Tai Chi and Fall Prevention in the Elderly
August 2000; Volume 3; 89-91
"You are old, Father William," the young man said,
"And your hair has become very white;
And yet you incessantly stand on your head—
Do you think, at your age, it is right?"
Lewis Carroll
Alice’s Adventures in Wonderland
By V. Jane Kattapong, MD, MPH
Tai chi, also known as tai chi chuan, tai chi quan, Tajiquan, or T’ai Chi, is an ancient Chinese martial art form that has evolved into a style of exercise. Tai Chi continues to be practiced today by millions of elderly Chinese people,1 and is gaining popularity in the United States. Because Tai Chi is popularly believed to confer health benefits, and now is commonly on the activity lists of many senior centers, it is worthwhile examining the evidence regarding the effects of Tai Chi. In fact, given the seemingly unwieldy postures that are adopted, Lewis Carroll himself might say to an elderly practitioner of Tai Chi, "Do you think, at your age, it is right?"
Background—Falls in the Elderly
Falls are a serious public health problem among the elderly. About 30% of people over 65 fall each year, and about 15% of the elderly fall multiple times in a year.2 The morbidity associated with falls in the elderly is far from trivial, since up to 15% of falls result in serious injury,2,3 including hip fractures, fractures at other sites, soft tissue injuries,4,5 or even death.3 Among those elderly who survive falls, many experience a decline in ability to perform activities of daily living and other physical and social activities.6
The beneficial effects of exercise have been well established and include improved muscle strength, muscle mass, cardiovascular status, fatigue resistance, and hypertension.1,7 Exercise has been shown to decrease the risk of falls in the elderly.2
Background—Tai Chi
According to the beliefs of traditional Chinese medicine, all elements in the universe are governed by a powerful force, Tao, which is divided into opposing aspects, Yin and Yang. Good health depends on maintaining an appropriate balance between the inactivity of Yin and the activity of Yang.8 An imbalance in Yin and Yang disturbs one’s Chi, or vital energy, resulting in disease.
Tai Chi means "supreme ultimate" and Chuan means "fist."8 Tai Chi originated in China more than 300 years ago as a form of shadow boxing,9 and later evolved into a martial art form employed against foreign invaders or peasant rebels.10 In the original conceptualization, the Tai Chi practitioner’s stance could be either gentle or vigorous, with harmonious, deliberate movements. Tai Chi was understood as a gentle flow of movement used to dissipate force through and past one’s body.8
Tai Chi Theory
Since its inception, Tai Chi has evolved into an exercise form that relies on control of bodily movement in the surrounding space, with an emphasis on mind-body interaction. Through integrating the inactivity of Yin and the activity of Yang, the movements of Tai Chi strive to balance Chi in the body’s meridians. When practiced regularly, this activity is believed to strengthen Chi and result in a decreased likelihood to succumb to illness.8
Procedure
There are three basic principles governing the current practice of Tai Chi.8,11 First, one’s posture must be relaxed, with the body extended. Deep breathing and a mindful awareness of one’s body in surrounding space must be achieved in order to assume the proper posture. Second, one’s mind must be both calm and alert. And third, body movements must be coordinated and sequenced carefully. Currently there is no standardized training or licensure required for practitioners or teachers of Tai Chi in the United States.
Clinical Trials
In order to assess the impact of exercise and balance training interventions on risk of falling in the elderly, the National Institute on Aging and the National Institute for Nursing Research implemented the Frailty and Injuries: Cooperative Studies on Intervention Techniques (FICSIT) trials in 1990.12
One goal of the FICSIT trials was to examine the effects of novel interventions on frailty and falls in the elderly. Eight research sites across the country were involved with the FICSIT trials. At most of the sites, participants received interventions that consisted of "conventional" endurance, flexibility, resistance, and balance training. However, at the Atlanta site, 180 community-dwelling individuals aged 70 or older were randomized to receive Tai Chi, individualized balance training, or a wellness discussion group (the control group) for 15 weeks.13
Those elderly people receiving the Tai Chi intervention had a significantly lower risk of falling (measured as time to a fall) than the control group receiving only wellness discussion.2 In contrast, the group receiving balance training had no risk advantage in comparison to the control group.
