Tai Chi is a Chinese system of physical exercises that is believed to facilitate the flow of life force in the body, promoting good health and vitality. (1) It is originally derived from martial arts and involves slow flow of movement and shift of balance. It is usually used to improve and maintain health, the cardiovascular and immune systems, physical and mental relaxation and balance. (2) Tai Chi has its origin rooted back to the second millennium B.C., when Indians started practicing yoga. The Chinese practiced yoga as shaolin chuan in the 13th century A.D. Different families of China developed different Tai Chi styles. As a result, Tai Chi came to be associated with China and its different families.(3) There are different styles of Tai Chi and all styles are usually done in standing position, which can be performed either as a solo or two person exercise. The most common one is called Chang Chuan. Zhang San Feng inherited and developed the Tai Chi Chuan from his family, (960-1279 C.E.). Tai Chi is suitable for every one because it has low impact on the body; it is inexpensive; there is no need for special equipment; it can be done indoors or outdoors, alone or in a group; and it has no side effect. Tai chi was developed to improve different health conditions. Many studies have advocated the use of Tai chi for balance (4-9), osteoarthritis (17-20) and osteoporosis. (24-25)
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Literature Review:
Tai chi has only recently been recognized as a potentially effective exercise for fall prevention and other health outcomes among older people in Western societies, even though this traditional Chinese exercise has been practiced for centuries for health promotion and self defense in Asian countries. (10) The Tai Chi exercise usually contains the element of strengthening, balance, postural alignment, deep diaphragmatic breathing and relaxation with slow, gentle well coordinated movements. It is not only a physical activity, but also one that involves the training of mental control. People use Tai Chi for development of mind body interaction, breathing regulation with body movement, hand coordination and calmness. (11) There are different types of Tai Chi and the most popular styles include Yang Style Tai Chi Chuan, Wu Tai Chi, Chen Style Tai Chi and Sun Style Tai Chi. (12) The first style is a variation of the original techniques of Tai Chi as practiced by the early proponents and incorporates 24 basic movements in its plain form. A very wide stance with bent knees for the majority of the practice sessions makes this style very demanding both physically and spiritually. The second style, called Wu, integrates 24 movements in the simple form, but can include more, even 36 specialized movements in the short variation, which is gentle and requires a narrow, high stance with less demand on the knee positioning as compared to the Yang style. The third and most well known style is based on a series of 20 movements, involving a higher stance, though requires relatively lesser transfer of weight from one to the other leg as compared to the other two formats outlined above. The last style, Sun-style Tai Chi, is recognized by its small high postures with flowing movements forward and backward accompanied by connected circular arm movements.
Balance
Falls are the leading cause of deaths related to injury among people 65 years and older in the United States. More than one-third will fall each year; two-thirds of those who fall will fall again within 6 months. Although falling is not normal, older people are more likely to fall because of sensory changes, bones that are less dense, slower reflexes, and reduced strength. These changes affect walking and balance. (13) These are the intrinsic factors of falling. On the other hand, environmental factors can also increase the probability of falls, including poor condition of sidewalks and steps, wet or icy walking surfaces, loose carpets and inadequate lighting. Some of the identified risk factors such as imbalance, muscular weakness and lack of flexibility can be changed to reduce the incidence of falling by practicing Tai Chi. (4-9)
In Portland, a study was conducted on 256 healthy, physically inactive older adults age 70-92 to determine whether improved functional balance through a Tai Chi intervention is related to subsequent reductions in falls among elderly persons. Participants, 77 males and 179 females, were randomly assigned to receive either Tai Chi or an exercise stretching control program. Both groups participated in a 60 minute exercise session conducted three times per week for six consecutive months. The Tai Chi group received 24 forms of Yang style, which emphasizes multidirectional weight shifting, awareness of body alignment, and multi-segmental arms, legs and trunk movement coordination. Breathing was also emphasized and integrated into the Tai Chi movement routine. Sessions included 5-10 min of warm-up, 30 min of Tai Chi practice, and 5-10 min of cool-down. As for the stretching control group, they received stretching exercises for the trunk and upper body, accompanied by deep abdominal breathing, and relaxation. After the treatment session, three balance related measures were used (1) Berg balance scale, (2) dynamic gait index and (3) functional reach test. Falls were assessed using fall counts recorded by each participant. The result showed that Tai Chi participants who showed improvements in measures of functional balance at the intervention endpoint significantly reduced their risk of falls during the 6-month post intervention period, compared with those in the control group.(4)
