Tai Chi to Prevent Falls Among the Elderly

By Dónal P. O'Mathúna, PhD, Dr. O'Mathúna is a lecturer in Health Care Ethics, School of Nursing, Dublin City University, Ireland; he reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.

Part 2 of a Series on Tai Chi: Risk of Falling as Outcome

Tai chi is increasingly being used in fall prevention programs, especially with the elderly. Part 1 of this article described tai chi in some detail and reviewed research studies involving the practice where the incidence of falls was the primary outcome. The review found a relatively small number of studies, which were generally supportive of tai chi as a program to reduce falls in those living in the community. Another group of studies have measured outcomes regarded as indicators of a person's risk of falling. These studies will be the focus of this article.

Fear of Falling

In addition to physical injury, falls can lead the elderly to become afraid of falling. Approximately half of the elderly living in the community experience such fear of falling, although it can have a variety of sources.1 This fear can lead to a debilitating spiral of loss of confidence, reduced physical activity and social involvement, more falls, further frailty, and loss of independence. Tai chi is one of several interventions that has been evaluated to determine if it reduces fear of falling, which may be taken as a predictor of reduced falling. A 2007 systematic review of these interventions identified 12 high-quality randomized controlled trials (RCTs), of which three evaluated tai chi.1

Two of these studies also measured the number of falls and were reviewed in more detail in Part 1.2,3 Both were carried out with older people living in the community. The number of falls, and the fear of falling, was reduced significantly in both. A third study in this area randomly assigned 49 people, older than age 60 who lived in the community, to either a tai chi or control group.4 Those assigned to the control group were asked to make no changes in their physical activity and did not meet together except when outcomes were being measured. Tai chi was practiced as a group for one hour daily for eight weeks. If participants could not attend the group session they were asked to conduct a 30-minute session at home. On average, subjects participated in 35 hours of tai chi over the eight weeks. Using the Falls Efficacy Scale, those in the tai chi group had significant improvements in their fear of falling compared to the control group (P = 0.006). The authors noted that their study design did not allow determination of whether the benefit may have arisen at least in part from the regular social interaction in the tai chi group.

Balance

Impaired balance has been identified as a major intrinsic factor contributing to falls among the elderly.5 Beginning in the 1990s, a number of cross-sectional studies showed that tai chi practitioners exhibited less swaying and had better balance than matched controls who did not practice tai chi.6 However, many of these studies were conducted using younger and middle-aged adults, not older adults.7 Also, since these were cross-sectional studies, differences could have existed prior to training in tai chi.

One trial found no correlation between balance performance and number of years of tai chi experience.5 Therefore, an RCT was conducted with 49 community-dwelling older people (average age 69 years) who had no experience with tai chi.5 Those in the intervention group undertook 90 minutes of tai chi together, six days a week for eight weeks. Those in the control group met together for a general education program that lasted the same length of time. Using two validated balance measures, the tai chi group had significantly better balance at four weeks, eight weeks, and four weeks after the intervention stopped. Their scores on these tests were similar to those recorded by experienced tai chi practitioners, suggesting that the benefits of tai chi for balance can be achieved within four weeks.

One of the studies reviewed in Part 1 found fewer falls after tai chi training than with exercise training, and also showed improved balance.3 Regression analysis found that those participants who improved their balance were also significantly less likely to fall in the subsequent six months. In addition, the study of fear of falling in 49 older community dwellers described above found significant improvements in one-leg balancing among those in the tai chi group (P < 0.001).4 Another RCT involved 49 elderly men with osteopenia or osteoporosis.8 The community-dwelling men (aged 60-82 years) were randomly assigned to a non-intervention control or 18 weeks of tai chi practiced for 45 minutes, twice a week. Significant improvements in balance were found for the tai chi group while no changes were found in the control group.

In contrast, another study randomly assigned 180 community-dwelling elderly people (aged 65-74 years) to one of three groups.9 One group engaged in tai chi, another performed resistance exercises, and the third had no intervention. The exercise sessions were conducted three times per week for one year. No significant differences were found between the groups with respect to balance, flexibility, muscle strength, or number of falls. Among women in the study, those in the tai chi and exercise groups had significantly less loss of bone mineral density than women in the control group (P < 0.05).