A follow-up assessment at four months after the intervention had been completed asked participants questions regarding perceived benefits.13 Participants who had received either the Tai Chi or the balance training intervention reported increased confidence in balance and movement. Only those who had received the Tai Chi intervention felt that their daily activities, and their life in general, had been affected by the intervention. Many who had received the Tai Chi intervention reported that they continued to practice this form of exercise regularly.13
One group of the FICSIT investigator physical therapists identified aspects of posture and gait that may lead to postural instability. These aspects include slowed movements, reduced range of motion, reduced muscle strength, increased flexed posture, reduced rotational movements, reduced arm swing, and decreased unilateral weight shifts and stance times.1 To counter these potential contributors to instability, the investigators condensed the 108 Tai Chi forms, or maneuvers, into 10 forms that may work to lessen the areas of instability. These forms are illustrated in Figure 1.
Other Investigations of Tai Chi
A MEDLINE search revealed no other controlled trials of Tai Chi. However, one cross-sectional study compared 28 elderly male practitioners with an average of 13.2 years of Tai Chi experience with 30 elderly sedentary men.14 The average age of the practitioner group was 67.5 years, and the average age of the sedentary group was 66.2 years. Compared with the sedentary group, the Tai Chi group had significantly better measures of resting heart rate, three-minute step test heart rate, and balance and flexibility measures.14
Adverse Effects
Tai Chi does not appear to have adverse effects. It does not appear to increase joint swelling or tenderness.15
Conclusion
Limited numbers of controlled trials have evaluated the benefits of Tai Chi on balance and fall prevention in the elderly. However, the available information suggests a positive effect.
Recommendation
Consider recommending a several month trial of Tai Chi to ambulatory patients who wish to improve their sense of balance and reduce their fear of falling. As Lewis Carroll might say, "For those of an advanced age, Tai Chi seems to be sage."
Dr. Kattapong is a board-certified neurologist and a principal in MediCat Consulting, a health services consulting firm in Tucson, AZ.
References
1. Wolf SL, et al. The effect of Tai Chi Quan and computerized balance training on postural stability in older subjects. Phys Ther 1997;77:371-381.
2. Province MA, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. JAMA 1995;273:1341-1347.
3. Sattin RW. Falls among older persons: A public health perspective. Annu Rev Public Health 1992;13:489-508.
4. Tinetti ME, et al. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-1707.
5. Sjorgen H, Bjornstig U. Injuries among the elderly in the home environment. J Aging Health 1991;3:107-125.
6. Dunn JE, et al. Mortality, disability, and falls in older persons: The role of underlying disease and disability. Am J Public Health 1992;82:395-400.
7. Wolf SL, et al. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. J Am Geriatric Soc 1996;44:489-497.
8. Wolf SL, et al. Exploring the basis for Tai Chi Chuan as a therapeutic exercise approach. Arch Phys Med Rehabil 1997;78:886-892.
9. Koh TC. Tai chi chuan. Am J Chin Med 1981;9:15-22.
10. Chinese Sports Editorial Board. Simplified Tajiquan. 3rd ed. Beijing, China: Foreign Languages Printing House; 1986.
11. Preliminary Study of Reducing Aging with Tajiquan. People’s Republic of China: People’s Sports and Exercise Publication; 1983.
12. Ory MG, et al. Frailty and injuries in later life: The FICSIT trials. J Am Geriatr Soc 1993;41:283-296.
13. Kutner NG, et al. Self-report of Tai Chi practice by older adults. J Gerontol B Psychol Sci Soc Sci 1997;52:P242-P246.
14. Hong Y, et al. Balance control, flexibility, and cardio-respiratory fitness among older Tai Chi practitioners. Br J Sports Med 2000;34:29-34.
15. Cerrato PL. Tai chi: A martial art turns therapeutic. RN 1999;62:59-60.
August 2000; Volume 3; 89-91
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