Emerging Treatments and Technologies

B R I E F R E P O R T

Mobility Impairment in Type 2 Diabetes

Association with muscle power and effect of Tai Chi intervention
RHONDA ORR, MEXSPSC1 ELIZABETH COMINO, PHD3 tially beneficial. The same exercise phys-
TRACEY TSANG, BAPPSC(EXSPSC)(HONS)1 MARIA FIATARONE SINGH, MD1,4 iologist conducted both group exercise
PAUL LAM, MBBS2 sessions (10 min warm-up and cool-
down, 45 min exercise) twice weekly. The
Tai Chi group performed Tai Chi for Dia-
betes (15), a 12-movement hybrid from

T
he increasing prevalence of type 2 QOL in older adults (6 –13), it has never
diabetes is a major health concern. been tested specifically in a diabetic cohort Sun and Yang styles. Control subjects per-
Reducing the vascular complica- for benefits across multiple domains. formed sham exercise (e.g., seated calis-
tions of diabetes has been a primary focus If Tai Chi was shown to be effective thenics, stretching) (16).
of treatment. However, the less- for mobility and other health outcomes All testing was conducted by the ex-
recognized complications of physical dis- relevant to this cohort, it may present a ercise physiologist before randomization
ability, cognitive impairment, and viable alternative exercise modality. The and after completing 32 sessions (within
depression that impact on quality of life aim of this study was to examine the phys- 5 months of randomization). Mobility im-
(QOL) are also important primary care iologic impairments associated with mo- pairment was determined from measures
considerations in older patients with dia- bility in older adults with type 2 diabetes of balance and gait speed (habitual and
betes. and to investigate whether Tai Chi would maximal). Static balance (timed single-leg
Diabetes has been associated with a improve mobility in this cohort relative to stance with eyes open and closed), dy-
greater risk of decline in function and in- sham exercise. namic balance (3-m forward tandem
creased prospect of severe disability (1,2). walk), and balance index (summary score
Studies have sought to identify relation- RESEARCH DESIGN AND of static balance and postural control per-
ships or causal pathways between the syn- METHODS — We conducted a 16- formance on a Chattecx balance platform)
dromes of mobility, disability, and week single-blind, randomized, sham- (17) were measured.
neuropsychological function in adults exercise controlled trial with an intention- Physiological capacity assessments
with type 2 diabetes (1,3). Few have si- to-treat design. Baseline outcomes included knee extensor strength (one rep-
multaneously examined these factors po- assessment was blinded. The study was etition maximum), peak power, peak
tentially modifiable by physical activity approved by human research ethics com- contraction velocity, and endurance (18)
(4) across multiple domains or at more mittees of the Universities of Sydney and and overall exercise capacity (6-min
than one point in time. New South Wales. Written informed con- walk) (19). Health status included num-
The dose of aerobic and resistance ex- sent was obtained by participants. ber of comorbidities, body composition
ercise necessary to achieve metabolic ben- We studied 38 type 2 diabetic pa- (waist circumference, total body fat
efits in clinical trials has sometimes led to tients (79% female). We excluded pa- [%BF]) (20), fasting blood glucose, cog-
poor compliance (5). Older adults with tients who were physically active, nition (14), QOL (21), and attitude to-
diabetes, often characterized by long- institutionalized, or cognitively impaired ward diabetes (22).
term sedentariness, overweight/obesity, (Mini-Mental State Examination ⱕ24) Statistical analyses were performed
and multiple comorbidities, may demon- (14) or had arthritic pain, unstable condi- using Statview 5.0. Values are reported as
strate better adherence to a low-intensity, tions, or disease precluding them from means ⫾ SD or median (range). Groups
low-impact exercise, such as Tai Chi. Al- the planned exercises. Participants were were compared using t tests or ␹2. The effect
though Tai Chi has demonstrated im- randomly allocated to the Tai Chi or con- of time and group-by-time interactions
proved balance, gait speed, muscle trol groups, named Eastern or Western were analyzed with repeated-measures
strength, cardiorespiratory fitness, and exercise, both presented as being poten- ANOVA. Variables, different between
groups and their baseline values, were used
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● as covariates in ANCOVA models. Relation-
From the 1Exercise and Sport Science Department, University of Sydney, Sydney, Australia; the 2Family ships between variables of interest were an-
Medicine Department, University of New South Wales, New South Wales, Australia; the 3Health Equity alyzed with multiple and forward stepwise
Training Research and Evaluation Department, University of New South Wales, New South Wales, Australia;
and the 4University of Sydney, Sydney, Australia, and Hebrew SeniorLife and Jean Mayer USDA Human
linear regression or Spearman rank-order
Nutrition Center on Aging, Tufts University, Boston, Massachusetts. correlation. Statistical significance was ac-
Address correspondence and reprint requests to Rhonda Orr, P.O. Box 170, Lidcombe, NSW, 1825, cepted at P ⱕ 0.05.
Australia. E-mail: r.orr@fhs.usyd.edu.au.
Received for publication 1 June 2006 and accepted in revised form 7 June 2006.
P.L. was the creator of the Tai Chi for Diabetes form and producer of its video and is the founder of Tai Chi
Productions, which distributes these videos and similar products and services. RESULTS — Participant characteris-
Abbreviations: %BF, total body fat; QOL, quality of life. tics and performance data are presented
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion in Table 1. Participants were obese (63%),
factors for many substances. displayed metabolic syndrome (82%),
DOI: 10.2337/dc06-1130 had one or more diabetes complications
© 2006 by the American Diabetes Association.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby (40%), had comorbidities (predomi-
marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. nantly osteoarthritis [84%] and hyperten-

