprovided subjects. Dr Wolf provided facili-ties/equipment and institutional liaisons. DrO’Grady provided consultation (includingreview of manuscript before submission).The authors acknowledge Nana Freret, RN,MS, for her tireless effort at coordinating thisproject; Susan Murphy for her assistance inproject coordination; Lois Ricci, RN, EdD,and Carol Holbert, PhD, RN, for provision ofthe wellness program; Mary Jowers, RN, forher assistance with evaluations and fall sur-veillance; Tingsen Xu, PhD, tai chi GrandMaster, for devising and implementing thetai chi program; and Gregory Bailey for pro-vision of tai chi exercise classes at half of thefacilities.

This study was approved by the Emory Uni-versity Human Investigation Committee.

This research was supported by National In-stitutes of Health grant AG14767 from theNational Institute on Aging and coupons forredeemable products from Kroger Corpora-tion and CVS Pharmacies for each partici-pant upon completion of participation.

The findings and conclusions in this reportare those of the authors and do not neces-sarily represent the views of the fundingagency.

This article was received December 1, 2005,and was accepted January 9, 2007.

DOI: 10.2522/ptj.20050378

References1 Gregg EW, Pereira MA, Caspersen CJ.

Physical activity, falls, and fractures amongolder adults: a review of the epidemiologicevidence. J Am Geriatr Soc. 2000;48:883–893.

2 Kannus P, Parkkari J, Koskinen S, et al.Fall-induced injuries and deaths amongolder adults. JAMA. 1999;281:1895–1899.

3 Cumming RG, Nevitt MC, Cummings SR.Epidemiology of hip fractures. EpidemiolRev. 1997;19:244–257.

4 Wolf SL, Sattin RW, Kutner M, et al. In-tense tai chi exercise training and fall oc-currences in older, transitionally frailadults: a randomized, controlled trial.J Am Geriatr Soc. 2003;51:1693–1701.

5 Li F, Harmer P, Fisher KJ, et al. Tai Chi andfall reductions in older adults: a random-ized controlled trial. J Gerontol A Biol SciMed Sci. 2005;60:187–194.

6 Li F, Harmer P, McAuley E, et al. An eval-uation of the effects of Tai Chi exercise onphysical function among older persons: arandomized controlled trial. Ann BehavMed. 2001;23:139–146.

7 Hartman CA, Manos TM, Winter C, et al.Effects of T’ai Chi training on function andquality of life indicators in older adultswith osteoarthritis. J Am Geriatr Soc.2000;48:1553–1559.

8 Yeh GY, Wood MJ, Lorell BH, et al. Effectsof tai chi mind-body movement therapy onfunctional status and exercise capacity inpatients with chronic heart failure: a ran-domized controlled trial. Am J Med.2004;117:541–548.

9 Mustian KM, Katula JA, Gill DL, et al. TaiChi Chuan, health-related quality of lifeand self-esteem: a randomized trial withbreast cancer survivors. Support CareCancer. 2004;12:871–876.

10 Taggart HM, Arslanian CL, Bae S, et al. Ef-fects of T’ai Chi exercise on fibromyalgiasymptoms and health-related quality oflife. Orthop Nurs. 2003;22:353–360.

11 Li F, Harmer P, McAuley E, et al. Tai Chi,self-efficacy, and physical function in theelderly. Prev Sci. 2001;2:229–239.

12 Wolf SL, Sattin RW, O’Grady M, et al. Astudy design to investigate the effect ofintense Tai Chi in reducing falls amongolder adults transitioning to frailty. Con-trol Clin Trials. 2001;22:689–704.

13 Speechley M, Tinetti M. Falls and injuriesin frail and vigorous community elderlypersons. J Am Geriatr Soc. 1991;39:46–52.

14 Wood RH, Gardner RE, Ferachi KA, et al.Physical function and quality of life inolder adults: sex differences. South Med J.2005;98:504–512.

15 Diehr P, Patrick DL. Probabilities of tran-sition among health states for older adults.Qual Life Res. 2001;10:431–442.

16 McCullough ME, Laurenceau JP. Genderand the natural history of self-rated health:a 59–year longitudinal study. Health Psy-chol. 2004;23:651–655.

17 Wolf SL, Coogler C, Xu T. Exploring thebasis for Tai Chi Chuan as a therapeuticexercise approach. Arch Phys Med Reha-bil. 1997;78:886–892.

18 Bergner M, Bobbitt RA, Carter WB, et al.The Sickness Impact Profile: developmentand final revision of a health status mea-sure. Med Care. 1981;19:787–805.

