BTR 3: Arnis-based Exercise Program for Balance Control | Behind the Research

00:00 Johann Hello everyone, welcome to Behind the Research, a segment of PT MEAL podcast in partnership with the Philippine Journal of Physical Therapy. In this segment, we will take a deep dive into the research and talk to the authors of select articles published in the Philippine Journal of Physical Therapy. In this episode, we will discuss the research entitled, Arnis-based Exercise Program for Balance Control in Community-Dwelling Older Adults, a Study Protocol for a Pilot Randomized Control Trial. I'm pleased to have in the show its principal author, Associate Professor Donald Lipardo, a faculty member in the College of Rehabilitation Sciences in the University of Santo Tomas. Welcome, Dr. Lipardo to the podcast.

00:44 Dr. Lipardo  Hi, thank you, thank you for the invitation. And I'm glad this is finally happening. 

00:53 Johann I appreciate you being here. I know you're very busy. So I want to thank you for taking the time to have this conversation at last. So it's an honor actually, it's my honor to be here. So, the research is about Arnis. And when I first saw it, I was like, excited about it, because at last, we're talking about our own martial arts in the Philippines. And in conferences and in seminars, we talk about fall prevention. And we hear a lot about Tai Chi, which is coming from China. So Arnis is our own martial arts. So why can't we, you know, it's about time to have that. So in this research, you'll investigate the effectiveness of Arnis-based exercise program on balance control in healthy community-dwelling older adults and have a 12-week pilot randomized control trial involved in measuring balance, concern for falling, and lower limb strength of the participants. So my first question would be what inspired you to choose Arnis as the basis for your program for the older adults?

02:05 Dr. Lipardo All right. So when I did my PhD, like four, three, four to five years ago, I went to the Hong Kong Polytechnic University and I saw there a lot of people doing exercise, doing Tai Chi. And I think that inspired me to think about why not do a community based exercise in the But not Tai Chi, which is very, you know, oriental, very Chinese in nature, but something that is more familiar with Filipinos. And I thought of Arnis being the national martial arts of the Philippines. So in your opinion, how does Arnis compare to other martial arts like Tai Chi? Well, Arnis in itself is more combative, right? So you actually need a pairing partner. But I think it has to be modified. We actually redesigned Arnis so that it will be more applicable to older adults. And in Arnis, there is footwork, our movements. You need to rotate the trunk. You need to thrust your upper extremities. And we saw that those techniques may be able to challenge the balance of an individual, particularly older adults. And therefore, based on that, we designed the program and adopted it based on the age of our target population, which is the geriatric population.

03:47 Johann Nice. It's similar to Tai Chi, which they have slower movements, but they step into the side. Tied the side forward with their arms rotating as well. But with our martial arts, Arnis, similar with footwork at the same time, the heading up and down, right?

04:14 Dr. Lipardo Yeah. I think with Arnis, we make use of sticks. And I think with the incorporation of that, the exercise will be more functional. 

04:20 Johann They can visualize what they can do. Could you provide us with more detail of what the Arnis-based exercise program that you're going to do in your study?

04:40 Dr. Lipardo All right. So the current protocol for the pilot RCT is actually based on the previous study. We did a qualitative study. We explored the opinions of experts coming from different fields of different backgrounds, like physical therapists, a sports scientist, a geriatrician, an Arnis expert, and one senior citizen herself. So based on their comments and suggestions, we came up with a 12-week program. That 12-week program is divided into three phases. The first phase, the first four weeks, will be for familiarization of the Arnis techniques movement. So the intensity set is just low. Then the second phase, wherein we incorporate now more challenging movements, the intensity set there is a transition from low to moderate. And finally, the last four weeks, the phase three will be at the moderate level.

05:55 Johann So this time, it's really going to be more challenging for the older adults. So who would administer or lead the exercise? Is it going to be a physical therapist or an Arnis expert? 

06:06 Dr. Lipardo In our case, we want it to be a bit uniform at this stage because it's still in the pilot run. So we recorded the exercise in a video so that the participants will just follow what is being presented in the video, but in the presence of a physical therapist supervising them. All the exercises were pre-approved by an Arnis expert. And the older adults in the previous study approved that those movements are doable in their age group. 

06:56 Johann Got it. How would you try to control the number? I've read that the program is going to be three times a week of administration of the program. But would you allow the participants to practice on their own in their free time? Or are you going to control that?