Yet another study showed that after one hour of tai chi, three times weekly for 12 weeks, 39 older people (average age 65 years) had improvements on a battery of tests measuring balance, muscle strength, endurance, and flexibility.10 However, no control group was used in this particular study.

Two of the RCTs described above that found a reduced incidence of falls also measured physical functioning. The earlier RCT involved 200 participants and conducted several measurements of muscle strength, flexibility, cardiovascular endurance, and body composition.2 Few statistically significant differences were found, except that those in the tai chi group had less loss of grip strength and greater lower extremity range of motion than the control group. The other RCT found significantly greater improvements in trunk flexibility among those in the tai chi group compared to the control group (P < 0.001).

A quasi-controlled study randomly assigned two long-term care facilities to be either the tai chi or control site.11 A total of 68 residents participated. Tai chi classes were taught three times per week for 35 minutes for 12 weeks at one site, while the control site received no exercise intervention. The number of falls did not differ between the sites, but outcomes for muscle strength, flexibility, balance, and mobility were significantly better in the tai chi group compared to control (P < 0.001).

Adverse Effects

No adverse effects of tai chi were reported in the studies reviewed here.

Conclusion

The first part of this review examined the small number of existing studies evaluating tai chi in the elderly, and generally found tai chi reduced the incidence of falls among community-dwelling adults. The studies examined here of risk factors for falls lend further support to the conclusion that tai chi is beneficial. The total number of studies remains small, however, and much heterogeneity exists in study design and outcomes measured. Much variety exists in the tai chi protocols and frequency of practice, with little consensus regarding the schedule needed for beneficial or optimal effects. Further research is needed before firm recommendations can be offered, but the indications are that tai chi is useful in helping to reduce falls and risk of falls.

Recommendation

Tai chi training may be of benefit in helping prevent falls in elderly people living in the community. Less evidence is available to support the use of tai chi for those who are more frail or reside in nursing homes.

Tai chi programs vary considerably in duration and rigor; therefore, they should be approached carefully and the intensity increased gradually. As with any exercise program, individualized medical advice should be sought before commencing, and any changes carefully monitored.

People should remain alert to any symptoms that indicate overexertion. Keeping such cautions in mind, regular practice of tai chi may help improve balance and physical functioning, and thus contribute to reducing the incidence of falls and fear of falling.

References

1. Zijlstra GA, et al. Interventions to reduce fear of falling in community-living older people: A systematic review. J Am Geriatr Soc 2007;55:603-615.

2. Wolf SL, et al. Selected as the best paper in the 1990s: Reducing frailty and falls in older persons: An investigation of tai chi and computerized balance training. J Am Geriatr Soc 2003;51:1794-1803.

3. Li F, et al. Tai Chi and fall reductions in older adults: A randomized controlled trial. J Gerontol A Biol Sci Med Sci 2005;60:187-194.

4. Zhang JG, et al. The effects of Tai Chi Chuan on physiological function and fear of falling in the less robust elderly: An intervention study for preventing falls. Arch Gerontol Geriatr 2006;42:107-116.

5. Tsang WW, et al. Effect of 4- and 8-wk intensive Tai Chi Training on balance control in the elderly. Med Sci Sports Exerc 2004;36:648-657.

6. Tsang WW, et al. Tai Chi improves standing balance control under reduced or conflicting sensory conditions. Arch Phys Med Rehabil 2004;85:129-137.

7. Ramachandran AK, et al. Effect of Tai Chi on gait and obstacle crossing behaviors in middle-aged adults. Gait Posture 2007;26:248-255. Epub 2006 Oct 10.

8. Maciaszek J, et al. Effect of Tai Chi on body balance: Randomized controlled trial in men with osteopenia or osteoporosis. Am J Chin Med 2007;35:1-9.

9. Woo J, et al. A randomised controlled trial of Tai Chi and resistance exercise on bone health, muscle strength and balance in community-living elderly people. Age Ageing 2007;36:262-268. Epub 2007 Mar 13.

10. Taylor-Piliae RE, et al. Improvement in balance, strength, and flexibility after 12 weeks of Tai chi exercise in ethnic Chinese adults with cardiovascular disease risk factors. Altern Ther Health Med 2006;12:50-58.

11. Choi, JH, et al. Effects of Sun-style Tai Chi exercise on physical fitness and fall prevention in fall-prone older adults. J Adv Nurs 2005;51:150-157.