Tai chi exercise has been recommended as suitable for the improvement of health in the elderly. The purpose of this study was to investigate the effects of tai chi on lower urinary tract symptoms (LUTSs), quality of life (QoL), and sex hormone levels in patients with benign prostate hypertrophy (BPH). The elderly patients with BPH were randomized to receive tai chi or usual care. Fifty-six participants were randomized into either the tai chi group (
With the recent increase in the elderly population and their increased demand for better health-related quality of life (QoL), lower urinary tract symptoms (LUTSs), which produce discomfort in elderly men, are receiving more attention. Benign prostate hypertrophy (BPH), a major cause of LUTS in elderly men, is a urinary tract disease caused by a combination of prostate hypertrophy, lower urinary tract obstruction, and dysfunction of the bladder muscles. Among elderly men over 65 years, the prevalence of BPH increases to 40–70%, and among elderly men over 70 years, it increases to 90% [
It is known that those with LUTS experience interference with daily activities, including discomfort, restricted travel and outings, lowered QoL due to concerns about urinary function, prostate cancer, embarrassment about urinary problems, and even psychological problems [
The causes of BPH have not yet been clarified, but genetic factors, nutrition, lack of exercise, racial differences, and chronic illnesses, such as high blood pressure and diabetes, are believed to play a role. From 60% to 70% of men over 60 have high blood pressure, and over 50% of high blood pressure patients show abnormal histological findings or symptoms of prostate hypertrophy [
Tai chi has been recommended as an exercise suitable for improving elderly men’s cardiopulmonary function and muscle strength and for reducing tension, anxiety, and mood disorders [
The purpose of this study was to investigate whether tai chi improves LUTS, quality of life, and sex hormone levels in patient with BPH. Positive results might lead to tai chi being adopted as a nursing intervention for patients with BPH.
Patients with BPH were recruited through bulletin board invitations to participate in a 12-week tai chi program at the Dong-A University Medical Center. Patients were eligible to participate in the program if they met the following conditions: (a) male aged over 60 with BPH, (b) able to understand the content of questionnaires and experimental schedules, (c) had not participated in regular exercise in the previous six months, (d) a lower urinary tract symptoms score greater than 25 points, (e) had not received transurethral resection, and (f) were not participating in any other form of CAM. The subjects were informed about the nature of BHP and the study procedures. We received approval for the study from the Dong-A University Hospital's Institutional Review Board before we approached the subjects; all the subjects provided written informed consent (Figure
A diagram of the study design, showing the flow of participants.
We randomly assigned the patients to either the tai chi group or the control group by tossing a coin. There was no blinding or allocation concealment for either the participants or the practitioner. Nursing assistants who did not participate in the trial and who were blinded to the allocation results performed the outcome assessments.
This study's outcome measures included the following: (1) the international prostate symptom score (IPSS), (2) urination-related quality of life, (3) serum testosterone, and (4) blood glucose and insulin. The outcome measures were assessed before and 12 weeks after the intervention by a nurse who did not know the experimental protocol or the subjects' allocation.
The LUTSs were measured using the IPSS. The IPSS is identical to the American Urology Association (AUA) symptom index, which was developed by AUA in 1991. The WHO international consultation on BPH changed its name to IPSS [
The urina-tion-related QoL questionnaire consisted of 18 items in 3 subscales that used a 5-point Likert response scale [
For the degree of discomfort, 7 international prostrate symptoms were measured. The subjective discomfort felt by each respondent was quantified. The 5-point scale ranged from 0 (no symptoms) to 4 (very uncomfortable). The reliability, as measured by Cronbach’s
A 5-point Likert scale consisting of 4 questions that was developed by Epstein et al. [
A 5-point Likert scale consisting of 7 questions that was developed by Epstein et al. [
Serum testosterone was measured using a radioimmunoassay (Coat-A-Count Total Testosterone Kit, DPC, LA, USA). The units for serum testosterone were ng/mL. The normal value for males over 50 years old is 1.81
Insulin resistance is the reduced response of peripheral tissues to insulin action. Methods to evaluate it based on fasting serum insulin and fasting blood glucose have been developed. One of these is the quantitative insulin sensitivity check index (QUICKI). This index is a measure of insulin sensitivity rather than insulin resistance (i.e., the lower the QUICKI score, the higher the insulin resistance). QUICKI is recommended for measuring insulin resistance because it has relatively small measurement error and is well correlated with clamp methods, which are the standard test [
The intervention program used 11 basic and 9 combined movements (20 total) that were developed by Dr. Paul Lam. The tai chi program consisted of a warm-up exercise (15 min), 20 main movements (40 min), and a cool-down exercise (5 min). The study's warm-up and cool-down exercises involved stretching and relaxing the head, neck, upper body, lower body, and entire body.
