Discussion
disability, osteoporosis
OSTEOPOROSIS, BEND
The main findings of the study are that an 8 week course of training in SSG produced a significant interaction between group and time for the combined set of all outcome measurements (C7WD, SH, BSL, BSR, CSRL, CSRR, TUG, BADL, and BSES) (Modified ANOVA-Type Statistic (MATS) p-value < 0.001) and for the four categories of posture, flexibility, gait, and cognition (all Wald-Type Statistic (WTS) p-values < 0.05) and in all cases the changes in the Exercise Group were in the direction predicted as being beneficial. No significant interaction effect between time and group was found after either one session or four weeks for any of the categories (all WTS p > 0.05) with significant effects only arising after eight weeks (all WTS p < 0.05). Thus although beneficial changes occurred over time the minimum period required to produce statistically significant benefit from performing SSG training was 8 weeks. For the Control Group no significant changes were identified for posture, flexibility and cognition, however a significant deterioration was observed in gait with TUG increasing significantly over 8 weeks (WTS p = 0.003).The significant reduction in C7WD and increase in SH is consistent with a reduction in forward head position of participants after eight weeks of SSG training. Forward head position increases as a result of aging, osteoporosis and disability [The results of the Back Scratch test (BSL and BSR) and Chair Sit and Reach test (CSRL and CSRR) showed that there was a significant improvement in flexibility in the Exercise Group compared to the Control Group and, as for posture, all flexibility measures exhibited gradual changes in the predicted direction during the period of training (The 8 week SSG training program also produced a significant improvement in TUG. On the fifth swing of SSG, participants are required to slightly bend their knees and dip down twice, once on the backward swing and again on the forward swing. Thus, during this element of the SSG exercise there is a coordinated movement involving both hamstrings and quadriceps which is likely to increase the ease of performing sit-to-stand and maintenance of body stability in TUG [Finally, the results of the questionnaires provided evidence of the wide ranging benefits of SSG relevant to cognition. In particular, the results of the Barthel Activities of Daily Living Index (BADL) questionnaire showed that enhancements had occurred in the ease of performing typical activities of daily living, such as washing, dressing, preparing food, in the Exercise Group compared to the Control Group. This finding is consistent with reports that other exercise, including Qi-Gong [There are two observations relating to the data that were acquired and the findings obtained in the present study that should be discussed. Firstly, there are no missing data for all 56 participants for the measurements that were recorded at baseline and after 4 and 8 weeks of SSG training. Perhaps it is surprising that the database entries are complete and that the need never arose to impute missing values. However, there are two reasons that may account for this. Firstly, the SSG classes that were offered to the Community were extremely popular and there was great enthusiasm to participate and attend all the sessions that were offered. This was probably because SSG is a gentle exercise that is comfortable to perform, is expected to have a positive effect on health and well-being, was offered within a convenient setting at a convenient time, and, not least, was performed in a group setting which reduces inhibitions, and increases engagement and enjoyment. The participants were also interested to learn at the end of the study whether the exercise was proven to be beneficial for the Community. Secondly, the outcome measures were recorded by a dedicated team of young researchers who engaged with the members of the community and always offered gentle encouragement and kind support.Secondly, for the combined set of all outcome measurements (C7WD, SH, BSL, BSR, CSRL, CSRR, TUG, BADL, and BSES) and for the four categories of posture, flexibility, gait, and cognition an 8 week course of training in SSG produced a significant interaction between group and time and in all cases the changes in the Exercise Group were in the direction predicted as being beneficial. Therefore there is perhaps some concern about the fact that in making measurements and assessments, the investigators were not blinded to whether participants were from the Exercise group or the Control group, and they also knew whether the measurement referred to Baseline, or to after 4 or 8 weeks of SSG training. This potentially creates a situation that is contrary to the principle of equipoise whereby investigators involved in both designing and carrying out clinical trials should be free of any preferences. However, complete blinding would have been very impractical in the present study and great care has been taken to avoid the potential of biases being introduced. There are several facts that suggest that the results that have been obtained are reliable. In particular, the outcome variables were objectively measured using standardised procedures involving the use of accurate measuring devices, rulers and a stop watch, the observer could not see a record of previous measurements when recording the potential change that had occurred after 4 weeks, and then between 4 weeks and 8 weeks. Furthermore, none of the outcome variables that have been studied can be described as exploratory or speculative, and it was not unexpected that improvements in posture, flexibility and gait would occur together in a person who is functioning better as a result of exercising.There are also some more general limitations to be discussed. Firstly, there is an element of subjectivity in the measurement of some of the outcome variables. For example, when recording standing height and C7WD as measures of posture it is possible, consciously or perhaps unwittingly, to encourage a participant to stand tall. Provided the chair and the distance to be covered is the same on each occasion, the situation is less subjective when a stop watch is used for TUG measurements. However, ultimately, it is desirable for a study such as the present one to be performed using entirely objective measurement systems such as a 3D motion analysis system and Electromyography. Secondly, while there is no evidence of any systematic errors [In addition to the above consideration of potential limitations of the study, the cluster based sampling scheme should also be discussed further. If the Exercise group had been recruited through contacting, for example, a Yoga Club and the Control group by contacting a Chess Club it is likely that participants from the Yoga Club may be physically more flexible at the start of the study and perhaps readily become more flexible as the training progressed so confounding an investigation of the benefits of SSG. More subtly, a similar confound could have been introduced if perhaps one of the Communities was located near to a transport route so that residents were frequently employed in office work in the city whereas the other Community was in a more remote location and residents worked locally and were engaged in farming and physical work. Hess et al. (2015) [