Developing and Translating Content Outline

Innovative Exercise Programs for

Older Adults  Program of Research
• Tai Chi
Kuei-Min Chen, PhD, RN, FAAN • Yoga
Professor, College of Nursing • Elastic Band
Dean, Office of Global Affairs • Acupunch
Director, Master Program of Long-term Care in Aging
 Developing and translating an
Director, Center for Long-term Care Research
Kaohsiung Medical University, Taiwan exercise intervention program
E-mail: kmc@kmu.edu.tw • Silver Yoga (SY)
1 2

Using Complementary
Alternative Therapies to Program of Research I
Promote Health of Tai Chi
Older Adults
3 4
Effects of Traditional Tai Chi on the Well-Being
of Community-Dwelling Elders in Taiwan
 Chen, K. M.*, Snyder, M., & Krichbaum, K. (2002). Translation and
equivalence: The Profile of Mood States Short Form in English and
Chinese. International Journal of Nursing Studies, 39, 619-624. (SSCI)
 Chen, K. M.*, Snyder, M., & Krichbaum, K. (2001). Tai Chi and well-
being of Taiwanese community-dwelling elders. Clinical
Gerontologist, 24(3/4), 137-156.
 Chen, K. M.*, Snyder, M., & Krichbaum, K. (2001). Facilitators and
barriers to elders’ practice of Tai Chi: A mind-body, low-intensity
exercise. Journal of Holistic Nursing, 19(3), 238-255.
 Chen, K. M.*, & Snyder, M. (2001). Well-being of community-dwelling
elders: An overview of research. Journal of Mental Health and Aging,
7(4), 435-443.
 Chen, K. M.*, Snyder, M., & Krichbaum, K. (2001). Clinical use of Tai
Chi in elderly populations. Geriatric Nursing, 22(4), 198-200. (SSCI)
 Chen, K. M.*, & Snyder, M. (1999). A research-based use of Tai
Chi/movement therapy as a nursing intervention. Journal of Holistic
Nursing, 17(3), 267-279.
Development of a Simplified Tai-Chi Therapy for
the Elders in Long-term care Facilities
(NSC 91-2314-B-242-006)
 Chen, K. M.*, Chen, W. T., & Huang, M. F. (2006).
Development of the Simplified Tai-Chi Exercise Program
(STEP) for frail older adults. Complementary Therapies
in Medicine, 14, 200-206. (SCI)
 Chen, K. M.*, Chen, W. T., Wang, J. J., & Huang, M. F.
(2005). Frail elders’ views of Tai Chi. The Journal of
Nursing Research, 13, 11-20. (SSCI)
 Chen, W. T., Chen, K. M.*, & Huang, M. F. (2004). Using
focus groups among the elderly. The Journal of Nursing,
51(4), 82-87.
7
Effects of Traditional Tai Chi on the Well-Being
of Elders Resided in Long-Term Care Facilities
(NSC 90-2314-B-242-003)
 Chen, K. M.*, Hsu, Y. C., Chen, W. T., & Tzeng, H. F.
(2007). Well-being of institutionalized elders after Yang-
style Tai Chi practice. Journal of Clinical Nursing, 16,
845-852. (SSCI)
 Hsu, Y. C., & Chen, K. M.* (2005). Challenges of doing
intervention research with the elderly Taiwanese
population: Example of a Tai Chi / movement therapy.
Geriatric Nursing, 26(6), 358-365. (SSCI)
 Chen, K. M.*, & Liu, T. H. (2004). The state of the art:
Research-based use of Tai Chi in the elderly
populations. The Journal of Long-Term Care, 8(2), 223-
235.
5 6
Effects of the Simplified Tai Chi Therapy on the
Well-being of Elders in Long-term Care Facilities
(NSC 92-2314-B-242-002) (NSC 93-2314-B-242-002)
 Chen, K. M.*, Lin, J. N., Lin, H. S., Wu, H. C., Chen, W. T., Li, C. H., &
Lo, S. K. (2008). The effects of a Simplified Tai-Chi Exercise Program
(STEP) on the physical health of older adults living in long-term care
facilities: A single group design with multiple time points.
International Journal of Nursing Studies, 45, 501-507. (SSCI)
 Lin, J. N., & Chen, K. M.* (2007). Cultural issues and challenges of the
informed consent in older adults. Tzu Chi Nursing Journal, 6(5), 65-
72.
 Chen, K. M.*, Lin, J. N., Lin, H. S., Wu, H. C., Chen, W. T., & Li, C. H.
(2007). A feasible method to enhance and maintain the health of
elderly living in long-term care facilities through long-term, simplified
Tai-Chi exercises. The Journal of Nursing Research, 15(2), 156-164.
(SSCI) 8
Simplified Tai-Chi Exercise Program
(STEP)
Tai Chi
 STEP I: Warm up (9 exercises)
 STEP II: Tai-Chi movements (12 forms)
 STEP III: Cool down (3 movements)