The 11 basic tai chi movements involved the commencement form, opening and closing hands, waving hands in the cloud (left), opening and closing hands, the fair lady working at the shuttle, opening and closing hands, toe kicks left and right, opening and closing hands, waving hands in the cloud (right), opening and closing hands, and the closing form. The nine combined forms included waving hands in the cloud (left), opening and closing hands, stroking the bird’s tail (left), opening and closing hands, stroking the bird’s tail (right), opening and closing hands, waving hands in the cloud (right), opening and closing hands, and the closing form. When the participants performed the opening and closing hands, they also performed breathing exercises.
The participants in the tai chi group attended classes 3 times weekly for twelve weeks; the classes were led by two tai chi instructors. We individually instructed the participants in the appropriate movements. The patients learned and practiced the motions during the first 5 weeks. The participants were actually performing the routine competently during the last seven weeks. A special guide book for home practice, containing pictures and written descriptions of the exercises in the tai chi program, was produced. The participants were asked to practice their exercises at home using the guide book two times daily (in the morning and evening). The participants recorded the frequency and duration of their home tai chi in their exercise logs, which the instructors assessed during every weekly session. A videotape was available if the participants desired.
The subjects in both groups were diagnosed as BPH and did not receive standard drug therapies. The control subjects received no other treatment and did not participate in any structured exercise programs during the study period. They were contacted by the researchers twice weekly by telephone to confirm that they were not taking part in any other exercise activities and to provide an impetus to keep them participating in the study. The control group subjects who were interested in tai chi were provided with an exercise program after the study ended.
We wished to estimate the sample size that would be sufficient to detect an appropriate difference in the IPSS between the tai chi and control groups. Because no previous trials have been performed, we calculated the sample size using the results of a drug trial. In this drug trial, the mean difference in the IPSS between the groups was −3.9 [
The results were analyzed using SPSS software. All the outcomes were compared using the unpaired
Fifty-six patients were eligible under our study's criteria. We randomly allocated these patients to either the tai chi group (
Table
The demographic characteristics of the subjects.
Tai Chi ( | Control group ( | |||
---|---|---|---|---|
Mean ± SD | Mean ± SD | |||
Age (yr) | 1.23 | .23 | ||
Number (%) | Number (%) | |||
Married | ||||
Yes | 14 (100) | 12 (92) | 1.19 | .48 |
No | 0 (0) | 1 (8) | ||
Educational level | ||||
Junior high | 2 (15) | 5 (36) | 4.53 | .10 |
High | 3 (23) | 6 (43) | ||
College | 8 (62) | 3 (21) | ||
Employed | ||||
Yes | 3 (21) | 1 (7) | 1.17 | .60 |
No | 11 (79) | 13 (93) | ||
Monthly income (in ten thousand Won) | ||||
<100 | 6 (44) | 7 (50) | .89 | .93 |
100–150 | 3 (21) | 4 (29) | ||
151–200 | 2 (14) | 1 (7) | ||
201–250 | 3 (21) | 2 (14) | ||
Perceived health status | ||||
Healthy | 4 (29) | 5 (36) | .60 | 1.00 |
Average | 8 (57) | 6 (43) | ||
Bad | 2 (14) | 3 (21) | ||
Surgical history for the prostate | ||||
Yes | 2 (14) | 1 (7) | .37 | .54 |
No | 12 (86) | 13 (93) | ||
Medication for the prostate | ||||
Yes | 6 (43) | 8 (57) | .57 | .71 |
No | 8 (57) | 6 (43) | ||
Exercise | ||||
Yes | 9 (64) | 13 (93) | 3.39 | .17 |
No | 5 (36) | 1 (7) |
SD: standard deviation.
As shown in Table
Homogeneity tests of the outcomes between the groups.
