Challenges inherent to t'ai chi research: part II-defining the intervention and optimal study design

Evaluating Exercise Prescription and Instructional Methods Used in Tai Chi Studies Aimed at Improving Balance in Older Adults: A Systematic Review

OBJECTIVES

To develop an evaluation instrument to determine to what extent Tai Chi interventions aimed at improving the balance of older adults disclosed their exercise prescription (Ex R_x ) and instructional methods and met best-practice exercise recommendations for balance improvement.

DESIGN

Review.

SETTING

PubMed, Scopus, and CINAHL databases were searched from their inception until August 22, 2014.

PARTICIPANTS

Adults aged 60 and older without debilitating disease.

MEASUREMENTS

Three electronic databases were searched to identify randomized controlled trials (RCTs) of Tai Chi interventions aimed at improving balance in older adults without severe debilitating diseases. Three Ex R_x (frequency, time, intervention length) and 10 instructional (e.g., style, number of forms) methods of the included RCTs were evaluated.

RESULTS

Twenty-seven interventions were identified from 26 RCTs. On average, Tai Chi was performed for a mean 56.5 ± 14.4 minutes per session for 2.8 ± 1.4 sessions per week for 19.7 ± 12.7 weeks. Most interventions reported all three Ex R_x methods items, with a mean reporting rate of 92.6 ± 19.2%. For the 10 instructional methods items, the mean reporting rate was 41.1 ± 18.0%, significantly lower than for the Ex R_x methods items (P < .001). Fewer than half of the interventions reported unsupervised practice (15%), progression (22%), or the use of breathing (30%) and relaxation (15%) techniques. The instructional methods items most important for targeting Tai Chi practice to improve balance were not routinely disclosed, with only 15% reporting names of forms and 52% reporting movement principles.

CONCLUSION

Most Tai Chi interventions disclosed their Ex R_x methods yet routinely failed to report instructional methods. To increase the effectiveness of Tai Chi to improve balance in older adults, future RCTs should disclose their Ex R_x and instructional methods, especially methods that target balance.

Cognitive Benefits of Social Dancing and Walking in Old Age: The Dancing Mind Randomized Controlled Trial

Background

A physically active lifestyle has the potential to prevent cognitive decline and dementia, yet the optimal type of physical activity/exercise remains unclear. Dance is of special interest as it complex sensorimotor rhythmic activity with additional cognitive, social, and affective dimensions.

Objectives

To determine whether dance benefits executive function more than walking, an activity that is simple and functional.

Methods

Two-arm randomized controlled trial among community-dwelling older adults. The intervention group received 1 h of ballroom dancing twice weekly over 8 months (~69 sessions) in local community dance studios. The control group received a combination of a home walking program with a pedometer and optional biweekly group-based walking in local community park to facilitate socialization.

Main outcomes

Executive function tests: processing speed and task shift by the Trail Making Tests, response inhibition by the Stroop Color-Word Test, working memory by the Digit Span Backwards test, immediate and delayed verbal recall by the Rey Auditory Verbal Learning Test, and visuospatial recall by the Brief Visuospatial Memory Test (BVST).

Results

One hundred and fifteen adults (mean 69.5 years, SD 6.4) completed baseline and delayed baseline (3 weeks apart) before being randomized to either dance (n = 60) or walking (n = 55). Of those randomized, 79 (68%) completed the follow-up measurements (32 weeks from baseline). In the dance group only, “non-completers” had significantly lower baseline scores on all executive function tests than those who completed the full program. Intention-to-treat analyses showed no group effect. In a random effects model including participants who completed all measurements, adjusted for baseline score and covariates (age, education, estimated verbal intelligence, and community), a between-group effect in favor of dance was noted only for BVST total learning (Cohen’s D Effect size 0.29, p = 0.07) and delayed recall (Cohen’s D Effect size = 0.34, p = 0.06).

Conclusion

The superior potential of dance over walking on executive functions of cognitively healthy and active older adults was not supported. Dance improved one of the cognitive domains (spatial memory) important for learning dance. Controlled trials targeting inactive older adults and of a higher dose may produce stronger effects, particularly for novice dancers.

Trial registration

Australian and New Zealand Clinical Trials Register (ACTRN12613000782730).

Connecting East and West by a developmental theory for older adults: Application of Baltes' Selection, Optimization, and Compensation model

Age-related changes in cognitive and physical function can affect safe driving performance. As the population of older adults increases in the United States there will be a simultaneous rise in the number of older adult drivers. Tai Chi, a non-traditional form of exercise with both physical and cognitive benefits may enhance driving performance. A lifespan developmental theory (Baltes' Selective Optimization with Compensation model) is used to study the relationship between Tai Chi exercise and driving performance in older adults. Application of this theory was pivotal in building a bridge between a non-traditional practice and Western-based research to study an intervention that can be used to promote and sustain well-being in older adults.

Effects of tai chi chuan on anxiety and sleep quality in young adults: lessons from a randomized controlled feasibility study

OBJECTIVE

To determine feasibility and estimate the effect of a 10-week tai chi chuan (TCC) intervention on anxiety and sleep quality in young adults.

PARTICIPANTS

Seventy-five adults (18-40 years) from a predominately undergraduate midsized university.

METHODS

This was an assessor blinded, randomized feasibility trial, and participants were randomized into one of three groups: 10 weeks of TCC meeting 2 times per week, 10 weeks of TCC with a DVD of the curriculum, and control group receiving a handout on anxiety management. Anxiety and sleep quality were assessed 4 times: baseline, 4 weeks, 10 weeks (immediate post-intervention), and 2 months post-intervention. Retention was defined as a participant attending the baseline assessment and at least one other assessment. Adherence to the intervention was set a priori as attendance at 80% of the TCC classes.

RESULTS

Eighty-five percent of participants were retained during the intervention and 70% completed the 2 month follow-up assessments. To increase statistical power, the two TCC groups were combined in the analyses of anxiety and sleep quality measures. No significant changes in anxiety were found in the control group, while levels of anxiety decreased significantly over time in the two TCC groups. Sleep quality scores improved across time for all three groups, but adherent TCC participants reported greater improvement than control participants.

CONCLUSION

TCC may be an effective nonpharmaceutical means of improving anxiety and poor sleep quality in young adults.

