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By Craig D. Schneider, MD, and Sarah E. Morgan, MD
Tai chi (supreme ultimate fist or boxing) is a martial arts form that developed in the context of Chinese Taoism during the 17th century1 and has been influenced by Buddhism. As such, in addition to its use in self-defense, its traditional focus is on achieving mental equanimity, healthy longevity, and a unity of mind and body.
The continuous popularity of tai chi in China has attracted growing interest in the Western world. A stroll through the local video rental shop will reveal multiple tai chi home video lessons. One might argue that the image of elderly people practicing tai chi has even become a metaphor for healthy aging, now being featured prominently in pharmaceutical advertisements for arthritis pain relievers.
The Practice of Tai Chi
Tai chi is a slow, low-impact exercise that involves the coordination of deep breathing with graceful, repetitive movements, meditation, and self-awareness. Like traditional Chinese medicine, it is grounded in the energy-based concepts of yin (receptive, inactive) and yang (creative, active)—opposing, complementary life forces. Its practice is believed to enhance the balance and flow of these energies within the body.
Tai chi generally is taught in group sessions by an instructor. Multiple schools have evolved and the most common forms take from five minutes to an hour to complete. Participants guided by the coaching of their teacher perform movements in unison. There is no standardized training or licensure required for tai chi instructors in the United States, but many knowledgeable in this area recommend selecting a teacher with at least five years of experience. Tai chi is considered a life-long endeavor one continues to perfect over time. After initial instruction, it may be practiced independently, at home, with no cost for equipment. Thus, it has attracted increased attention as a potentially suitable "low-tech" approach to improving balance and decreasing falls in the elderly.2
Falls and the Elderly
It is a well-documented fact that falls among the elderly represent a significant public health problem in the United States. Approximately 30% of people older than age 65 living in the community fall at least once annually, and the number is even higher among the institutionalized.3 About 20% of these falls require medical attention. Among older adults, falls are the leading cause of injury-associated death4 and the most common cause of nonfatal injury and hospital admission for trauma.5
Falls have an enormous impact on quality of life in the elderly population, as fall survivors experience a greater decline in their ability to carry out activities of daily living (ADLs), less involvement in recreational activities, and a greater likelihood of becoming institutionalized. The cost to society of unintentional injury among the elderly, the majority of which is spent on fall injuries, was estimated at $3.7 billion in 1984, and is projected to continue rising over the next few decades as the population ages.6
Common risk factors for fall include impaired gait and balance, weak lower-limb muscles, poor vision, the use of psychotropic medications, and specific medical conditions.7 Although not entirely consistent, a body of research has evolved suggesting tai chi may improve balance and decrease risk of falls.
Special Considerations Regarding Research on Tai Chi and Falls in the Elderly
The heterogeneity of tai chi practice styles and its diverse applications in injury and fall prevention make research on this topic challenging to interpret. Measured variables lack consistency across studies and include different duration and frequency of practice, numbers of previous falls, and practice setting (community dwelling vs. institutionalized). Outcome measures also vary widely, including diverse measures of stability, functional status, and feared vs. actual falls. In the studies reviewed, varying definitions of a fall were used with varying results. In addition, problems in fall reporting may have influenced outcome, as most falls never result in the seeking of help through the health care system,7 and long-term recall of falls is poor. The studies reviewed also suffer from difficulty in blinding subjects to their intervention.8
A Medline search from 1966 to 2003 using the key words "tai chi" or "tai ji" combined with "accidental falls" or "fall" produced 23 articles. Of these, eight were clinical trials, including three randomized controlled trials (RCTs). A larger number of articles dealing with potentially related factors such as self-efficacy, quality of life, balance, and functional mobility were found, but they were not directly linked to falls. Summarized below are the results of several pertinent studies.
In a 1996 RCT published by Wolf et al, 180 subjects age 70 or older living in a retirement community were randomized to receive a control intervention (educational programming), computerized balance training, or a 10-step modification of the yang form of tai chi in one-hour, twice-weekly sessions.9 After 15 weeks, the balance-training group achieved greater improvement in balance than either the tai chi or control groups (P < 0.001), but the tai chi group had reduced fear of falling (P < 0.05) and a rate of falls that was almost 50% lower compared to the others (P < 0.05). A sub-analysis of time to injurious falls showed a nonsignificant trend toward decreased risk of injurious falls in the tai chi group (relative risk [RR] = 0.812, P = 0.65).