Outcome | Tai chi ( | Control ( | ||
---|---|---|---|---|
IPSS | −1.03 | 0.31 | ||
QoL of BPH | −0.24 | 0.87 | ||
urination-related discomfort | 0.001 | 1.00 | ||
Worry & concern | 0.31 | 0.76 | ||
Interference with daily activities | 0.68 | 0.51 | ||
Testosterone (ng/mL) | 0.70 | 0.49 | ||
Insulin ( | −0.74 | 0.47 | ||
Blood glucose (mg/dL) | −0.46 | 0.65 | ||
QUICKI | −0.79 | 0.44 |
Values are expressed as mean ± standard deviation; IPSS: international prostate symptoms score; QoL of BPH: quality of life of benign prostate hyperplasia
QUICKI: quantitative insulin sensitivity check index.
Table
Effects of tai chi on IPSS, QoL, and biochemical outcomes.
Outcome | Tai chi ( | Control ( | ||||||
Before | After | After-Before | Before | After | After-Before | |||
IPSS | −2.36 | 0.03 | ||||||
QoL of BPH (Total) | −3.06 | 0.005 | ||||||
QoL of BPH (subscale) | ||||||||
urination-related discomfort | −2.01 | 0.06 | ||||||
Worry & concern | −2.45 | 0.02 | ||||||
Interference with daily activities | −1.94 | 0.06 | ||||||
Testosterone (ng/mL) | 2.92 | 0.007 | ||||||
Insulin ( | −0.27 | 0.79 | ||||||
Blood glucose (mg/dL) | −0.09 | 0.93 | ||||||
QUICKI | 1.38 | 0.18 |
The value are expressed as mean ± standard deviation; IPSS: international prostate symptoms score; QoL of BPH: quality of life of benign prostate hyperplasia; QUICKI: quantitative insulin sensitivity check index.
The level of testosterone increased significantly in the tai chi group compared to the control, while there were no significant intergroup differences in insulin, blood glucose, or the QUICKI
No adverse effects associated with the practice of tai chi were reported by the participants.
This randomized clinical trial investigated the efficacy of 12 weeks of tai chi on LUTS, quality of life, and sex hormone levels in elderly patients with BPH. Our study showed that tai chi significantly improves LUTS compared to a control group. The total of quality of life score was significantly more improved in the tai chi group than in the control group after 12 weeks. The worry and concern QoL subscale at 12 weeks showed a statistically significant difference from the control group. The testosterone showed significant intergroup differences, suggesting greater modulation of hormonal effects in relation to LUTS in the tai chi group compared to the control. This finding has not been previously reported.
This trial found up to a 31% and 24% within-group improvement from baseline for the LUTS and QoL scores, respectively, in the tai chi group. These results suggest a promising role for tai chi in LUTS related to BPH. These results are consistent with previous reports that increased physical activity and exercise are consistently related to a decreased risk for BPH and LUTS [
We recalculated the power of our trial for the mean IPSS differences using the two-sample
Assuming that tai chi is a potentially useful treatment option for patients with BPH, its possible mechanisms of action may be of interest. When performed regularly, the physical exercise of tai chi affects the cardiovascular and metabolic processes [
The limitations of this study include the relatively short period of observation (less than 6 months) and the high dropout and withdrawal rates. Although no significant baseline imbalances in the patient characteristics and LUTS scores were found, this high attrition may have increased the risk of bias because not all of the randomized patients were analyzed. Another risk of bias was from not employing allocation concealment and blinding, although we did use assessor blinding. This factor may have exaggerated the real effects of tai chi for LUTS and other outcomes. We also could not completely control for the placebo or expectation effects due to the lack of an equivalent exercise control group. One of authors participated in conducting the tai chi sessions. Thus, the practitioners’ attitudes toward the tai chi group (if present) may have affected the treatment procedure and outcomes, although we attempted to minimize these effects by the extensively controlled research setting; we found no evidence of protocol violations. The number of participants in this study was small, which increased the chance of type II error. Furthermore, we did not use the sample size calculations, and we could not exclude the possibility that the study was underpowered for detecting a meaningful effect of tai chi on several outcome measures.
Our results suggest that 12 weeks of tai chi may improve LUTS and QoL in elderly patients with BPH. Future tai chi RCTs should properly address the limitations and difficulties encountered in this study by employing an equivalent control group.
This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (KRF-2008-531-E00100).
The authors declare no conflict of interests.