Mindful movement and skilled attention

Bodily movement has long been employed as a foundation for cultivating mental skills such as attention, self-control or mindfulness, with recent studies documenting the positive impacts of mindful movement training, such as yoga and tai chi. A parallel “mind-body connection” has also been observed in many developmental disorders. We elaborate a spectrum of mindfulness by considering ADHD, in which deficient motor control correlates with impaired (disinhibited) behavioral control contributing to defining features of excessive distractibility and impulsivity. These data provide evidence for an important axis of variation for wellbeing, in which skillful cognitive control covaries with a capacity for skillful movement. We review empirical and theoretical literature on attention, cognitive control, mind wandering, mindfulness and skill learning, endorsing a model of skilled attention in which motor plans, attention, and executive goals are seen as mutually co-defining aspects of skilled behavior that are linked by reciprocal inhibitory and excitatory connections. Thus, any movement training should engage “higher-order” inhibition and selection and develop a repertoire of rehearsed procedures that coordinate goals, attention and motor plans. However, we propose that mindful movement practice may improve the functional quality of rehearsed procedures, cultivating a transferrable skill of attention. We adopt Langer’s spectrum of mindful learning that spans from “mindlessness” to engagement with the details of the present task and contrast this with the mental attitudes cultivated in standard mindfulness meditation. We particularly follow Feldenkrais’ suggestion that mindful learning of skills for organizing the body in movement might transfer to other forms of mental activity. The results of mindful movement training should be observed in multiple complementary measures, and may have tremendous potential benefit for individuals with ADHD and other populations.

Use of pragmatic community-based interventions to enhance recruitment and adherence in a randomized trial of Tai Chi for women with osteopenia: insights from a qualitative substudy

OBJECTIVE

This study aims to qualitatively evaluate the feasibility of using a pragmatic network of community-based Tai Chi schools to deliver 9-month exercise interventions to women with osteopenia and to explore the impact of this design feature on facilitators and barriers to trial recruitment and participant adherence during and after the trial.

METHODS

In a randomized trial comparing 9 months of Tai Chi plus usual care with usual care alone for postmenopausal women with moderately low bone mass, exit interviews were conducted with 43 participants randomized to the pragmatically delivered Tai Chi intervention. Transcripts were digitially recorded, transcribed, and imported into NVivo, a computer-assisted qualitative data analysis software. Qualitative content analysis was used to code the data. Patterns emerging from among the codes were further examined and clustered into themes.

RESULTS

Analyses revealed features of pragmatically delivered Tai Chi programs that both facilitated and impeded study participation and/or posttrial adherence. Direct facilitators included convenience of class locations and times, alternative learning modalities, quality of teaching, community and social support, and perceived health benefits. Barriers consisted primarily of time-related issues. A possible causal mechanism (self-efficacy) was also identified.

CONCLUSIONS

Factors related to the use of pragmatically delivered interventions are beneficial for fostering both study participation and posttrial adherence to the Tai Chi programs. This qualitative substudy is valuable for identifying these factors and a possible causal mechanism. These findings will assist in the design and conduct of future studies exploring the use of Tai Chi in fracture prevention and health-related quality of life in postmenopausal women.

Complexity-Based Measures Inform Effects of Tai Chi Training on Standing Postural Control: Cross-Sectional and Randomized Trial Studies

Background

Diminished control of standing balance, traditionally indicated by greater postural sway magnitude and speed, is associated with falls in older adults. Tai Chi (TC) is a multisystem intervention that reduces fall risk, yet its impact on sway measures vary considerably. We hypothesized that TC improves the integrated function of multiple control systems influencing balance, quantifiable by the multi-scale “complexity” of postural sway fluctuations.

Objectives

To evaluate both traditional and complexity-based measures of sway to characterize the short- and potential long-term effects of TC training on postural control and the relationships between sway measures and physical function in healthy older adults.

Methods

A cross-sectional comparison of standing postural sway in healthy TC-naïve and TC-expert (24.5±12 yrs experience) adults. TC-naïve participants then completed a 6-month, two-arm, wait-list randomized clinical trial of TC training. Postural sway was assessed before and after the training during standing on a force-plate with eyes-open (EO) and eyes-closed (EC). Anterior-posterior (AP) and medio-lateral (ML) sway speed, magnitude, and complexity (quantified by multiscale entropy) were calculated. Single-legged standing time and Timed-Up–and-Go tests characterized physical function.

Results

At baseline, compared to TC-naïve adults (n = 60, age 64.5±7.5 yrs), TC-experts (n = 27, age 62.8±7.5 yrs) exhibited greater complexity of sway in the AP EC (P = 0.023), ML EO (P<0.001), and ML EC (P<0.001) conditions. Traditional measures of sway speed and magnitude were not significantly lower among TC-experts. Intention-to-treat analyses indicated no significant effects of short-term TC training; however, increases in AP EC and ML EC complexity amongst those randomized to TC were positively correlated with practice hours (P = 0.044, P = 0.018). Long- and short-term TC training were positively associated with physical function.

Conclusion

Multiscale entropy offers a complementary approach to traditional COP measures for characterizing sway during quiet standing, and may be more sensitive to the effects of TC in healthy adults.

Trial Registration

ClinicalTrials.gov NCT01340365

Qigong and fibromyalgia: randomized controlled trials and beyond

Introduction. Qigong is currently considered as meditative movement, mindful exercise, or complementary exercise and is being explored for relief of symptoms in fibromyalgia. Aim. This narrative review summarizes randomized controlled trials, as well as additional studies, of qigong published to the end of 2013 and discusses relevant methodological issues. Results. Controlled trials indicate regular qigong practice (daily, 6–8 weeks) produces improvements in core domains for fibromyalgia (pain, sleep, impact, and physical and mental function) that are maintained at 4–6 months compared to wait-list subjects or baselines. Comparisons with active controls show little difference, but compared to baseline there are significant and comparable effects in both groups. Open-label studies provide information that supports benefit but remain exploratory. An extension trial and case studies involving extended practice (daily, 6–12 months) indicate marked benefits but are limited by the number of participants. Benefit appears to be related to amount of practice. Conclusions. There is considerable potential for qigong to be a useful complementary practice for the management of fibromyalgia. However, there are unique methodological challenges, and exploration of its clinical potential will need to focus on pragmatic issues and consider a spectrum of trial designs. Mechanistic considerations need to consider both system-wide and more specific effects.