Chen, K. M.*, Chen, W. T., & Huang, M. F. (2006). Development of the

Simplified Tai-Chi Exercise Program (STEP) for frail older adults.
Complementary Therapies in Medicine, 14, 200-206.(SCI) 9 2018/10/17

Development of a Silver Yoga Program

for Older Adults
(NSC 94-2314-B-242-006)
 Chen, K. M.*, & Tseng, W. S. (2008). Pilot-testing
of a newly-developed silver yoga exercise
program for female older adults. The Journal of
Program of Research II 
Nursing Research, 16, 37-46. (SSCI)
Chen, K. M.*, Tseng, W. T., Ting, L. F., & Huang,
G. F. (2007). Development and evaluation of a

Yoga yoga exercise programme for older adults.

Journal of Advanced Nursing, 57(4), 432-441.
(SSCI)
 Chen, K. M.*, & Hong, S. M. (2006). Exploring the
body-mind therapeutic benefits of yoga. The
11
Journal of Long-term Care, 10(2), 190-202. 12
 Application and Evaluation of the
Silver Yoga Program in Older Adults
(NSC 95-2314-B-242-004-MY2)
 Chen, K. M.*, Wang, H. H., LI, C. H., & Chen, M. H. (2011).
Community vs. institutional elders’ evaluations of and
preferences for yoga exercises. Journal of Clinical
Nursing, 20, 1000-1007. (SSCI)
 Chen, K. M.*, Chen, M. H., Chao, H. C., Hung, H. M., Lin, H.
S., & Li, C. H. (2009). Sleep quality, depression state, and
health status of older adults after silver yoga exercises:
Cluster Randomized Trail. International Journal of
Nursing Studies, 46(2), 154-163. (SSCI)
 Chen, K. M.*, Chen, M. S., Hong, S. M., Chao, H. C., Li, C.
H., & Lin, H. S. (2008). Physical fitness of older adults in
senior activity centers after 24-week silver yoga exercises.
Journal of Clinical Nursing, 17, 2634-2646. (SSCI)
13
Silver Yoga (SY) (Chen et al., 2007)
 Warm-up (20 min.): 8 postures to loosen up body
structure
 Hatha yoga (20 min.): 7 gentle stretching postures to
increase range of motion and progressive muscle
relaxation with special consideration for older adults’
physical abilities and tolerance
 Relaxation (10 min.): 3 activities to rest the body
 Guided-imagery meditation (15 min.): 2 imagery-guiding
directions to facilitate relaxation.
15
Applying the Silver Yoga Exercises to
the Frail and Demented Seniors
(FY 95-RD-030)
 Fan, J. T., & Chen, K. M.* (2011). Using silver yoga
exercises to promote physical and mental health of elders
with dementia in long-term care facilities. International
Psychogeriatrics, 23(8), 1222-1230. (SSCI)
 Chen, K. M.*, Fan, J. T., Wang, H. H., Wu, S. J., Li, C. H., &
Lin, H. S. (2010). Silver yoga exercises improved physical
fitness of transitional frail elders. Nursing Research,
59(5), 364-370. (SSCI)
 Chen, K. M.*, Chen, M. H., Lin, M. H., Fan, J. T., Lin, H. S.,
& Li, C. H. (2010). Effects of yoga on sleep quality and
depression in elders in assisted living facilities. Journal
of Nursing Research, 18(1), 53-61. (SSCI)
14
Yoga
2018/10/17