07:15 Dr. Lipardo For a research study, things need to be controlled. So we need to advise the participants to stick to the protocol of doing the, well, at least for those who are assigned to the intervention group, to stick to the protocol that is to attend the sessions three times.

07:37 Johann A week and do their usual activities to the other days of the week. Because they might enjoy it that much. Yeah. On their own. 

07:49 Dr. Lipardo We're giving them fancy sticks. It's not the usual stick by the Arnis experts, but sticks with pads and color. So they might enjoy playing with it. But yes, they are reminded that, well, before they sign the consent form, that the protocol is three times a week for 12 weeks. 

08:10 Johann Yeah, I'm familiar with that. Padded sticks. I got a pair for my grandfather in the Philippines when I visited him. And I gave it to his physical therapist to use it. And they were using that as well. I saw the exercises and I don't know if they did some Arnis moves or techniques there. But I saw that they sell that in, I forgot what store that was. So anyway, what do you hope to achieve with this pilot study and what are the potential implications for the results? 

08:51 Dr. Lipardo Okay. So with this study, since this is a pilot study, we want to see the initial effects of the program to a small group of people. And then we can use the results as a basis for doing a more extensive study, a larger randomized controlled trial.

09:17 Johann Nice. Yeah. And we talked about earlier that when I was trying to research about Arnis-based exercise program, I didn't see any study coming up.

09:30 Dr. Lipardo Even in other fields like in physical education. So I think this is very pioneering.

09:37 Johann Exactly. Considering that Arnis has been there for a long time and no one thought of doing a study on that. So what are the types of or kinds of challenges or difficulties that you're expecting or trying to look for, not look forward, but trying to try to avoid during the course of the study?

09:59 Dr. Lipardo Initially, our main concern is the COVID pandemic. So when we decided the protocol, it was to be implemented by a tele-rehabilitation. But now that there's no easing in the restrictions, we actually submitted our modification of the protocol and do the exercises on site with the therapist. But they still watch the video recording of the exercise, but this time on site with the physical therapist. So the first challenge really was to how are we going to implement the study given the pandemic conditions? The second one would be adherence. Some participants who initially consented to participate withdrew because of some obligations that they need to do like they need to watch over their grandchildren. Some still are working. So it's kind of challenging to schedule the exercises with those participants who already consented. And perhaps 12 weeks may be a long time for them, but we'll try our best to implement our study based on the protocol and see after the program, obtain their comments and suggestions. So actually there's a follow-up study here. We'll be doing a qualitative study among the participants of the earnings group so that we'll know whether the exercise program is acceptable to them and what are their thoughts and their perceptions about the program.

11:52 Johann  That would be interesting to see. My question, I know you're interested in your research about fall risk reduction and geriatric rehabilitation. I was just thinking, would community-dwelling older adults like in our setting, Philippine culture, would there be a difference if it was administered as a group or individual individually?

12:29 Dr. Lipardo There are advantages and disadvantages of conducting the exercise program individually or in groups. So logistically speaking, it's more difficult to do it individually because you need a lot of manpower, financial support as well. The scheduling is going to be very challenging. But with individual sessions, there will be a more focused session with the older adults and the physical therapist may be able to really monitor the participants. For the group sessions, there are studies that will tell you that being in a group will entice the older adults to exercise because they see their peers with them, they enjoy the company, the socialization that comes with the group session. But on the downside, it will be challenging for physical therapists. There's only one physical therapist monitoring them, like six to ten persons in one session seeing how they actually execute the movements. If there's someone experiencing imbalance or might fall, it will be very challenging to the PT administering the exercise. We kind of weigh on those things and that is also something that we can think about in the future whether it's better to do it individually or in groups.

14:14 Johann  It's a pilot research wise, it's best to administer it individually so we can track, is it right? Yes. So we can track effectiveness. Gotcha. I think you've touched on this a while ago, but how would you control outside factors that might affect the results of the participants like diet or other activities in their lives?

14:44 Dr. Lipardo We did not control for diet. So in our inclusion and exclusion criteria, we did not include that. So for exclusion, we just stated that they should be really healthy. So no medical conditions, they should have no history of cerebrovascular disease, Parkinson's, whatsoever other severe conditions affecting the heart or the lungs. And in terms of cognition, we also screened them so that those with low scores in the cognitive tests that we conducted are not included in the study. So those are the things that we controlled, but the others, no, we did not consider the nutrition. For physical activity, we informed them that they can do their usual activity and that the Arnis-based exercise will be in addition to what they usually do.