The effects of tai chi on depression, anxiety, and psychological well-being: a systematic review and meta-analysis

BACKGROUND

Tai chi, also called taiji or tai chi chuan, is a form of mind-body exercise that originated from China. It combines Chinese martial arts and meditative movements that promote balance and healing of the mind and body, involving a series of slowly performed, dance-like postures that flow into one another. As it comprises mental concentration, physical balance, muscle relaxation, and relaxed breathing, tai chi shows great potential for becoming widely integrated into the prevention and rehabilitation of a number of medical and psychological conditions.

PURPOSE

A growing body of clinical research has begun to evaluate the efficacy of tai chi as a therapy for a variety of health issues. A systematic review and meta-analysis were carried out on randomized controlled trials (RCTs) and quasi-experimental (Q-E) trials that studied the effects of tai chi on psychological well-being.

METHOD

Drawn from English and Chinese databases, 37 RCTs and 5 Q-E studies published up to May 31, 2013 were included in the systematic review. The methodological quality of the RCTs was evaluated based on the following criteria: adequate sequence generation, allocation concealment, blinding, completeness of outcome data, selective reporting, and other potential biases. Statistical analyses were performed using Review Manager version 5.0.

RESULTS

The studies in this review demonstrated that tai chi interventions have beneficial effects for various populations on a range of psychological well-being measures, including depression, anxiety, general stress management, and exercise self-efficacy. Meta-analysis was performed on three RCTs that used depression as an outcome measure (ES=-5.97; 95% CI -7.06 to -4.87), with I2=0%.

CONCLUSION

In spite of the positive outcomes, the studies to date generally had significant methodological limitations. More RCTs with rigorous research design are needed to establish the efficacy of tai chi in improving psychological well-being and its potential to be used in interventions for populations with various clinical conditions.

Functional benefits of tai chi training in senior housing facilities

OBJECTIVES

To determine the effects of tai chi training on functional performance and walking with and without the addition of the performance of a cognitive task, in older adults living in supportive housing facilities.

DESIGN

Secondary data analysis comparing a single-blind, randomized controlled trial of tai chi training with an attention-matched educational control intervention with crossover to tai chi.

SETTING

Two supportive housing facilities.

PARTICIPANTS

Sixty-six men and women living in supportive housing facilities entered the study, and 57 aged 87±7 completed all study procedures.

INTERVENTION

Interventions consisted of two 1-hour-long instructor-led group sessions per week for 12 weeks. Tai chi training consisted of movements based upon the Yang-style short form. Educational sessions consisted of lectures and discussions of age-related health topics.

MEASUREMENTS

Subjects were tested for physical function (Short Physical Performance Battery, SPPB), balance (Berg Balance Scale, BBS), mobility (timed up-and-go, TUG), and walking speed under normal and cognitive dual-task conditions.

RESULTS

The tai chi group exhibited greater improvement in SPPB scores (baseline 8.1±2.9, follow-up 9.0±2.6) than controls (baseline 8.2±2.6, follow-up 8.2±2.6) (P=.005). Tai chi also increased normal and dual-task walking speed (P<.001) yet did not affect BBS (P=.02) or TUG (P=.02) after accounting for multiple comparisons. The dual-task cost (percentage change) to walking speed was unaffected. After the crossover tai chi intervention, the control group improved performance in the SPPB, BBS, and TUG, and increased walking speed under normal and dual-task conditions (P=.008).

CONCLUSION

Tai chi training may be a safe and effective therapy to help improve physical function and dual-task walking in very old adults living in supportive housing facilities.

Mindfulness-based interventions in multiple sclerosis: beneficial effects of Tai Chi on balance, coordination, fatigue and depression

Background

Patients suffering from Multiple Sclerosis (MS) experience a wide array of symptoms, including balance problems, mobility impairment, fatigue and depression. Physical exercise has recently been acknowledged as a treatment option complementary to medication. However, information regarding putative effects of structured exercise programs on neurological symptoms is sparse. Tai Chi, a Chinese martial art incorporating physical exercise and mindfulness training, has been shown to yield health benefits in various neurological groups. It seems particularly suitable for patients with motoric deficits as it challenges coordination and balance. The purpose of the current study was to explore the therapeutic value of structured Tai Chi training for coordination, balance, fatigue and depression in mildly disabled MS patients.

Methods

A sample of 32 MS patients (Expanded Disability Status Scale, EDSS < 5) was examined. A structured Tai Chi course was devised and a Tai Chi group participated in two weekly sessions of 90 minutes duration for six months, while a comparison group received treatment as usual (TAU). Both groups were examined prior to and following the six-months interval with regards to balance and coordination performance as well as measures of fatigue, depression and life satisfaction.

Results

Following the intervention, the Tai Chi group showed significant, consistent improvements in balance, coordination, and depression, relative to the TAU group (range of effect-sizes: partial η² = 0.16 – 0.20). Additionally, life satisfaction improved (partial η² = 0.31). Fatigue deteriorated in the comparison group, whereas it remained relatively stable in the Tai Chi group (partial η² = 0.24).

Conclusions

The consistent pattern of results confirms that Tai Chi holds therapeutic potential for MS patients. Further research is needed to determine underlying working mechanisms, and to verify the results in a larger sample and different MS subgroups.

Biomechanical considerations of foot-ground contact in T'ai Chi Chuan

Although numerous studies have linked t'ai chi chuan (TCC) practice with benefits for balance, reduction in the number of falls, and in the fear of falling, most of them did not address the causes of these benefits in depth. Some studies, however, sought to determine the causes from the biomechanical point of view. This article aims to thoroughly describe and critically review recent papers on foot-ground contact in TCC practice, one of the parameters involved in balance biomechanics in TCC performance. No previous review on this subject has been found. Nine electronic databases were searched for publications between 1996 and 2013. Studies were excluded if they were not published in English or were abstracts, posters, or summaries from conferences. From a total of 195 articles identified, 4 randomized controlled trials and 3 non-randomized controlled trials were eligible for the analysis. The number of studies that assessed foot-ground contact in TCC and effects on normal gait, postural control improvement, and fall prevention is still quite small. These studies were based on intervention protocols and used populations that were too heterogeneous to allow reliable comparisons. According to the studies analyzed, TCC practice clearly improved parameters associated with foot-ground contact. Nevertheless, the manner in which these benefits are transferred to daily displacement habits still remains unclear.