19 Patrick DL, Deyo RA. Generic and disease-specific measures in assessing health sta-tus and quality of life. Med Care.1989;27:S217–S232.

20 Deyo RA, Inui TS, Leininger JD, et al. Mea-suring functional outcomes in chronic dis-ease: a comparison of traditional scalesand a self-administered health status ques-tionnaire in patients with rheumatoid ar-thritis. Med Care. 1983;21:180–192.

21 Tak E, Staats P, Van Hespen A, et al. Theeffects of an exercise program for olderadults with osteoarthritis of the hip.J Rheumatol. 2005;32:1106–1113.

22 Simko LC, McGinnis KA. What is the per-ceived quality of life of adults with con-genital heart disease and does it differ byanomaly? J Cardiovasc Nurs. 2005;20:206–214.

23 Clark NM, Janz NK, Dodge JA, et al.Changes in functional health status ofolder women with heart disease: evalua-tion of a program based on self-regulation.J Gerontol B Psychol Sci Soc Sci. 2000;55:S117–S126.

24 Redeker NS, Wykpisz E. Effects of age onactivity patterns after coronary artery by-pass surgery. Heart Lung. 1999;28:5–14.

25 MacKenzie EJ, Bosse MJ, Castillo RC, et al.Functional outcomes following trauma-related lower-extremity amputation. J BoneJoint Surg Am. 2004;86:1636–1645.

26 Mock C, MacKenzie E, Jurkovich G, et al.Determinants of disability after lower ex-tremity fracture. J Trauma. 2000;49:1002–1011.

27 Lipsett PA, Swoboda SM, Dickerson J,et al. Survival and functional outcome af-ter prolonged intensive care unit stay. AnnSurg. 2000;231:262–268.

28 Grady KL, Meyer PM, Dressler D, et al.Longitudinal change in quality of life andimpact on survival after left ventricular as-sist device implantation. Ann ThoracSurg. 2004;77:1321–1327.

29 Holzner B, Kemmler G, Kopp M, et al. Pre-operative expectations and postoperativequality of life in liver transplant survivors.Arch Phys Med Rehabil. 2001;82:73–79.

30 Cress ME, Schechtman KB, Mulrow CD,et al. Relationship between physical per-formance and self-perceived physical func-tion. J Am Geriatr Soc. 1995;43:93–101.

31 Cress ME, Buchner DM, Questad KA, et al.Exercise: effects on physical functionalperformance in independent older adults.J Gerontol A Biol Sci Med Sci. 1999;54:M242–M248.




32 Breeze E, Jones DA, Wilkinson P, et al.Area deprivation, social class, and qualityof life among people aged 75 years andover in Britain. Int J Epidemiol. 2005;34:276–283.

33 Rothman ML, Hedrick S, Inui T. The Sick-ness Impact Profile as a measure of thehealth status of noncognitively impairednursing home residents. Med Care.1989;27:S157–S167.

34 Gerety MB, Cornell JE, Mulrow CD, et al.The Sickness Impact Profile for nursinghomes (SIP-NH). J Gerontol. 1994;49:M2–M8.

35 Goldsmith G, Brodwick M. Assessing thefunctional status of older patients withchronic illness. Fam Med. 1989;21:38–41.

36 Weinberger M, Samsa GP, Hanlon JT, et al.An evaluation of a brief health status mea-sure in elderly veterans. J Am Geriatr Soc.1991;39:691–694.

37 Damiano AM. Sickness Impact Profile: Us-er’s Manual and Interpretation Guide.Baltimore, Md: The Johns Hopkins Univer-sity; 1996.

38 Kutner NG, Barnhart H, Wolf SL, et al. Self-report benefits of Tai Chi practice by olderadults. J Gerontol B Psychol Sci Soc Sci.1997;52:P242–P246.

39 Butcher JL, MacKenzie EJ, Cushing B, et al.Long-term outcomes after lower extremitytrauma. J Trauma. 1996;41:4–9.

40 Jurkovich G, Mock C, MacKenzie E, et al.The Sickness Impact Profile as a tool toevaluate functional outcome in trauma pa-tients. J Trauma. 1995;39:625–631.

41 McCarthy ML, McAndrew MP, MacKenzieEJ, et al. Correlation between the mea-sures of impairment, according to themodified system of the American MedicalAssociation, and function. J Bone JointSurg Am. 1998;80:1034–1042.

