Tai Chi to Prevent Falls in the Elderly
October 1998; Volume 1: 116-118
By Jay K. Udani, MD
The u.s. elderly population has a one in three chance of sustaining a fall this year, and half of those who do fall will fall again.1 The risk goes beyond injury, death, and the $10 billion annual direct health care costs. Those who fall become fearful, withdrawn, and experience social and functional deterioration.1 Numerous risk factors are associated with falling, and impairment of gait and balance are two chief risk factors associated with falling.1 Interventions that improve balance have been proven to reduce the risk of falling, and Tai Chi, an ancient Chinese Martial Art form, may help restore balance to the elderly patient.
Risk Factors
Structural and motor risk factors for falls include impaired balance, muscle weakness and atrophy, reduced flexibility, and reduced range of motion. These, together with visual impairment, contribute to impaired gait, which itself is a risk factor. Incontinence and benign prostatic hyperplasia may cause leakage and slipping, or may necessitate multiple trips to the bathroom in the middle of the night and dangerous navigation through the darkness. Sedatives, antidepressants, and antihypertensives increase fall risk, and patients on more than four medications of any kind are at increased risk.1,2 Fear of falling, difficulty falling asleep at night, and having fallen in the past year are also significant risk factors for future falls.
History/Culture/Tradition
Tai Chi traces its roots to the development of Yoga in ancient India. In the 5th century AD, an Indian sage named Bodhidharma introduced the foundations of Yoga to the Shaolin monks of southern China, who eventually formed the basis for the martial arts.3 In the 13th century AD, Chang Sang Feng developed a new form of the martial arts, called Tai Chi.4 It is said that he developed Tai Chi after watching a stork and snake fight.5 Over the centuries, various Chinese families developed a number of different Tai Chi styles, each named for that particular family. The most common style practiced today is the Yang school of Tai Chi, developed in the 19th century.
The literal translation of Tai Chi Chuan (also known as tajii, tajii-quan, and tai chi) reveals that Tai means "moving" or "movement;" Chi means "life force;" and Chuan means "fist." Tai Chi Chuan is a set of flowing movements based on animal postures. The routines, called "forms" or "sets," are designed to stimulate and balance the Chi in the body.6 Many of the "forms" simulate the movements of long-lived animals, including storks and turtles.
What began as a form of self-defense for monks has evolved over the centuries in China to become a system of balance and muscular control designed to improve and maintain physical health, calm the mind, enhance the powers of meditation, and increase longevity.7 Sometimes called "moving meditation," Tai Chi and its related discipline, Qi Gong, are practiced by tens of millions of Chinese daily.
Medical Claims
Numerous claims have been made about the healing properties of Tai Chi. These include the ability to decrease blood pressure, cholesterol,3 tension, depression, fatigue, and anxiety;8 to prevent thrombosis;7 and to improve circulation, digestion, and appetite.3
Principles
Two fundamental principles of Traditional Chinese Medicine are chi (life force or energy) and balance. Balance in one's life allows a person to maintain a strong and unblocked flow of chi, which, in turn, results in the ability to prevent illness and improve health.
The three basic principles of Tai Chi are: 1) the body should be extended and relaxed; 2) the mind must be alert but calm; and 3) all body movements require a well-coordinated sequencing of segments.8 The basic stance in Tai Chi involves five attributes that make it unique among the martial arts.3 This stance is combined with deep diaphragmatic breathing, which is common to the martial arts and many forms of meditation.
Mechanism of Action
Tai Chi teachers instruct patients how to walk safely with a narrow stance and rotate their bodies slowly. Practitioners of Tai Chi become familiar with their own physical limitations through practice of the various "forms." Every session takes the practitioner to the edge between balance and falling.
Clinical Trials
We searched Medline by PUBMED and OVID, as well as the Internet, published bibliographies, and alternative medicine literature CD-ROMs using the keywords "Tai Chi," "Tai Chi Chuan," and "Martial Arts." All studies identified and reviewed here include community-dwelling populations. All studies showing significant reductions in falling or the risk factors associated with falling had Tai Chi interventions lasting between 10 and 15 weeks, and varying from one to three times per week.
Three modifiable risk factors for falls in the elderly are flexibility, balance, and strength, as noted above. All but one study10 looked only at the ability of Tai Chi to modify these and other risk factors as a surrogate for decreasing the rate of falls in the elderly.
Two studies showed significantly increased flexibility in the Tai Chi populations vs. the control population. One study looked at veteran practitioners with an average of 12 years of experience,11 and the other introduced the intervention group to Tai Chi for 12 months.12 The study with the experienced practitioners showed a non-significant increase in flexibility as measured by an electronic inclinometer.11 The other study showed a significant increase of 11% in thoracic/lumbar flexibility (P < 0.05) and an 18.1% increase in muscle strength of knee extensors (P < 0.01).
Two uncontrolled studies examined the issue of balance. One, a case series, compared Tai Chi practitioners to non-practitioners on five separate balance tests.13 The Tai Chi practitioners did significantly better (P < 0.05) on three of the five tests. The other study was also a case series of a self-selected group of elderly volunteers.14 This study showed a significant increase in the Single Limb Timed Test (a validated test for measuring balance in the elderly) with eyes open (P < 0.05) after Tai Chi. The same study failed to show a difference in the SLTT balance test performed with eyes closed.