Qualitative analysis of a controlled trial of qigong for fibromyalgia: advancing understanding of an emerging health practice

OBJECTIVES

A randomized controlled trial (RCT) and an extension trial of qigong (Chaoyi Fanhuan qigong [CFQ]) in patients with fibromyalgia were recently completed. In the present study, a qualitative analysis of comments from the RCT was undertaken using motivation and amount of practice to determine whether initial experiences provided information relevant to outcomes.

INTERVENTION

Participants in the RCT received instruction in qigong (level 1 CFQ), practiced 45 min/day for 8 weeks and continued practice to 6 months; open-ended qualitative comments on experiences were invited at 8 weeks and 4 and 6 months. Extension trial participants received further instruction (level 2 CFQ) and practiced regularly for 8 weeks-6 months. Comments from the original RCT were considered as narratives for the extension trial subgroup (n=20) and thematically, according to amount of practice, for all participants who completed the RCT (n=73).

RESULTS

Narrative comments from the RCT for those who completed the extension trial (n=13) and those who withdrew from that trial (n=7) were considered separately. Participants reporting benefits within the first 8 weeks were more likely to maintain practice and report continued benefits at 4-6 months than those who withdrew from the trial. Thematic comments for all who completed the RCT (n=73) were considered in relation to amount of practice (per protocol, intermediate, minimal). Participants who practiced per protocol during the initial 8 weeks (≥5 hours/wk) were more likely to maintain practice over 4-6 months and to report beneficial health effects from qigong.

CONCLUSIONS

This retrospective qualitative analysis of information collected in an RCT of qigong for fibromyalgia indicates that favorable initial experiences with the practice over 8 weeks predispose to continued practice and more health effects. Future individual trials and meta-analyses of qigong will need to attend to the amount, and potentially quality, of practice undertaken in considering trial outcomes.

Efficacy and safety of Tai Chi for Parkinson's disease: a systematic review and meta-analysis of randomized controlled trials

Background and Objective

In Parkinson's disease (PD), wearing off and side effects of long-term medication and complications pose challenges for neurologists. Although Tai Chi is beneficial for many illnesses, its efficacy for PD remains uncertain. The purpose of this review was to evaluate the efficacy and safety of Tai Chi for PD.

Methods

Randomized controlled trials (RCTs) of Tai Chi for PD were electronically searched by the end of December 2013 and identified by two independent reviewers. The tool from the Cochrane Handbook 5.1 was used to assess the risk of bias. A standard meta-analysis was performed using RevMan 5.2 software.

Results

Ten trials with PD of mild-to-moderate severity were included in the review, and nine trials (n = 409) were included in the meta-analysis. The risk of bias was generally high in the blinding of participants and personnel. Improvements in the Unified Parkinson's Disease Rating Scale Part III (mean difference (MD) −4.34, 95% confidence interval (CI) −6.67–−2.01), Berg Balance Scale (MD: 4.25, 95% CI: 2.83–5.66), functional reach test (MD: 3.89, 95% CI: 1.73–6.04), Timed Up and Go test (MD: −0.75, 95% CI: −1.30–−0.21), stride length (standardized MD: 0.56, 95% CI: 0.03–1.09), health-related quality of life (standardized MD: −1.10, 95% CI: −1.81–−0.39) and reduction of falls were greater after interventions with Tai Chi plus medication. Satisfaction and safety were high. Intervention with Tai Chi alone was more effective for only a few balance and mobility outcomes.

Conclusions

Tai Chi performed with medication resulted in promising gains in mobility and balance, and it was safe and popular among PD patients at an early stage of the disease. This provides a new evidence for PD management. More RCTs with larger sample size that carefully address blinding and prudently select outcomes are needed. PROSPERO registration number CRD42013004989.

Exercise mode heterogeneity among reported studies of the qigong practice Baduanjin

There has not been a uniform method for the practice of Baduanjin, and most published research reports involving this set of traditional Chinese exercise have provided incomplete descriptions of the movements used for those studies. This paper reviews elements of past research methodologies of Baduanjin intervention studies and provides considerations for future research. Ambiguities and inconsistencies in the descriptions of the movements, along with some implications which arise from this are discussed.

Rating of Perceived Exertion and Affective Responses during Tai Chi Chuan

Ratings of perceived exertion (RPE) and affective responses were assessed during Tai Chi Chuan. A total of 16 women ( M age = 61.2 yr., SD = 8.8) participated in this study. Individuals practiced Tai Chi Chuan three times / week during seven weeks, and were assessed session-by-session (21 Wu Tai Chi Chuan sessions) in three moments (15, 30, and 45 min.) using Borg's scale (CR 0–10) and the Feeling Scale (+5/–5). With regard to RPE, there was a difference between 15 and 30 min. and between 15 and 45 min. The same pattern of differences was observed for the affective response. The RPE during the seven weeks ranged from “fairly light” to “moderate” and the affective response from “good” to “very good.” Thus, Tai Chi Chuan was perceived as a low-moderate intensity and pleasurable (positive affect) exercise by middle-aged and elderly women.

Feasibility and effects of TAI CHI for the promotion of sleep quality and quality of life: a single-group study in a sample of older Chinese individuals in Hong Kong

Poor sleep in later life is a global issue that reduces many individuals' quality of life (QOL). The purpose of this pilot study was to test the feasibility and effects of a simplified tai chi exercise intervention on sleep quality and QOL among Chinese community-dwelling older adults with poor sleep quality. This single-group, descriptive feasibility study included 34 individuals with poor sleep quality who agreed to participate in a 12-week tai chi intervention. Twenty-six individuals completed the program (23.5% dropout rate). Older adults with poor sleep quality who completed the intervention showed significant improvement in the Medical Outcomes Study Short Form-36 mental component and the Pittsburgh Sleep Quality Index global and component scores. The low recruitment and attendance and high dropout rates might be associated with participants' age, gender, and sleep quality. Further long-term studies are required to examine the potential effects of the tai chi intervention. [Journal of Gerontological Nursing, 40(3), 46-52.].