Program of Research III
Elastic Band
17
Developing, Establishing, and Testing the Health
Indicators, Health Assessment Toolkit, and
Health Promotion Program for Older Adults
(NSC 97-2314-B-037-052-MY3)
 Hsieh, H. F., Chen, K. M.*, Lin, M. H., Wang, Y. C., & Huang, H. T. (2014,
December). Social welfare utilization and needs of older adults in Taiwan:
Survey research. Nursing Outlook, 62(6), 459-468. (SSCI)
 Chen, K. M.*, Lin, M. H., Wang, Y. C., Li, C. H., & Huang, H. T. (2013).
Psychological and socioeconomic health of community-dwelling older adults.
International Journal of Psychology, 48(6), 1038-1049. (SSCI)
 Chen, K. M.*, Tseng, W. S., Huang, H. T., & Li, C. H. (2013). Development and
feasibility of a senior elastic band exercise program for aged adults: A
descriptive evaluation survey. Journal of Manipulative and Physiological
Therapeutics, 36(8), 505-512. (SCI)
 Chen, K. M.*, Lin, M. H., Wang, Y. C., Huang, H. T., & Li, C. H. (2012). A model-
based survey of physical health in community-dwelling older adults. The
Journal of Nursing Research, 20(4), 239-248. (SSCI)
 Chen, K. M.*, Hung, H. M., Lin, H. S., Haung, H. T., & Yang, Y. M. (2011).
Development of the model of health for older adults. Journal of Advanced
Nursing, 67(9), 2015-2025. (SSCI)
19
Developing, Establishing, and Testing the Health
Indicators, Health Assessment Toolkit, and
Health Promotion Program for Older Adults
(NSC 97-2314-B-037-052-MY3)
 Chen, M. C., & Chen, K. M.* (in press). Economic and living statuses of
community-dwelling older adults and the related factors. Geriatrics &
Gerontology International. (SSCI)
 Chan, S. Y., & Chen, K. M.*. (2017). Self-perceived health status and sleep
quality of older adults living in community after elastic band exercises. Journal
of Clinical Nursing, 26, 2064-2072. (SSCI)
 Liao, L. Y., Chung, W. S., & Chen, K. M.* (2017). Free radicals and antioxidant
enzymes in older adults after regular senior elastic band exercising: An
experimental randomized controlled pilot study. Journal of Advanced Nursing,
73(1), 108-111. (SSCI)
 Chan, S. Y., Kuo, C. C., Chen, K. M.*, Tseng, W. S., Huang, H. T., & Li, C. H.
(2016). Health promotion outcomes of a newly-developed elastic band exercise
program for older adults in the community: A pilot test. The Journal of Nursing
Research, 24(2), 137-144. (SSCI)
 Yang, H. J., Chen, K. M.*, Chen, M. D., Wu, H. C., Chang, W. J., Wang, Y. C., &
Huang, H. T. (2015). Applying the transtheoretical model to promote functional
fitness of community older adults participating in elastic band exercises.
Journal of Advanced Nursing, 71(10), 2338-2349. (SSCI) 18
Development, Application, and Evaluation of the
Senior Elastic Band Exercise Program for
Elderly Residents in Long-term Care Facilities
(NSC 99-2628-B-037-066-MY3)
 Chen, K. M.*, Li, C. H., Huang, H. T., & Cheng, Y. Y. (2016). Feasible
modalities and long-term effects of elastic band exercises in nursing
home older adults in wheelchairs: A cluster randomized controlled
trial. International Journal of Nursing Studies, 55, 4-14. (SSCI)
 Chen, K. M.*, Huang, H. T., Cheng, Y. Y., Li, C. H., & Chang, Y. H. (2015).
Sleep quality and depression of nursing home older adults in
wheelchairs after exercises. Nursing Outlook, 63(3), 357-365. (SSCI)
 Chen, K. M.*, Li, C. H., Chang, Y. H., Huang, H. T, & Cheng, Y. Y. (2015).
An elastic band exercise program for older adults using wheelchairs in
Taiwan nursing homes: A cluster randomized trial. International
Journal of Nursing Studies, 52, 30-38. (SCI)
 Chen, K. M.*, Tseng, W. S., Chang, Y. H., Huang, H. T., & Li, C. H.
(2013). Feasibility appraisal of an elastic band exercise program for
older adults in wheelchairs. Geriatric Nursing, 34(5), 373-376. (SSCI)
20
 Development and Evaluation of an Evidence-based
Intervention Protocol of the WSEB Program for the Senior Elastic Band (SEB)
Demented Seniors in Long-term Care Facilities (Chen et al., 2013)

(NSC 102-2314-B-037-054-MY2)  Warm-up (12 min.): 7 movements to loosen

 Chen, K. M.*, Kuo, C. C., Chang, Y. H., Huang, H. T., & up the body and elevate the energy of
Cheng, Y. Y. (2017). Resistance band exercises reduce participants
depression and behavioral problems of wheelchair-bound  Aerobic motions (10 min.): 7 low-to-medium
older adults with dementia: A cluster-randomized
controlled trial. Journal of the American Geriatrics speed exercises to enhance the
Society, 65(2), 356-363. (SSCI) cardiovascular-respiratory workout
 Chen, M. C., Chen, K. M.*, Chang, C. L., Chang, Y. H.,  Static stretching (18 min.): 6 low-speed,
Cheng, Y. Y., & Huang, H. T. (2016). Elastic band exercises
improved activities of daily living and functional fitness of gentle stretching exercises to build up
Wheelchair-bound older adults with cognitive impairment: muscle power/endurance and increase
A cluster randomized controlled trial. American Journal of range of motion and flexibility
Physical Medicine & Rehabilitation, 95(11), 789-799. (SCI)
21 22