A similar study published the next year by Wolf and colleagues, demonstrated a 55% RR reduction in fear of falling in the tai chi group (P = 0.08).10 Wolf’s 1996 study was part of an eight-center FICSIT (Multicenter Trials of Frailty and Injuries: Cooperative Studies of Intervention Techniques) trial cooperative that assessed a variety of interventions in reducing falls and frailty in elderly patients. These included group resistance training, balance training, nutritional interventions, and individualized multidimensional treatments. Meta-analysis of the complete FICSIT trial’s one-year post intervention data revealed that the tai chi group had the most significant reduction in fall risk (RR = 0.63, P < 0.01) as measured by time to first fall. Analysts were unable to demonstrate a significantly decreased risk of injurious falls, defined as injuries involving fracture, requiring medical care, or resulting in significant impairment, due to the low number of events observed.6
A study published by Hain and colleagues in 1999 examined tai chi’s effects on balance in different age groups.11 This non-randomized clinical trial recruited 30 community-dwelling subjects with mild balance disorders to undergo eight weeks of tai chi in weekly, one-hour group sessions. Subjects ranged in age from 20 years to older than 75 years. Each subject completed a three-part pre-intervention evaluation to quantify balance (involving moving platform posturography, Romberg test, and reach test) as well as two questionnaires to assess perceived balance (modified from the Medical Outcomes Study and the Dizziness Handicap Inventory). Pre- and post-intervention analyses were then compared. Using a measure of significance that attempted to adjust for their statistical methods (P < 0.01), these investigators found significant improvements in measures of objective balance in those younger than age 61 and older than age 75, although subjective balance did not significantly improve.
The researchers contrasted their findings with those of Wolf’s group, which found no difference in balance (as measured by sway) in the tai chi group in spite of fewer falls and less fear of falling. The researchers did point out potential concerns regarding the safety of older tai chi participants. Although no falls occurred dur- ing group sessions, a roughly 1:2 staff-to-participant ratio was maintained, which allowed for significant spotting of participants. It was the stated impres- sion of the researchers that without this level of supervision, an appreciable risk of falling would exist in this population.
Nowalk and colleagues examined the ability of different interventions to reduce falls in the elderly in a study published in 2001.12 They randomized 110 residents at two long-term care facilities to one of three groups: a control group focused on enhancing quality-of-life programming for all residents, an individualized strength-training and conditioning program that took place three times/wk, or a group that combined monthly behavioral interventions (e.g., goal setting, role-playing, and artistic expression of past fall experiences) with tai chi three times/wk. Participants were at least 65 years of age, with an average age of 84 years. All were ambulatory without assistive devices and able to follow basic commands. Evaluation of falls, determined by incident reports filed by staff, occurred at six, 12, and 24 months. Neither time to first fall nor incidence of falls differed among treatment and control groups (P > 0.05). Adherence to the exercise programs was generally poor, but those with greater adherence had no fewer falls. Adherence was significantly worse in the tai chi group and this was hypothesized to be due to an inability of these subjects to continue to learn the required techniques.
Because of budgetary constraints, enrollment was not completed and the resulting sample size was insufficiently powered to answer the question posed. The authors concluded that "lack of treatment differences and low adherence rates suggest that residents of long-term care facilities may require individualized exercise interventions that can be adapted to their changing needs."
Taggert and colleagues examined the effects of a tai chi intervention on balance, functional mobility, and fear of falling among older women in a 2002 study.13 A single-factor, within-subjects design was used in which patients served as their own control (three months of usual activities) prior to a twice-weekly, 30-minute tai chi intervention stated by the authors to have been "developed for the elderly." Participants were residents of three retirement communities and were able to ambulate independently or with an assistive device. Measured data included an author-developed demographic survey instrument that recorded the presence or absence of several established fall risk factors, and tests for balance (the Berg Balance Scale), functional mobility (the Timed Up and Go Test), and fear of falling (the Falls Efficacy Scale). Measurements were made at baseline, after the three-month control period, and following the three-month tai chi intervention. Statistically significant improvements for scores in balance (P < 0.001), functional mobility (P < 0.05), and fear of falling (P < 0.001) were noted, but actual falls were not reported. Of the 69 women who entered the study, 45 completed it; 11 withdrew prior to the intervention and 13 withdrew during. Reasons given for attrition included falls with fracture (n = 4), other illness (n = 7), dissatisfaction with the intervention (n = 3), back pain caused by the intervention (n = 3; all used walkers to ambulate), and "too busy" (n = 6). It is interesting to note the author’s observation that six of nine cane users reported that they no longer used their canes when walking indoors by the end of the study.
Adverse Effects and Contraindications
Although tai chi does not appear to have any specific adverse effects, it is probably wise to rule out participation for those with known severe osteoporosis, as well as for individuals with acute back pain, knee problems, sprains, and fractures before recommending initiation of practice. According to at least one study, tai chi does not increase joint swelling or tenderness.14
A central tenet of geriatric medicine is that the etiology of health problems in the elderly is often multifactorial, and treatment therefore requires a multidisciplinary approach. Because of the heterogeneity of studies in this area, often with conflicting results, it is too early to say that tai chi is definitely useful in preventing falls in the elderly, but it appears promising and likely represents one useful tool within a multidisciplinary approach. More research is needed to determine the optimal means for measuring changes in balance and correlating these to reduction in risk of falls.
While awaiting more definitive well-designed clinical trials, there appears to be little risk in recommending a several month trial of tai chi in a supervised setting for ambulatory patients who wish to improve their balance and reduce their fear of falling.
Dr. Schneider is Director of Integrative Medicine and Dr. Morgan is a third-year resident, Department of Family Medicine, Maine Medical Center, Portland, ME.
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