The Efficacy of Exercise Programs for Parkinson's Disease: Tai Chi versus Combined Exercise

Background and Purpose

Exercise is recommended for every patient with Parkinson's disease (PD). The effectiveness of two different forms of exercise for PD, Tai Chi and combined stretching-strengthening exercise, was compared.

Methods

Patients with mild-to-moderate PD were recruited to join either the combined stretching-strengthening exercise group (n=7), the Tai Chi group (n=9), or the control (nonintervention) group (n=7). Exercise was performed three times a week over a period of 8 weeks. The Tai Chi exercise was led by certified instructors based on a Tai-Chi-for-arthritis program. The combined stretching-strengthening exercise comprised folk dancing, stepping, and elastic-band exercises. The subjects' functional fitness, parkinsonian symptoms, quality of life (QoL), and depression were evaluated.

Results

Both exercise groups yielded better results in their overall functional fitness after the intervention. However, no improvement with exercise was found for parkinsonian symptoms, as evaluated using the Unified Parkinson's Disease Rating Scale. With respect to the domains of QoL, the combined stretching-strengthening exercise group fared better in the social domain of QoL, and the Tai Chi group fared better in the emotional domain, while QoL and depression worsened in the control group. The postintervention QoL was improved relative to the control condition only for the Tai Chi group. Although the exercise interventions did not have any effect on depression, the control group was associated with a significant deterioration.

Conclusions

Exercise improved the functional fitness and QoL of PD patients, with Tai Chi yielding better results in QoL and favorable results in functional fitness. These findings suggest that Tai Chi could be a good exercise strategy for patients with PD.

Investigating short- and long-term transfer effects of a Taiji beginner course in participants' daily life

OBJECTIVE

In recent years research investigating various health benefits of Taiji practice has markedly increased. Despite this growing scientific interest, essential questions such as to what extent a Taiji course may exert noticeable effects in participants' everyday life, what these effects are, and how and where potential transfer effects occur, have hardly been considered. The aim of our study was to explore transfer effects from a Taiji course into participants' daily lives.

METHODS

We conducted a longitudinal observational study in 45 healthy participants at the end of their three-month Taiji beginner course (tp1) and at two months (tp2) as well as one year after course completion (tp3). Participants were asked to report their Taiji practice behavior at all time points, as well as to rate and describe perceived transfer effects of Taiji course contents on their daily life at tp1 and tp3.

RESULTS

Transfer effects were reported by 91.1% of all respondents after course completion (tp1) and persisted in 73.3% at the one-year follow-up assessment (tp3), counting "increase of self-efficacy", "improvement of stress management", and "increase of body awareness" as the most frequently mentioned effects. Transfer effects predominantly occurred in participants' work and social environments, as well as during everyday activities in public areas. While self-reliant Taiji practice frequency significantly decreased from 82.2% at tp1 to 55.6% at tp3 (P < 0.001), the magnitude of self-reported transfer effects did not (P = 0.35). As explorative analyses revealed, regular Taiji course attendance was highly correlated with stronger transfer effects at tp1 (r = 0.51; P < 0.001) and tp3 (r = 0.35; P = 0.020). Participants reporting high self-reliant Taiji practice frequency at tp2 were likely to maintain a regular practice routine at tp3 (r = 0.42; P < 0.004), whereas self-reliant practice frequency and transfer effects at tp1 were positively correlated with self-reliant practice frequency at tp3 on a trend level (r < 0.27; P > 0.08).

CONCLUSION

Our data underline the importance of regular course participation for pronounced and long lasting transfer effects into participants' everyday life. We discuss that several context and process-related aspects of a Taiji intervention are potentially relevant factors for enhancement of transfer effect.

Extension trial of qigong for fibromyalgia: a quantitative and qualitative study

This extension trial is an open-label observational trial of 20 subjects with fibromyalgia who undertook level 2 Chaoyi Fanhuan Qigong (CFQ) training following an earlier controlled trial of level 1 CFQ. Subjects practiced 60 min/day for 8 weeks and continued some daily practice for 6 months. Quantitative measures, assessed at baseline, 8 weeks, 4 and 6 months, were of pain, impact, sleep, physical and mental functions, and practice time. Qualitative comments also were recorded. Compared to baselines, CFQ practice led to significant improvements in pain, impact, sleep, and physical function in the 13 subjects (65%) who completed the trial; changes were present at 8 weeks and were maintained for the 6-month trial duration. A highly motivated subgroup of N = 5, who practiced the most, had the best outcomes in terms of end symptomology, and qualitative comments indicated health benefits in other domains as well. Qualitative comments by the remaining N = 8 trial completers and N = 7 withdrawals indicate different experiences with the practice. This extension trial indicates that diligent CFQ practice over time produces significant health gains in fibromyalgia in a subset of individuals. Future studies will need to address factors that might predispose to favourable outcomes.

Tai Chi’s Effects on Health-Related Fitness of Low-Income Older Adults

On a démontré que le Tai Chi peut influer positivement sur la condition physique liée à la santé (CLPS) des participants âgés, en leur offrant un moyen d’accoître la force musculo-squelettique. L’objectif de cette étude était d’examiner les effets de l’intervention de Tai Chi sur la forme physique, et de découvrir si ethnies culturellement étrangères au Tai Chi constituaient un obstacle à la participation à un programme communautaire pour les aînés à faible revenu. Soixante-dix-huit aînés d’origine mixte (55 ans et plus), qui n’étaient pas culturellement affiliés au Tai Chi, ont été recrutés pour cette étude. Les mesures de la condition liée à la santé ont été prises avant et après un programme de Tai Chi d’une durée de 16 semaines, avec sept séances par semaine. Des améliorations significatives en résultaient dans l’aptitude supérieur et inférieur musculo-squelettique ainsi que dans la flexion partielle parmi ceux qui pratiquaient le Tai Chi. Ces résultats suggèrent que le Tai Chi peut être efficace pour améliorer la CLPS, et que les ethnies non pas liées culturellement au Tai Chi n’éprouviaent pas un obstacle à la participation d’un échantillon de population âgée à un niveau socio-économique faible.