2120 DIABETES CARE, VOLUME 29, NUMBER 9, SEPTEMBER 2006

 2121
traction velocity was the sole common in-

over time. Physiological and health status

health, muscle function, and exercise ca-

significantly correlated with compliance

Orr and Associates

speed (P ⫽ 0.005) improved significantly

changes in physiological or health status.

tion velocity and mobility impairment in

type 2 diabetes. Muscle contraction veloc-
ity was the single characteristic indepen-

modest significant improvements in mo-

bility, although not different from sham
(16%; two or more falls in the past year).
At baseline, older age, more comorbidi-
ties, higher %BF, poorer cognition, QOL,
exercise capacity and muscle power, and
slower gait speed and muscle contraction

exercise. The dose and/or movements of

tations. Furthermore, the high prevalence

velocity were related to poor balance (P ⫽
0.043 to ⬍0.0001). Similarly, older age,

models revealed that slower muscle con-

first time the novel and robust relation-

dently associated with poorer balance and

contraction velocity were related to

⬍0.0001). Forward stepwise regression

dependent contributor to both balance

Balance (P ⫽ 0.03) and maximal gait

over time, but there were no group-by-

proved balance the most (P ⫽ 0.023). By

was associated with better baseline

lower baseline blood glucose and %BF in-

mal gait speed (r ⫽ 0.71, P ⫽ 0.0001),

0.34, P ⫽ 0.047) and gait speed (maximal

Improvements in balance index (r ⫽

(P ⫽ 0.90) nor could they be explained by

gait speed: r ⫽ 0.46, P ⫽ 0.008; habitual

ships between muscle power and contrac-

After 4 months, Tai Chi provided

the Tai Chi for Diabetes program may not

have been sufficient to elicit robust adap-
poorer QOL, exercise capacity, balance

CONCLUSIONS — We report for the

of obesity and osteoarthritis may have

sion [76%]), and were recurrent fallers

time interactions. Habitual gait speed

(P ⫽ 0.053) and 6-min walk (P ⫽ 0.06)

Participants with poorer QOL im-

pacity. Following stepwise regression,

dependently predicted improved maxi-

gait speed: r ⫽ 0.44, P ⫽ 0.011) were

did not significantly change after the
and muscle power, and slower muscle

but neither were related to each other

slower gait speed (P ⫽ 0.043 to

showed a trend toward improvement

contrast, increased maximal gait speed

compromised an optimal training style.

accounting for 65% of the variance.
and gait impairment at baseline.

gait in this cohort.

intervention.

Table 1—Baseline characteristics of participants and outcomes after Tai Chi and sham exercise
Tai Chi (n ⫽17) Sham exercise (control) (n ⫽ 18) Change Group
over time effect
Characteristic Baseline Follow-up % change Baseline Follow-up % change P value P value
Age (years) 65.9 ⫾ 7.4 64.9 ⫾ 8.1
Duration of diagnosed type 2 diabetes (years) 8.5 (0–25) 9.0 (0.7–50)
Number of comorbidities 6.9 ⫾ 6.7 6.1 ⫾ 8.8
Cognition (0–30)*† 28 (25–30) 27 (23–30)
Weight (kg) 87.5 ⫾ 13.7 88.1 ⫾ 12.3 ⫺1.1 ⫾ 3.0 80.7 ⫾ 16.1 80.6 ⫾ 16.2 ⫺0.1 ⫾ 1.9 0.2 0.3
%BF†‡ 43.0 ⫾ 4.8 42.7 ⫾ 5.7 ⫺0.6 ⫾ 3.4 37.3 ⫾ 8.4 36.8 ⫾ 9.1 ⫺1.0 ⫾ 2.8 0.1 0.7
Waist circumference (cm)†‡ 106.1 ⫾ 14.6 108.2 ⫾ 13.2 0.5 ⫾ 3.4 98.4 ⫾ 12.6 98.7 ⫾ 12.5 0.4 ⫾ 2.8 0.4 0.9
Blood glucose (mmol/l) 7.6 (3.9⫺15.6) 7.5 (5.7⫺12.5) 7.7 ⫾ 28.8 7.9 (5.6⫺13.9) 7.4 (5.4⫺15.4) ⫺3.2 ⫾ 20.4 0.9 0.2
7.5 ⫾ 4.0 8.2 ⫾ 4.4 ⫺4.6 ⫾ 19.7 6.4 ⫾ 3.8 6.8 ⫾ 4.0 9.0 ⫾ 5.9