15:49 Johann Okay. Do they have to be familiar with Arnis or do they have to have a history of how to use an Arnis stick?

15:59 Dr. Lipardo No, not really. It's not a requirement. The first phase of the study is actually dedicated to that familiarization with the Arnis technique. So it's four weeks of familiarization and basic movements were taught during that phase. And by the way, I forgot to mention those who are involved in Zumba and other ballroom dancing activities for seniors were also excluded.

16:29 Johann So they should be healthy but not participate in any other group exercise program. In your opinion, what would be the key advantages of using martial arts as an exercise intervention for older adults, especially in our setting, the Philippine setting compared to other types of exercises like what you mentioned, Zumba, aerobics, and Tai Chi, of course? 

16:54 Dr. Lipardo I think Arnis is something that is familiar to Filipinos. I mean, they know that it is part of our culture, the martial arts of our country, and with the use of the stick, it's going to be more functional. So they don't just swing their hands in any direction. It has some involved, the technique involves them gripping and executing the techniques, and the movement patterns. And it's going to involve the whole body, not just the arms and the legs. It's going to focus, increase their focus, their attention, and their concentration as well. So there are so many benefits that the program can give and therefore, based on these claim

18:00 Johann benefits, I think they will be enticed to perform the exercise. Yeah, right. When you mentioned that they're going to hold a stick, that involves grip, which is not part of Tai Chi, which they have their hands open and they're just moving it in a flowy movement. But with Arnis, the more snappy you get, the more force that you can generate.

18:26 Dr. Lipardo And you're right. And in fact, in other studies, grip strength is now being correlated with falls. So it's an indicator or you can actually use the grip strength as a measure of their ability to

18:44 Johann break a fall or decrease their fall risk. They're considering that as another vital sign. So after gait has been considered as a vital sign, gait speed, then strength, I think they're trying to push that as a sign as well. So based on the results of this pilot study that you're going to do, what would be your future

19:10 Dr. Lipardo plans in this research area and will you be expanding to a larger group? Yeah, definitely. We are actually hoping that with this podcast, we can invite collaborators so that we can conduct a larger randomized controlled trial involving more older adults. So the pilot study will be our basis, our baseline data. And this will now be used to compute for the sample size of future studies, the possible power that is needed to determine whether the Arnis program in itself is really effective. Yeah, that's the future direction is to conduct a larger randomized controlled trial. And hopefully, it's not just concentrated in Manila or NCR, but actually, we're conducting the study in Binangonan, Rizal with the help of Mamsin, the PT there. Hopefully, we are able to do this study, and this exercise and be implemented not just in Luzon, but also in Visayas and Mindanao and even internationally. I do hope that we are open to collaborations with other stakeholders, with other physical therapies, or even physical fitness in TUCS.

20:41 Johann How would you feel sir, if you later on, there would come a day that instead of in the communities, instead of you seeing Zumba and Tai Chi, you'll see Arnis being done by our community-dwelling older adults. That would be fun.

20:56 Dr. Lipardo I'm having goosebumps. Actually, that is my vision. So when I saw people doing Tai Chi in Hong Kong, that is my vision for the Philippines, that I see a group of individuals of primarily older adults doing Tai Chi. And I hope to see more people getting involved in exercise, even in old age.

21:23 Johann All right. So thank you very much again, Dr. Lipardo for coming to the podcast and talking more about your study on Arnis-based exercise programs for community-dwelling older adults. For those who are interested in reading up more about your article, it's still in the Philippine Journal of Physical Therapy. It's in volume one, issue three. So you can check that out for those who are watching this and interested in this. And you can reach out to Dr. Lipardo if you're interested in collaborating with them. And I believe that your contact information is in the journal as well, right? Yes, correct. That is correct. So yeah, for everyone who's interested in working with Dr. Lipardo there and interested in Arnis based exercise program, let's make that happen. Let's see our older adults doing community exercise with Arnis as their program. So again, thank you very much, Dr. Lipardo for being in the podcast. So for everyone watching and listening until next time, so stay curious and keep exploring the fascinating world of research with us here on Behind the Research. See you, everyone. Thank you.