42 MacKenzie EJ, Bosse MJ, Pollak AN, et al.Long-term persistence of disability follow-ing severe lower-limb trauma: results of aseven-year follow-up. J Bone Joint SurgAm. 2005;87:1801–1809.

43 Deyo RA, Diehl AK, Rosenthal M. Howmany days of bed rest for acute low backpain? A randomized clinical trial. N EnglJ Med. 1986;315:1064–1070.

44 Mossey JM, Shapiro E. Self-rated health: apredictor of mortality among the elderly.Am J Public Health. 1982;72:800–808.

45 Idler EL, Benyamini Y. Self-rated healthand mortality: a review of twenty-sevencommunity studies. J Health Soc Behav.1997;38:21–37.

46 Wilcox VL, Kasl SV, Idler EL. Self-ratedhealth and physical disability in elderlysurvivors of a major medical event. J Ger-ontol B Psychol Sci Soc Sci. 1996;51:S96–S104.

47 Idler EL, Kasl SV. Self-ratings of health: dothey also predict change in functional abil-ity? J Gerontol B Psychol Sci Soc Sci.1995;50:S344–S353.

48 Andresen EM, Patrick DL, Carter WB, et al.Comparing the performance of health sta-tus measures for healthy older adults. J AmGeriatr Soc. 1995;43:1030–1034.

49 Mulrow CD, Gerety MB, Cornell JE, et al.The relationship between disease andfunction and perceived health in very frailelders. J Am Geriatr Soc. 1994;42:374–380.

50 Hain TC, Fuller L, Weil L, Kotsias J. Effectsof T’ai Chi on balance. Arch OtolaryngolHead Neck Surg. 1999;125:1191–1195.

51 Schaller KJ. Tai Chi Chih: an exercise op-tion for older adults. J Gerontol Nurs.1996;22:12–17.

52 Wu G. Evaluation of the effectiveness ofTai Chi for improving balance and pre-venting falls in the older population: a re-view. J Am Geriatr Soc. 2002;50:746–754.

53 Li F, Fisher KJ, Harmer P, et al. Delineatingthe impact of Tai Chi training on physicalfunction among the elderly. Am J PrevMed. 2002;23:92–97.

54 Wolf SL, Barnhart HX, Ellison GL, CooglerCE. The effect of Tai Chi Quan and com-puterized balance training on postural sta-bility in older subjects. Atlanta FICSITGroup. Frailty and Injuries: CooperativeStudies on Intervention Techniques. PhysTher. 1997;77:371–381.

55 Husted C, Pham L, Hekking A, et al. Im-proving quality of life for people withchronic conditions: the example of t’ai chiand multiple sclerosis. Altern Ther HealthMed. 1999;5:70–74.

56 Brown DR, Wang Y, Ward A, et al. Chronicpsychological effects of exercise and ex-ercise plus cognitive strategies. Med SciSports Exerc. 1995;27:765–775.

57 Li F, Duncan TE, Duncan SC, et al. Enhanc-ing the psychological well-being of elderlyindividuals through Tai Chi exercise: a la-tent growth curve analysis. StructuralEquation Modeling. 2001;8:53–83.

58 Stadnyk K, Calder J, Rockwood K. Testingthe measurement properties of the ShortForm-36 Health Survey in a frail elderlypopulation. J Clin Epidemiol. 1998;51:827–835.

59 Mitrushina MN, Satz P. Correlates of self-rated health in the elderly. Aging (Mila-no). 1991;3:73–77.

60 Dening TR, Chi LY, Brayne C, et al.Changes in self-rated health, disability andcontact with services in a very elderly co-hort: a 6-year follow-up study. Age Ageing.1998;27:23–33.

61 Bailis DS, Segall A, Chipperfield JG. Twoviews of self-rated general health status.Soc Sci Med. 2003;56:203–217.

62 Montori VM, Guyatt GH. Commentary:intention-to-treat principle. Can Med As-soc J. 2001;165:1339–1341.

63 Fried LP, Tangen CM, Walston J, et al.Frailty in older adults: evidence for a phe-notype. J Gerontol A Biol Sci Med Sci.2001;56:M146–M156.




doi: 10.2522/ptj.20050378Originally published online April 3, 2007

2007; 87:525-535.PHYS THER. Michael O'GradyArlene I Greenspan, Steven L Wolf, Mary E Kelley andControlled TrialWho Are Transitionally Frail: A Randomized Tai Chi and Perceived Health Status in Older Adults

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Tai Chi and Perceived Health Status in Older Adults Who Are Transitionally Frail: A Randomized Controlled Trial