In the Atlanta Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) site, 200 healthy, older adults 70 years old and above were randomized to Tai Chi, individualized balance training and exercise control education groups for 15 weeks intervention and returning for a 4-month follow-up evaluation. This study included two exercise interventions: Tai Chi Quan, which included ten modified forms and computerized center of mass feedback for balance training, which involved placing subjects individually on a platform in which multiple force transducers were embedded. An education group was included as an exercise control condition, where the individual in the control group met weekly to discuss topics of interest like poly pharmacy, diet, sleep patterns, and other topics. These individuals were asked not to alter their existing exercise routines during the study. The result confirmed that both the Tai Chi group and the Balance Training group reported increased confidence in balance and movement, but only the Tai Chi group reported that their daily activities and their overall life had been affected; many of these subjects had changed their normal physical activity to incorporate ongoing Tai Chi practice.(5)
Another study was designed to examine the effect of a community-based Tai Chi program on injurious falls, balance, gait, and fear of falling among people aged 65 years and older in Taiwan. A total of 1200 subjects from six rural villages in Taichung County were distributed into two groups. 472 participants from two villages were provided with Tai Chi exercise, which included 13 movements of Chen style. The group did a one hour exercise per day, six days per week. Each one hour session consisted of ten minute warm up, 45 minute of Tai Chi practice and five minute cool down. The control group with 728 participants from four villages received educational program about falling prevention. They were provided by pamphlets with simple words, large letters, and attractive pictures for three types of exercises for the lower limb; stretching, strengthening and Tai Chi, and how to reduce environmental risk factors. After treatment that lasted for one year, participants were asked about the number of falls, which was defined as an event that resulted in an individual coming to rest unintentionally on the ground or other lower level, not as a result of a major intrinsic event like stroke. The balance, gait, and fear of falling were assessed at two follow up assessment. The balance component was consisted of 13 maneuvers; sitting balance, sit to stand, immediate standing balance (in the first 3-5 seconds), standing balance, balance with eyes closed, turning 360 degrees, nudging the sternum (slightly pushing the chest), turning the neck, unilateral stance, extending the back, putting down and picking up an object, and sitting down. As for the gait component, it was consisted of nine maneuvers; initiation of gait, step height and length, step symmetry and continuity, path deviation, trunk stability, walking stance, and turning while walking. Fear of falling was assessed by using a 10 centimeter visual analog scale. The ends of the scale were marked with the labels “No fear” and “Extremely fearful.” Each participant was asked to place a mark on the line at a point representing the extent of his or her fear. The result showed that the injurious falls among the Tai Chi’s villagers declined by 75% while in the control villager the decline was 44%. It also showed that the balance improvement in the Tai Chi group was greater than the control group, but there was no significant change in the fear of falling among both groups. (6)
In Korea there was a study; which included 59 fall prone older adults, done to determine changes in the physical fitness, fall avoidance efficacy and fall episodes of institutionalized older adults after practicing in 12 weeks Sun style Tai Chi exercise program. The participants were 60 years old or above and had at least one of the following fall-related risk factors: (1) impaired gait (2) impaired balance (3) history of falling in the previous year (4) postural hypotension and (5) use of four or more prescription medications that may affect balance. The 59 participants were divided into two groups. The first group was Tai Chi group, which included 29 participants and received 12 form of Sun-style Tai Chi exercise. The Tai Chi exercise program consisted of 10 minutes of warming-up exercise, 20 minutes of 12 Tai Chi movements and 5 minutes of cooling-down exercise. On the other hand the control group consisted of 30 participants and they maintained their routine activities without participating in any regular exercise classes. The muscle strength, balance, flexibility, mobility, fall episode and fall efficacy were measured before and after treatment. The muscle strength of the knee and the ankle muscle was measured using a manual muscle tester. Balance was assessed by how long in seconds the person could stand on one foot either with eyes closed or eyes opened. Flexibility was measured by asking the participants to bend forward and stretch both hands toward the feet without bending the knees to measure the distance in centimeters between the hands and the feet. Mobility was measured by the time taken in second to walk six meters on a marked floor. As for fall episode participants were asked to report any fall episode during the year whereas, fall avoidance efficacy was assessed by using a scale based on the perceived confidence that the person would be able to avoid falling. The findings revealed that the Tai Chi exercise program can safely improve physical strength, balance, flexibility, mobility and reduce fall risk for fall-prone older adults in residential care facilities.(7)
Another study was conducted on 702 relatively healthy community-dwelling people; aged 60 and older, to determine the effectiveness of a 16-week community-based Tai Chi program in reducing their falls and improving their balance. Participants were divided into two groups: 353 participants in Tai chi group; which was also divided into different classes, and 349 participants in control group. The majority of the Tai Chi classes took Sun-style Tai Chi (83%), two classes involved Yang-style tai chi (3%), and the remainder involved a mixture of several styles (14%). Control participants were instructed not to do any Tai Chi elsewhere during the 24 week study period. Falls during 16 and 24 weeks of follow-up were assessed using a calendar method. On the other hand, balance was measured by using six balance tests. The results indicated that the falls were less frequent in the Tai Chi group than the control group and there were statistically significant differences in changes in balance favoring the Tai Chi group on five of six balance tests.(8)