A large study exposed 110 patients to either balance training, strength training, balance and strength training, or fall prevention education alone.15 After three months of intervention, all patients in all groups were assigned to six months of weekly Tai Chi classes to assess whether Tai Chi would sustain the gains. Tai Chi sustained some of the improvements but not significantly.
The only study in the literature to measure the rate of falls in addition to modifying risk factors came out of the FICSIT (Frailty and Injuries: Cooperative Study of Intervention Techniques) trial.10 This was a prospective, controlled, clinical trial with 200 healthy, ambulatory, community-dwelling elderly patients randomized to one of three arms: Tai Chi, computerized balance training, and a control group that received fall prevention education. Data collection was blinded.
The intervention lasted 15 weeks, with four months of follow-up. The Tai Chi classes condensed the 108 classic Yang forms of Tai Chi into 10 forms that included a progressive reduction of standing support until a single-limb stance was achieved. Classes were held twice weekly, and home practice was encouraged but not monitored. The most clinically significant outcome measured was the occurrence rate of falls. After performing a multivariate analysis to adjust for confounding variables, the Tai Chi group demonstrated a 47.5% reduction in the rate of falls compared with the balance training and education groups (P = 0.01; risk ratio = 0.525). The Tai Chi group also showed a significant reduction in fear of falling (P = 0.046) compared with the balance training and education groups. The benefits of 15 weeks of twice weekly Tai Chi were found to remain four months after formal instruction had ended.10
Adverse Effects
To date, there have been no adverse effects attributed to Tai Chi in the literature. In one controlled study of the safety of Tai Chi in rheumatoid arthritis patients, Tai Chi did not significantly increase joint tenderness, number of swollen joints, or grip strength.16 Although improved flexibility and range of motion are the goals of treatment in patients with arthritis, weight-bearing exercise is reluctantly recommended by physicians for fear of aggravating joint symptoms16 and potentially exacerbating the ongoing degenerative changes.6
There are no data on patients who already have fallen, nor are there data for patients who are currently taking anticoagulants.
Conclusion
Every patient over age 65 needs a risk assessment for falls. Medication lists should be reviewed, and specific medical conditions such as incontinence, BPH, and decreased visual acuity need to be addressed. External hazards at home, such as throw rugs and extension cords, should be eliminated, and grab bars and night-lights should be installed where necessary.
If patients have impairments in balance, strength, flexibility, or gait, current practice is a physical therapy baseline evaluation, supervised activity when possible, and physical therapy when appropriate.
If patients are healthy, ambulatory, and willing, we recommend that they also consider Tai Chi classes to reduce their risk of falling. In the case of patients with balance impairment specifically, we would recommend Tai Chi as primary therapy for fall prevention. Patients who practice Tai Chi, alone or with others, several times weekly for at least 10 weeks should expect to improve their balance and flexibility.
References
1. Tinetti M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331(13):821-827.
2. Anonymous. Falls, You can reduce your risk. Mayo Clinic Health Letter. September 1997.
3. Anonymous. Introduction to Tai Chi. Available at http://www.smc.maricopa.edu/sub1/tai/intro.html, July 14, 1998.
4. Purcell J. A Brief History of Tai Chi. Available at http://www.fis.utoronto.ca/~mckenzie/InternalPower/ taihist.html, July 14, 1998.
5. Ketola H. Mission School of Traditional Yang Style Tai Chi Chuan. Available at http://www3.bc.sympatico.ca/ taichi/taichi.html, July 14, 1998.
6. Lumsden D, et al. Tai Chi for osteoarthritis: An introduction for primary care physicians. Geriatrics 1998; 53:84-88.
7. Anonymous. What is Tai Chi Chuan? Available at http://www.taichichuan.co.uk/wudang/frames/intro. htm, July 14, 1998.
8. Wolf S, et al. Exploring the basis for Tai Chi Chuan as a therapeutic exercise approach. Arch Phys Med Rehab 1997;78(8):886-892.
9. Campbell AJ, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997;315:1065-1069.
10. Wolf S, et al. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. J Am Geriatr Soc 1996;44(5):489-497.
11. Lan C, et al. Cardiorespiratory function, flexibility, and body composition among geriatric Tai Chi Chuan practitioners. Arch Phys Med Rehabil 1996;77:612-616.
12. Lan C, et al. 12 month Tai Chi training in the elderly: Its effect on health fitness. Med Sci Sports Exerc 1998;30(3):345-351.
13. Tse SK, Bailey DM. Tai Chi and postural control in the well elderly. Am J Occup Ther 1992;46(4):295-300.
14. Schaller K. Tai Chi Chuan, An exercise option for older adults. J Gerontol Nur 1996;22(10):12-17.
15. Wolfson L, et al. Balance and strength training in older adults: Intervention gains and Tai Chi maintenance. J Am Geriatr Soc 1996;44(5):498-506.
16. Kirsteins A, et al. Evaluating the safety and potential use of a weight bearing exercise, Tai Chi Chuan, for rheumatoid arthritis patients. Am J Phys Med Rehab 1991;70(3):136-141.
Dr. Udani is a Fellow in Integrative Medicine and Health Services Research, Cedars Sinai Medical Center, Los Angeles.
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