Wheelchair-bound Senior Elastic Band

SEB (WSEB) (Chen et al., 2013)

 Warm-up (10.5 min.): 6 exercises to loosen

up the body and cultivate energy for a safe
transition to the next phase
 Aerobic motion (11 min.): 6 low-to-medium
speed exercises to stimulate cardiovascular-
respiratory system
 Harmonic stretching (13.5 min.): 6 low-
speed, gentle stretching exercises to build
up muscle strength/endurance and increase
range of motion and flexibility
2018/10/17 24
 WSEB
Program of Research IV
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Development and Evaluation of an Evidence-based
Intervention Protocol for the Healthy Beat Acupunch
(HBA) Exercise Program for Community Older Adults
(MOST104-2314-B-037-041-MY3)
 Tung, H. T., Lai, C. C., Chen, K. M.*, & Tsai, H. Y. (in
press). Meridian cuffing exercises improved functional
fitness and cardiopulmonary functioning of community
older adults. Clinical Nursing Research. (SSCI)
 Tsai, H. Y., Chen, K. M.*, & Huang, H. T. (in press).
Acupunch exercise program development and feasibility
evaluation for older adults. Rehabilitation Nursing. (SSCI)
 Hsiao, C. Y., Chen, K. M.*, Tsai, H. Y., Huang, H. T.,
Cheng, Y. Y., & Tsai, A. Y. (2018). Self- perceived health
and sleep quality of community older adults after
acupunch exercises. American Journal of Geriatric
Psychiatry, 26(5), 511-520. (SSCI) 27
Acupunch
26
Healthy Beat Acupunch (HBA)
Tsai, Chen, & Huang (in press) Rehabilitation Nursing.
 Activating qi & blood: 5 slow, gentle motions
to regulate qi, loosen body, and elevate
energy for a safe transition to the next phase.
 Punching meridians: 14 low-to-medium speed
motions to punch 14 meridians, enhancing
cardiovascular-respiratory workout.
 Relaxing body & mind: 5 low-speed, muscle
relaxing motions with deep breathing to
soothe body & mind.
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 HBA

Developing an exercise
intervention program:
Silver Yoga (SY)

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What is Yoga?
 Yoga means union or joining together of the
body and mind of an individual with the
universal spirit (Stanescu et al., 1981)
 The goal of yoga therapy is to promote health
benefits and self-awareness (Feuerstein, 2000).

Background of Yoga  3 key elements:

• Breathing: mindfully breathing to control the
mind.
• Postures: manipulate muscles and body
structure.
• Meditation: pursuit a peaceful mind and self-
guided relaxation.
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 Types of Yoga
 Raja yoga (yoga of mental and spiritual
mastery) describes the inner workings of
the mind and prescribes a psychological
approach based on a practical system of
concentration and control of the mind
(Sivananda Yoga Vedanta Center 1998).
 Hatha yoga (yoga of physical postures and
breathing) consists of the control of
posture (asana) and the manipulation of
respiration (pranayama) (Miyamura et al. 2002). 33
Design of a 3-year
Research Project
35
Research-Based Use of Yoga
 Studies have supported yoga’s potential benefits in
reducing body mass index, low-density lipoprotein
cholesterol, fibrinogen, and blood pressure (Damodaran et al.,
2002).
 Through static physical postures, yoga uses stretching
to improve muscular strength and flexibility (Chen & Gan, 1997)
that could be beneficial for low-back-related pain
management (Hill, 2004).
 Yoga has been useful in treating various forms of
arthritis (Dash & Telles, 2001; Garfinkel & Schumacher, 2000) and reducing the
severity of muscular-skeletal disease (Garfinkel & Schumacher, 2000).
 Studies of yoga-based interventions conducted with
healthy populations have shown that these
interventions decreased depression and anxiety (Waelde &
Thompson, 2004), decreased sleep disturbances, improved
sleep quality (Cohen et al., 2004), and improved perceived self-34
efficacy (Waelde & Thompson, 2004).
The First Year
 Purpose
• To develop a safe and manageable yoga
exercise program specifically for seniors
• To evaluate the appropriateness of the
program for seniors
• To pilot-test the health promotion effects of
the SY for seniors.
 Two phases
36
 First Year: Phase I
 Design: Evaluation survey
 Participants: 10 experts
• 2 certified yoga instructors
• 2 gerontological nurse practitioners
• 2 physical therapist
• 2 osteopathy doctors
• 2 physical educators
 Data collection:
• A hard copy + VCD of SY descriptions and
demonstrations
• Evaluation criteria: clarity and feasibility
• Scoring: 1-4 (≦ 3  provide revision suggestions)
Preliminary Outcome Testing
 Physical Health
• Body compositions: BH, BW, BMI, body fat.
• Cardiovascular-respiratory fitness: breath-holding
duration, lung capacity (Peak Flow Meter), resting BP.
• Range of motion: flexion and abduction of shoulder
and hip joints (goniometer).
• Physical fitness: hand-grip strength (digital handgrip
dynamometer), lower body flexibility (sit-and-reach
test), lower limb muscle endurance (chair-stand test),
balance (one-leg-stand test).
• Physical health actualization: SF-12 physical
 Mental Health
• Sleep quality: PSQI
• Depression state: TDQ
• Mental health actualization: SF-12 mental
First Year: Phase II
 Design: Quasi-experimental, one-group, pre-post pilot
 Setting: senior activity center
 Participants: convenient sample of 14 females
 Intervention: SY
• Intensity: 4 weeks, 3 times/week, 70 min./session
• Attendance rate: 91.07%
 Data collection:
• Pretest + posttest: Preliminary outcome testing
• Posttest only: Program evaluation
– Evaluation criteria: difficulty, acceptability,
feasibility, helpfulness
– Scoring: 10-point Cantril ladder scale
37 – 5 open-ended questions 38
Silver Yoga Exercise Program
 Warm-up (20 min.): 8 postures to loosen up body
structure
 Hatha yoga (20 min.): 7 gentle stretching postures to
increase range of motion and progressive muscle
relaxation with special consideration for seniors’
physical abilities and tolerance
 Relaxation (10 min.): 3 activities to rest the body
 Guided-imagery meditation (15 min.): 2 imagery-guiding
directions to facilitate relaxation.
 Special characteristics:
• Accommodate the reduced body flexibility
experienced by many elders
39
• Less strenuous than those used in traditional yoga
40
 The Second + Third Year
 Purpose
• To test the physical and mental health of the
community-dwelling seniors after 15 months
long-term SY practice
• To examine whether the SY program could
be further shortened to ≦ 60 min.
• To test the effectiveness and feasibility of
using audiovisual SY module to enhance
and maintain the health of seniors
 Design
• Times-series, non-equivalent control group
Physical Health Outcomes
 Body composition
• BH, BW, BMI, & body fat percentage
 Cardiovascular-respiratory functions
• BP, breath-holding duration, & lung capacity (Peak
Flow Meter )
 Physical functions:
• hand-grip strength (digital handgrip dynamometer)
• lower body flexibility (sit-and-reach test)
• lower limb muscle endurance (chair-stand test)
• balance (one-leg-stand test)
• walking speed (six-meter walking test)
 Range of motions:
• flexion and abduction of shoulder and hip joints on
both sides (goniometer)
Methods
 Setting:
• 8 senior activity centers, southern Taiwan
 Participants:
• 204 recruited conveniently; 189 completed the study
(retention rate: 92.7%); 176 attendance rate ≧ 50%
 Random assignment based on centers:
• Exp. I: complete SY group (n = 57) (70 min.):
stretching + meditation (attendance rate: 89.54%)
• Exp. II: shortened SY group (n = 53) (55 min.):
stretching (attendance rate: 87.04%)
• Con.: wait-list control group (n = 66)
 Module:
• 1-6 months: instructor-led
• 7-15 months: VCD-guide
41 42
 Data collection points: pretest, 3, 6, 9, 12, & 15 months
Mental Health Outcomes
 Sleep quality: PSQI
• 18-item
• 7 subscales: subjective sleep quality, sleep latency,
sleep duration, habitual sleep efficiency, sleep
disturbances, use of sleeping medications, and
daytime dysfunction
 Depression state: TDQ
• 18-item; 1 composite score
 Self-actualization of health status: SF-12 Health Survey
• 12-item
• Physical health: physical functioning, role-physical,
bodily pain, and general health perceptions
43
• Mental health: vitality, social functioning, role- 44
emotional, and mental health
Translating Research Outcomes

 Developed 5 exercise programs,

trained > 300 regular volunteers at
community care centers and long-
term care facilities
 5 programs are currently practiced in
212 community care centers and 20
long-term care facilities

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47 48
Questions & Discussions

Thank You 49