In 2007, a study done to examined the effect of Tai Chi training on biomechanical responses to large, fast walking perturbations in balance-impaired seniors. 22 seniors with surgical interventions to knees, hips, and back were randomly divided into control or Tai Chi groups. All groups received training for one and half hour per day, five days per week for three weeks. Control training included balance education, awareness education, axial mobility exercises and stretching. The Tai Chi training included twelve Yang style postures. Subjects walked across a force plate triggered to move forward 15 centimeter at 40 centimeter per second at right heel strike (RHS). Kinematics, center of pressure (COP) and center of mass (COM) responses were measured. As a result, Tai Chi but not control training significantly reduced tripping, medial cross-step distance, and increased use of swing leg heel strike. COM anterior-posterior path significantly increased after the Tai Chi training. It is also enhanced balance responses by more efficacious use of mechanisms controlling stepping strategies of the swing leg. (9)
Osteoarthritis
Almost 21 million people in the United States are afflicted by osteoarthritis and it accounts for nearly 25% of all visits to primary care physicians. (14) Osteoarthritis is common type of arthritis affecting cartilage, which is the tissue that cushions the ends of bone within the joint. In osteoarthritis, the cartilage begins to fray and may entirely wear away. It can cause joint pain and stiffness. Disability result most often when the disease affects the spin and the weight bearing joint. (15) Unfortunately there is no cure for osteoarthritis; however treatments include diet, surgery, pharmacotherapy and exercises which help to slow the progression of the disease, ease pain and increase patient function. (16) Some studies prove that Tai chi is effective in improving the physical function and pain management in osteoarthritis patient. (17-20)
A randomized controlled trial was conducted; among 152 older persons with chronic symptomatic hip or knee osteoarthritis, aimed to determine whether Tai Chi or hydrotherapy classes can result in measurable clinical benefits for the participants. Participants were randomly allocated for 12 weeks to hydrotherapy classes and Tai Chi classes or a control group for one hour twice a week. Hydrotherapy group consist of 55 participants and received exercises in water with physiotherapist. On the other hand the Tai Chi group consists of 56 participants and received modified 24 forms of Sun style of Tai Chi and included a preliminary 10-minute warm-up session. The outcomes were assessed 12 and 24 weeks after randomization and included pain and physical function, general health status, psychological well-being, and physical performance by using up and go test, 50-foot walk time and timed stair climb. Both participants in hydrotherapy group and Tai Chi group achieved significant improvement in pain reduction, physical function and performance especially in the timed stair climbs, general health status and psychological well-being compared with the control group. (17)
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The University of Arkansas for Medical Sciences conducted a pilot study on seven elders with age 60 years and above with knee osteoarthritis. The study aimed to investigate the effect of 12-forms Sun-style Tai Chi on osteoarthritic knee pain and it was hypothesized that by attending more minutes or session or performing Tai Chi with higher of accuracy, elders would have less pain after the Tai Chi intervention. The design of this study was a one-arm design without a control group as a result the participants were blinding. The Tai Chi program included a warm up, Tai Chi, and cool down period for total of 20 minute per session. The instructor gradually increased the time that participants practiced from 20 to 40 minutes as participants gained physical strength and familiarity and they also added one new form of the Tai Chi in each following session. The Medical Outcomes Study short form (SF-36) includes 8 subscales: physical function, role-physical, bodily pain, general health, vitality, social functioning, role emotional and mental health. The results showed no significant differences in knee pain after the Tai Chi intervention in seven elders. However, more minutes of Tai Chi attendance related to improved pain scores and greater accuracy in Tai Chi performance was also correlated with improvements in pain scores. Three of four elders who participated in the Tai Chi practice regularly and more than 20 sessions showed clinically important improvements while other three elders who participated in no sessions or only a few sessions showed no improvement. (18)
Additional study was design to evaluate the effects of the Tai Chi exercise for Arthritis (TCEA) program on the physical status and quality of life of osteoarthritis elders. This study was longitudinal time series study with one group design. The participants were diagnosed with osteoarthritis of the lower extremities, aged 60 years or over and were recruited from an outpatient clinic at a community teaching hospital. Thirteen participants joined the TCEA exercise class three times per week for two years. The TCEA program included warm up, 12 forms of TCEA and cool down sections. The sequence of every class was (a) warm-up stretching exercise for five minutes, (b) 12 forms TCA eight set (c) stretching exercise for five minutes, (d) 12 forms TCA eight sets, and (e) cool-down stretching exercise or activity for five minutes. Each class lasted approximately 50 minutes. Physical status including body mass index (BMI), lean body mass, hand grasp strength, flexibility, and equilibrium were measured four times-at baseline, three months, one year, and two years of the TCEA exercise class. Quality of life was also measured at these time points. Participants experienced significant improvements in physical functioning, role limitations, and social functioning on the dimensions of quality of life. (19)