Physiologic complexity and aging: implications for physical function and rehabilitation

The dynamics of most healthy physiological processes are complex, in that they are comprised of fluctuations with information-rich structure correlated over multiple temporospatial scales. Lipsitz and Goldberger (1992) first proposed that the aging process may be characterized by a progressive loss of physiologic complexity. We contend that this loss of complexity results in functional decline of the organism by diminishing the range of available, adaptive responses to the innumerable stressors of everyday life. From this relationship, it follows that rehabilitative interventions may be optimized by targeting the complex dynamics of human physiology, and by quantifying their effects using tools derived from complex systems theory. Here, we first discuss several caveats that one must consider when examining the functional and rehabilitative implications of physiologic complexity. We then review available evidence regarding the relationship between physiologic complexity and system functionality, as well as the potential for interventions to restore the complex dynamics that characterize healthy physiological function.

T'ai chi as exercise among middle-aged and elderly Chinese in urban China

OBJECTIVES

T'ai chi is a form of mind-body practice used as exercise in China, though limited data are available on characteristics of t'ai chi users and factors associated with practice.

METHODS

Characteristics of and factors associated with t'ai chi practice among middle-aged and elder Chinese in Shanghai China were analyzed utilizing baseline data from the Shanghai Women's Health Study and Shanghai Men's Health Study. Logistic regression modeling was used to identify independent factors associated with the practice of t'ai chi among men and women.

RESULTS

T'ai chi is the most common form of regular exercise in Shanghai China among middle-aged and elderly persons (22%), including among women (28%) and men (15%). Other popular forms of exercise were walking (7%), dancing (4%), and jogging (3%). A majority of adults who practiced t'ai chi used it as their exclusive type of exercise (69%). Overall, t'ai chi practitioners as compared to nonpractitioners were more likely women, older, more educated, retired versus still working, and more likely to report chronic medical conditions including pulmonary, gastrointestinal, and cardiovascular conditions. T'ai chi activity was associated with other health behaviors including nonsmoking, consuming ginseng, and participating in other forms of physical exercise.

CONCLUSIONS

T'ai chi is the predominant form of exercise among middle-aged and elderly Chinese in urban China, particularly among those with older age and chronic medical diseases. Future research is needed to see whether t'ai chi has similar or different benefits than conventional forms of exercise such as walking and jogging.

Can Taichi reshape the brain? A brain morphometry study

Although research has provided abundant evidence for Taichi-induced improvements in psychological and physiological well-being, little is known about possible links to brain structure of Taichi practice. Using high-resolution MRI of 22 Tai Chi Chuan (TCC) practitioners and 18 controls matched for age, sex and education, we set out to examine the underlying anatomical correlates of long-term Taichi practice at two different levels of regional specificity. For this purpose, parcel-wise and vertex-wise analyses were employed to quantify the difference between TCC practitioners and the controls based on cortical surface reconstruction. We also adopted the Attention Network Test (ANT) to explore the effect of TCC on executive control. TCC practitioners, compared with controls, showed significantly thicker cortex in precentral gyrus, insula sulcus and middle frontal sulcus in the right hemisphere and superior temporal gyrus and medial occipito-temporal sulcus and lingual sulcus in the left hemisphere. Moreover, we found that thicker cortex in left medial occipito-temporal sulcus and lingual sulcus was associated with greater intensity of TCC practice. These findings indicate that long-term TCC practice could induce regional structural change and also suggest TCC might share similar patterns of neural correlates with meditation and aerobic exercise.

A systems biology approach to studying Tai Chi, physiological complexity and healthy aging: design and rationale of a pragmatic randomized controlled trial

INTRODUCTION

Aging is typically associated with progressive multi-system impairment that leads to decreased physical and cognitive function and reduced adaptability to stress. Due to its capacity to characterize complex dynamics within and between physiological systems, the emerging field of complex systems biology and its array of quantitative tools show great promise for improving our understanding of aging, monitoring senescence, and providing biomarkers for evaluating novel interventions, including promising mind-body exercises, that treat age-related disease and promote healthy aging.

MATERIAL AND METHODS

An ongoing, two-arm randomized clinical trial is evaluating the potential of Tai Chi mind-body exercise to attenuate age-related loss of complexity. A total of 60 Tai Chi-naïve healthy older adults (aged 50-79) are being randomized to either six months of Tai Chi training (n=30), or to a waitlist control receiving unaltered usual medical care (n=30). Our primary outcomes are complexity-based measures of heart rate, standing postural sway and gait stride interval dynamics assessed at 3 and 6months. Multiscale entropy and detrended fluctuation analysis are used as entropy- and fractal-based measures of complexity, respectively. Secondary outcomes include measures of physical and psychological function and tests of physiological adaptability also assessed at 3 and 6months.

DISCUSSION

Results of this study may lead to novel biomarkers that help us monitor and understand the physiological processes of aging and explore the potential benefits of Tai Chi and related mind-body exercises for healthy aging.

Meditative movement for depression and anxiety

This review focuses on Meditative Movement (MM) and its effects on anxiety, depression, and other affective states. MM is a term identifying forms of exercise that use movement in conjunction with meditative attention to body sensations, including proprioception, interoception, and kinesthesis. MM includes the traditional Chinese methods of Qigong (Chi Kung) and Taijiquan (Tai Chi), some forms of Yoga, and other Asian practices, as well as Western Somatic practices; however this review focuses primarily on Qigong and Taijiquan. We clarify the differences between MM and conventional exercise, present descriptions of several of the key methodologies of MM, and suggest how research into these practices may be approached in a systematic way. We also present evidence for possible mechanisms of the effects of MM on affective states, including the roles of posture, rhythm, coherent breathing, and the involvement of specific cortical and subcortical structures. We survey research outcomes summarized in reviews published since 2007. Results suggest that MM may be at least as effective as conventional exercise or other interventions in ameliorating anxiety and depression; however, study quality is generally poor and there are many confounding factors. This makes it difficult to draw definitive conclusions at this time. We suggest, however, that more research is warranted, and we offer specific suggestions for ensuring high-quality and productive future studies.

Tai chi treatment for depression in Chinese Americans: a pilot study

OBJECTIVE

This study examined the feasibility, safety, and efficacy of using tai chi for treating major depressive disorder.

DESIGN

Thirty-nine Chinese Americans with major depressive disorder were randomized into a 12-wk tai chi intervention or a waitlisted control group in a 2:1 ratio. The key outcome measurement was the 17-item Hamilton Rating Scale for Depression. Positive response was defined as a decrease of 50% or more on the 17-item Hamilton Rating Scale for Depression, and remission was defined as a score of 7 or lower on the 17-item Hamilton Rating Scale for Depression.