DIABETES CARE, VOLUME 29, NUMBER 9, SEPTEMBER 2006

Daily medications (n) 0.9 0.2
Mobility
Balance index (§) 111.1 ⫾ 23.1 107.3 ⫾ 23.1 2.5 ⫾ 14.9 111.5 ⫾ 22.2 104.1 ⫾ 22.2 5.8 ⫾ 12.6 0.03* 0.5
Single leg stance, eyes open (s) 8.96 (0.4⫺30) 17.9 (0.6⫺30) 47.7 (⫺79.2 to 3,473.2) 30 (1.3⫺30) 24.2 (0⫺30) 0 (⫺100 to 407) 0.6 0.4
Single leg stance, eyes closed (s) 3.9 (0.4⫺19.6) 2.8 (0.1⫺14.0) ⫺22.6 (93.6 to 190.9) 2.2 (0.6⫺6.0) 2.0 (0⫺8.3) ⫺23.1 (⫺100 to 730) 0.2 0.2
Tandem walk score储 19.1 ⫾ 7.0 18.1 ⫾ 8.3 ⫺4.7 ⫾ 27.6 18.5 ⫾ 6.3 17.2 ⫾ 6.2 ⫺5.3 ⫾ 23.4 0.2 0.8
Habitual gait speed (m/s) 1.0 ⫾ 0.2 1.1 ⫾ 0.2 12.3 ⫾ 27.4 1.1 ⫾ 0.2 1.2 ⫾ 0.3 7.9 ⫾ 26.6 0.053 0.7
Maximal gait speed (m/s) 1.6 ⫾ 0.3 1.7 ⫾ 0.3 6.6 ⫾ 10.3 1.6 ⫾ 0.3 1.7 ⫾ 0.3 5.9 ⫾ 12.8 0.005¶ 0.9
Physiological capacity
Muscle strength (nmol/l) 91.3 ⫾ 31.5 97.8 ⫾ 24.8 12.9 ⫾ 28.9 89.7 ⫾ 30.3 90.7 ⫾ 33.8 4.9 ⫾ 28.1 0.3 0.5
Peak muscle power (W) 215.9 ⫾ 75.4 220.9 ⫾ 64.9 4.8 ⫾ 18.1 221.7 ⫾ 74.5 217.4 ⫾ 74.5 ⫺0.4 ⫾ 16.7 1.0 0.5
Peak muscle velocity (rad/s) 2.7 ⫾ 0.8 2.6 ⫾ 0.7 0.8 ⫾ 34.1 2.6 ⫾ 0.8 2.8 ⫾ 0.6 15.5 ⫾ 46.0 1.0 0.3
Muscle endurance (number of repetitions) 4 (2⫺13) 5.5 (0⫺14) 0 (⫺100 to 450) 4 (2⫺11) 3 (0⫺14) ⫺36.6 (⫺100 to 200) 0.5 0.5
6-min walk distance (m) 474.0 ⫾ 76.1 481.8 ⫾ 83.0 1.7 ⫾ 7.4 456.6 ⫾ 117.8 470.1 ⫾ 118.2 3.6 ⫾ 8.2 0.06 0.6
Values of normally distributed data are means ⫾ SD. Non–normally distributed data are median (range). *Cognition was assessed by the Mini-Mental State Examination, which uses a scale of 0-30, with scores ⬍24
indicating cognitive impairment (14). †Significant difference between groups at baseline (P ⫽ 0.02– 0.04). ‡%BF was determined using bioelectrical impedance analysis (20). §Balance index: a lower score indicates
better overall balance performance (17). 储Tandem walk score equals time to complete course plus number of errors made during the test; a lower score indicates better balance. ¶P values were determined by factorial
ANOVA. A P value of ⬍0.05 was accepted as statistically significant.
Diabetes: mobility impairment and Tai Chi
Enhanced balance and gait speed were
not related to each other. Compliance, how-
ever, was related to improved mobility, sug-
gesting that the observed improvements
cannot be solely considered a learning ef-
fect. Unmeasured aspects of group partici-
pation, such as changes in motor control,
socialization, or neuropsychological func-
tion, may explain our results.
In conclusion, mobility impairments
in an older, obese cohort with type 2 dia-
betes are associated with low muscle
power and may therefore respond more
robustly to an exercise intervention spe-
cifically designed to improve muscle con-
traction velocity, such as explosive
resistance (power) training.
Acknowledgments — We thank Douglass
Hanly Moir Pathology for their sponsorship,
Keiser Sports Health for their donation of K400
Electronics for pneumatic-resistance machines,
and the participants for their dedication.
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