In 2009, a recent study included 40 individuals with symptomatic tibiofemoral osteoarthritis that done to evaluate the effectiveness of Tai Chi in the treatment of knee osteoarthritis symptoms. Patients were randomly assigned to 60 minutes of Tai Chi and received ten modified forms from classic Yang style or assigned as control group who received wellness education and stretching twice a week. Tai Chi sessions contained of ten minutes self-massage and a review of Tai Chi principles, 30 minutes of Tai Chi movement, ten minutes of breathing technique, and ten minutes of relaxation. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at 12 weeks. The WOMAC is a validated, self-administered instrument specifically designed to evaluate knee and hip osteoarthritis. It has three subscales included pain, stiffness and function. The secondary outcomes included visual analog scale, timed chair stand, 6-minute walk test and standing balance. Additional measures included the Center for Epidemiologic Studies Depression Scale, outcome expectations for exercise, self-efficacy, and the physical component summary and mental component summary of the Short Form 36 to assess quality of life. The result of Tai Chi group compared with the control group exhibited significantly greater improvement in WOMAC pain, physical function, patient global visual analog scale, chair stand time, Center for Epidemiologic Studies Depression Scale, self-efficacy score and Short Form 36 physical component summary. (20)
Osteoporosis
A disease, occurring especially in women following menopause, in which the bones become extremely porous and are subject to fracture. (21) In general, women lose about 1% of their bone density per year during and after menopause. However, nearly 35% of women lose bone at a faster rate during the late perimenopausal period. (22) Osteoporosis can be present without any symptoms for decades because osteoporosis doesn’t cause symptoms until bone fractures. Treatments of osteoporosis include healthy diet which contain calcium and vitamin D to absorb calcium properly, medication and active lifestyle to improve balance, coordination and develop muscle strength. All these can reduce the risk of falling and fracturing a bone. Beneficial exercise includes weight bearing exercises, swimming, and walking. (23) Tai Chi can be useful for osteoporosis management especially for postmenopausal women because it include low-weight-bearing exercise. (24-25)
A case-control study done in the University Medical School in Hong Kong designed to evaluate the potential benefits of regular Tai Chi Chuan exercise on the weight-bearing bones of postmenopausal women. 34 postmenopausal women age range from 50 to 59 years who had stopped menstruating for one to nine years, were randomly distributed into two groups: 17 participants in the Tai Chi Chuan exercises group and 17 participants in the non-exercising control group. The main outcome measure was bone mineral density (BMD) in the lumbar spine and proximal. Baseline results showed that the Tai Chi group had significantly higher BMD than the control group in the lumbar spine, proximal femur and it also showed that regular Tai Chi Chuan exercise may help retard bone loss in the weight-bearing bones of postmenopausal women. (24)
Another study done to evaluate the potential benefits of programmed Tai Chi Chun exercise on the weight-bearing bones of early postmenopausal women. The study included 132 healthy postmenopausal women with mean age 54.5 years who ceased menstruation between one to ten years. 67 of participants were randomized into the Tai Chi Chun exercise group and others in the sedentary control group. Subjects in the Tai Chi group participated in a supervised Yang style for 50 minutes a day, five times a week, over 12 months, whereas control subjects retained their sedentary lifestyle without participation in physical exercises. BMD was measured in the lumbar spine and proximal femur by using dual-energy x-ray absorptiometry and in the distal tibia by using multislice peripheral quantitative computed tomography (pQCT). All BMD measurements were repeated after 12 months in both groups. Fracture rate was also documented. BMD measurements revealed a general bone loss in both Tai Chi and sedentary control subjects at all measured skeletal sites, but with a reportedly slower rate in the Tai Chi group. A significant retardation of bone loss was found in both trabecular and cortical compartments of the distal tibia in the Tai Chi group as compared with the controls, as measured by pQCT. A total of four fracture cases were documented during follow-up, including three subjects in the control group and one in the TCC group. (25)
Conclusion:
In conclusion, Tai Chi is an effective exercise program that improves physical strength flexibility, mobility and balance which lead to reduce falling among elderly people. It is also effective in improving physical function and performance, pain management, general health status and psychological well-being in knee or hip osteoarthritis patients. The impacts of the Tai Chi on BMD are limited by the quantity of research to date. However some of these researches showed that regular Tai Chi Chuan exercise may help retard bone loss in the weight-bearing bones of postmenopausal women and decrease fractures. Based on that, Tai Chi exercises should be included in physical therapy treatment especially for elderly people with high risk of falling, hip and knee osteoarthritis, and for postmenopausal women with osteoporosis.
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