RESULTS

Of the participants (n = 39), 77% were women, and mean (SD) age was 55 (10) years. There were 26 (67%) participants in the tai chi intervention group and 13 (33%) in the control group. Of the participants in the tai chi group, 73% completed the intervention; no adverse events were reported. We observed trends toward improvement in the tai chi intervention group, compared with the control group, in positive treatment-response rate (24% vs. 0%) and remission rate (19% vs. 0%), although the differences in our small sample did not reach statistical significance.

CONCLUSIONS

A randomized controlled trial of tai chi is feasible and safe in Chinese American patients with major depressive disorder. These promising pilot study results inform the design of a more definitive trial.

Efeito da prática do Tai Chi Chuan sobre a resistência aeróbia de idosas sedentárias

OBJETIVO: Investigar o efeito da prática do Tai Chi Chuan (TCC) sobre a resistência aeróbia de idosas sedentárias. Métodos: Fizeram parte do estudo 11 idosas sedentárias (67,9 ± 6,8 anos; 25,9 ± 2,8 kg/m²), as quais foram submetidas aos testes de marcha estacionária de dois minutos e teste de caminhada de seis minutos pré e pós-intervenção de 12 semanas de TCC. RESULTADOS: Houve aumento da resistência aeróbia das idosas analisadas após 12 semanas de prática de TCC, demonstrado tanto por meio do teste de caminhada de seis minutos (510 ± 64 vs. 536 ± 63 metros; p = 0,006) quanto no teste de marcha estacionária de dois minutos (83 ± 20 vs. 110 ± 19 execuções; p = 0,001). CONCLUSÃO: De acordo com os resultados obtidos, é possível concluir que a prática do TCC é capaz de promover aumento da resistência aeróbia de idosas sedentárias.

A randomized controlled trial of qigong for fibromyalgia

Introduction

Fibromyalgia is difficult to treat and requires the use of multiple approaches. This study is a randomized controlled trial of qigong compared with a wait-list control group in fibromyalgia.

Methods

One hundred participants were randomly assigned to immediate or delayed practice groups, with the delayed group receiving training at the end of the control period. Qigong training (level 1 Chaoyi Fanhuan Qigong, CFQ), given over three half-days, was followed by weekly review/practice sessions for eight weeks; participants were also asked to practice at home for 45 to 60 minutes per day for this interval. Outcomes were pain, impact, sleep, physical function and mental function, and these were recorded at baseline, eight weeks, four months and six months. Immediate and delayed practice groups were analyzed individually compared to the control group, and as a combination group.

Results

In both the immediate and delayed treatment groups, CFQ demonstrated significant improvements in pain, impact, sleep, physical function and mental function when compared to the wait-list/usual care control group at eight weeks, with benefits extending beyond this time. Analysis of combined data indicated significant changes for all measures at all times for six months, with only one exception. Post-hoc analysis based on self-reported practice times indicated greater benefit with the per protocol group compared to minimal practice.

Conclusions

This study demonstrates that CFQ, a particular form of qigong, provides long-term benefits in several core domains in fibromyalgia. CFQ may be a useful adjuvant self-care treatment for fibromyalgia.

Trial registration

clinicaltrials.gov NCT00938834.

Quality of reporting of randomized clinical trials in tai chi interventions-a systematic review

Objectives. To evaluate the reporting quality of published randomized clinical trials (RCTs) in the Tai Chi literature following the publication of the CONSORT guidelines in 2001. Data Sources. The OVID MEDLINE and PUBMED databases. Review Methods. To survey the general characteristics of Tai Chi RCTs in the literature, we included any report if (i) it was an original report of the trial; (ii) its design was RCT; (iii) one of the treatments being tested was Tai Chi; and (iv) it was in English. In addition, we assessed the reporting quality of RCTs that were published between 2002 and 2007, using a modified CONSORT checklist of 40 items. The adequate description of Tai Chi interventions in these trials was examined against a 10-item checklist adapted from previous reviews. Results. The search yielded 31 Tai Chi RCTs published from 2002 to 2007 and only 11 for 1992–2001. Among trials published during 2002–2007, the most adequately reported criteria were related to background, participant eligibility and interpretation of the study results. Nonetheless, the most poorly reported items were associated with randomization allocation concealment, implementation of randomization and the definitions of period of recruitment and follow-up. In addition, only 23% of RCTs provided adequate details of Tai Chi intervention used in the trials. Conclusion. The findings in this review indicated that the reporting quality of Tai Chi intervention trials is sub-optimal. Substantial improvement is required to meet the CONSORT guidelines and allow assessment of the quality of evidence. We believe that not only investigators, but also journal editors, reviewers and funding agencies need to follow the CONSORT guidelines to improve the standards of research and strengthen the evidence base for Tai Chi and for complementary and alternative medicine.

T'ai chi for the treatment of osteoarthritis: a systematic review and meta-analysis

Objectives To summarise and critically evaluate the evidence from randomised clinical trials (RCTs) of t'ai chi as a treatment for patients with osteoarthritis (OA). Design Eleven databases were searched from their inception to July 2010. RCTs testing t'ai chi against any type of controls in human patients with OA localised in any joints that assessed any type of clinical outcome measures were considered. Two reviewers independently performed the selection of the studies, data abstraction and validations. The risk of bias was assessed using Cochrane criteria. Results Nine RCTs met the inclusion criteria, and most of them had significant methodological weaknesses. Six RCTs tested the effects of t'ai chi compared with that of an attention-control programme, a waiting list and routine care or self-help programmes in patients with OA in the knee. The meta-analysis suggested that t'ai chi has favourable effects on pain (n=256; standard mean difference (SMD), -0.79; 95% CI -1.19 to -0.39; p=0.0001; I(2)=55%), physical function (n=256; SMD, -0.86; 95% CI -1.20 to -0.52; p<0.00001; I(2)=38%) and joint stiffness (n=256; SMD, -0.53; 95% CI -0.99 to -0.08; p=0.02; I(2)=67%). Conclusion The results are encouraging and suggest that t'ai chi may be effective in controlling pain and improving physical function in patients with OA in the knee. However, owing to the small number of RCTs with a low risk of bias, the evidence that t'ai chi is effective in patients with OA is limited.

Physical activity and cognition in older adults: the potential of Tai Chi Chuan

The purpose of this article is to review the potential of Tai Chi Chuan as a mode of physical activity that could have cognitive benefits for older adults and to provide potential directions for future research. A brief introduction to Tai Chi Chuan and its related physical benefits is provided. In addition, the empirical literature related to Tai Chi Chuan and cognition is reviewed. Potential mediators of the relationship between Tai Chi Chuan and cognition, including physical resources, disease status, and mental resources, are discussed. Based on the limitations of the extant literature, it is argued that future research in this area must provide more detailed descriptions of Tai Chi Chuan, particularly in terms of intensity and program progression. Consideration of the specific type of cognition that is expected to benefit is also encouraged, and approaches for further efforts to understand how Tai Chi Chuan affects cognition are recommended.

Tai Chi for osteopenic women: design and rationale of a pragmatic randomized controlled trial

Background

Post-menopausal osteopenic women are at increased risk for skeletal fractures. Current osteopenia treatment guidelines include exercise, however, optimal exercise regimens for attenuating bone mineral density (BMD) loss, or for addressing other fracture-related risk factors (e.g. poor balance, decreased muscle strength) are not well-defined. Tai Chi is an increasingly popular weight bearing mind-body exercise that has been reported to positively impact BMD dynamics and improve postural control, however, current evidence is inconclusive. This study will determine the effectiveness of Tai Chi in reducing rates of bone turnover in post-menopausal osteopenic women, compared with standard care, and will preliminarily explore biomechanical processes that might inform how Tai Chi impacts BMD and associated fracture risks.

Methods/Design

A total of 86 post-menopausal women, aged 45-70y, T-score of the hip and/or spine -1.0 and -2.5, have been recruited from primary care clinics of a large healthcare system based in Boston. They have been randomized to a group-based 9-month Tai Chi program plus standard care or to standard care only. A unique aspect of this trial is its pragmatic design, which allows participants randomized to Tai Chi to choose from a pre-screened list of community-based Tai Chi programs. Interviewers masked to participants' treatment group assess outcomes at baseline and 3 and 9 months after randomization. Primary outcomes are serum markers of bone resorption (C-terminal cross linking telopeptide of type I collagen), bone formation (osteocalcin), and BMD of the lumbar spine and proximal femur (dual-energy X-ray absorptiometry). Secondary outcomes include health-related quality-of-life, exercise behavior, and psychological well-being. In addition, kinetic and kinematic characterization of gait, standing, and rising from a chair are assessed in subset of participants (n = 16) to explore the feasibility of modeling skeletal mechanical loads and postural control as mediators of fracture risk.

Discussion

Results of this study will provide preliminary evidence regarding the value of Tai Chi as an intervention for decreasing fracture risk in osteopenic women. They will also inform the feasibility, value and potential limitations related to the use of pragmatic designs for the study of Tai Chi and related mind-body exercise. If the results are positive, this will help focus future, more in-depth, research on the most promising potential mechanisms of action identified by this study.

Trial registration

This trial is registered in Clinical Trials.gov, with the ID number of NCT01039012.

Tai chi for breast cancer patients: a systematic review

The objective of this review was to assess the effectiveness of tai chi for supportive breast cancer care. Eleven databases were searched from inception through December 2009. Controlled trials testing tai chi in patients with breast cancer that assessed clinical outcome measures were considered. The selection of studies, data extraction, and validations were performed independently by two reviewers. Risk of bias was assessed using Cochrane criteria. Three randomized clinical trials (RCTs) and four non-randomized controlled clinical trials (CCTs) met our inclusion criteria. The three RCTs tested the effects of tai chi on breast cancer care compared with walking exercise, psychological support therapy, or spiritual growth or standard health care and showed no significant differences between tai chi and these control procedures in quality of life and psychological and physical outcome measures. The meta-analysis also failed to demonstrate significant effects of tai chi compared with control interventions (n = 38, SMD, 0.45, 95% CI -0.25 to 1.14, P = 0.21; heterogeneity: chi(2) = 0.23, P = 0.63; I (2) = 0%). All of the four CCTs showed favorable effects of tai chi. Three trials suggested effectiveness in psychological and physical outcome measures, whereas one study was too poorly reported to be evaluated in detail. All of the CCTs had a high risk of bias. Collectively, the existing trial evidence does not show convincingly that tai chi is effective for supportive breast cancer care. Future studies should be of high methodological quality, with a particular emphasis on including an adequate control intervention.

T'ai chi and qigong for health: patterns of use in the United States

BACKGROUND

Little is known in the United States about those who practice t'ai chi and qigong, two mind-body techniques that originated in Asia.

OBJECTIVE

The objective of this study is to characterize use of t'ai chi and qigong for health with regard to sociodemographics, health status, medical conditions, perceptions of helpfulness, and disclosure of use to medical professionals.

METHODS

We analyzed associations of t'ai chi and qigong use for health using cross-sectional data from the 2002 National Health Interview Survey (NHIS) Alternative Medicine Supplement (n = 31,044). The 2002 NHIS estimated the number of t'ai chi and qigong users for health to be 2.5 and 0.5 million persons, respectively. We collapsed t'ai chi and qigong use into a single category (TCQ) for analysis, representing 2.8 million individuals.

RESULTS

We found that neither age nor sex was associated with TCQ use. TCQ users were more likely than nonusers to be Asian than white (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.30-3.15), college educated (OR 2.44, 95% CI 1.97-3.03), and less likely to live in the Midwest (OR 0.64, 95% CI 0.42-0.96) or the southern United States (OR 0.51, 95% CI 0.36-0.72) than the West. TCQ use was associated independently with higher reports of musculoskeletal conditions (OR 1.43, 95% CI 1.11-1.83), severe sprains (OR 1.65, 95% CI 1.14-2.40), and asthma (OR 1.50, 95% CI 1.08-2.10). Half of TCQ users also used yoga for health in the last 12 months. Most TCQ users reported their practice to be important to maintain health, but only a quarter of users disclosed their practice to a medical professional.

CONCLUSIONS

In the United States, TCQ is practiced for health by a diverse population, and users report benefits for maintaining health. Further research is needed to establish efficacy and safety for target populations, including those with musculoskeletal and pulmonary disease, as well as for preventive health.