ArticlePDF AvailableLiterature Review

Tai Chi as a Balance Improvement Exercise for Older Adults: A Systematic Review

Authors:

Abstract

The purpose of this systematic review was to identify exercise parameters and the most common outcome measures used in tai chi (TC) research. Ovid Medline and PubMed were used to identify longitudinal studies published from January 2000 to July 2007 written in English with the key words tai chi, tai ji, tai chi quan, tai ji quan, balance, falls, and falling. Qualifying studies had subjects aged 60 years or older. In all 19 qualified prospective studies, older vigorous and likely transitional frail individuals seemed to benefit more from TC than did older frail individuals. The most commonly used TC parameters were Yang's style, with 12 or fewer forms, durations of 12 weeks or longer, frequencies of twice a week or more, and session lengths of at least 45 minutes. The most common outcome measures observed were a combination of 2 to 5 of the following 10 measures (from most to least common): fear of falling, single-leg stance, posturography, rate of falling, flexibility, walking velocity, Berg Balance Scale, Timed up and Go, Functional Reach, and ankle and knee joint strength and range of motion. Improvements were reported in almost all of these measures. This review indicates that TC may be an economic and effective exercise program for improving balance and balance confidence in older adults.
INTRODUCTION
Tai chi (TC), a Chinese martial art and exercise system, has
lately been recognized as an effective intervention for fall
risk prevention among older people.1-3 The term
tai chi is
the common English spelling of the martial art/exercise, but
it is also spelled in the literature as “taiji,” “taijiquan,”
“taichichuan,” and “t’ai chi”; “taijiquan,” the Chinese
pinyin romanization, is the form most often found in schol-
arly social science literature.
The Library of Congress and
most university libraries also catalogue romanized Chinese
with pinyin
.
We choose the popular romanization tai chi
because it is the spelling most familiar to both clinicians and
patients and is the standard rendition of the term in
PubMed
.
Through slow, repetitive, and alternating move-
ment of the legs with the knees slightly flexed, TC practi-
tioners shift their body weight from one leg to the other in
sequential, graceful movements that emphasize smooth
trunk rotation and coordination between the body and
extremities.4,5 The literature reviewed in this article indi-
cates that TC has been used to enhance postural control,
especially for those suffering from complicated conditions
with disruptions in their visual and somatosensory sys-
tems.6 ,7 The practice of TC is thought to increase awareness
of body alignment during movement by focusing on the
placement of the feet, an upright position of the head and
trunk, and the intentional, attentive body movement in the
direction of the specific TC postures.8 Furthermore, several
scientific studies of TC have demonstrated improvements in
lower extremity range of motion,9 strength,9 and proprio-
ception,10 as well as enhanced neuromuscular responses
involved in controlling the ankle joint during perturba-
tions11 and in controlling stepping strategies of the swing
leg during gait.12
In the last 2 decades, particularly since 2000, investiga-
tions have been conducted regarding the effectiveness of TC
in improving balance in older people.1-3 However, significant
differences among these studies in terms of the selection of
subjects, appropriate TC exercise parameters, and outcome
measures challenge interpretation of TC effectiveness and
indicate a need for more standardized assessment procedures.
The purpose of this systematic review is to identify the types
of older adults who could benefit the most from practicing
TC, the most appropriate TC protocol (in terms of TC style,
number of forms, duration, frequency, and time length of
sessions) for improving balance, and the balance parameters
that TC could improve in terms of balance measurements.
Systematic Review
Tai Chi as a Balance Improvement Exercise
for Older Adults: A Systematic Review
Hao Liu, PhD, PT1; Adam Frank, PhD2
ABSTRACT
Purpose:
The purpose of this systematic review was to identi-
fy exercise parameters and the most common outcome meas-
ures used in tai chi (TC) research.
Methods: Ovid Medline and PubMed were used to identify
longitudinal studies published from January 2000 to July
2007 written in English with the key words tai chi, tai ji, tai chi
quan, tai ji quan, balance, falls, and falling.
Qualifying studies
had subjects aged 60 years or older.
Results:
In all 19 qualified prospective studies, older vigorous
and likely transitional frail individuals seemed to benefit more
from TC than did older frail individuals
.
The most commonly
used TC parameters were Yang’s style, with 12 or fewer forms,
durations of 12 weeks or longer, frequencies of twice a week
or more, and session lengths of at least 45 minutes
.
The most
common outcome measures observed were a combination of
2 to 5 of the following 10 measures (from most to least com-
mon): fear of falling, single-leg stance, posturography, rate of
falling, flexibility, walking velocity, Berg Balance Scale, Timed
up and Go, Functional Reach, and ankle and knee joint
strength and range of motion. Improvements were reported in
almost all of these measures.
Conclusions:
This review indicates that TC may be an eco-
nomic and effective exercise program for improving balance
and balance confidence in older adults.
Key Words:
falls, rehabilitation, TCM exercise, Traditional
Chinese Medicine
(J Geriatr Phys Ther 2010;33:103-109)
Address correspondence to: Hao Liu, PhD, PT, Physi
cal
Therapy Program, University of North Texas Health
Science Center, 3500 Camp Bowie Blvd., Fort Worth,
TX 76107 (hao.liu@unthsc.edu).
DOI: 10.1097/JPT.0b013e3181eda1c4
103
J
ournal of GERIATRIC Physical Therapy
Copyright © 2010 The Section on Geria tri cs o f t he American Physic al Th erap y As soci atio n. Una uthorized reprod uctio n o f this ar ticle is proh ibit ed.
1
Physical Therapy Department, University of North Texas
Health Science Center, Fort Worth, Texas
2
Honor College, University of Central Arkansas, Conway.
Systematic Review
METHODS
Data Sources and Searches
Ovid Medline and PubMed were used to identify articles
published since January 2000 that were written in English
and contained the key words tai chi, tai ji, tai chi quan, tai ji
quan, “balance”, “falls”, and “falling.” The year 2000 is a
somewhat arbitrary but significant benchmark for beginning
this review. Although several health-related scholarly articles
appeared on TC prior to that year, the literature increases in
both scope and number after 2000
.
For example, from 1980
to 1999, a PubMed search finds 29 articles with the term tai
chi in their titles.
From 2000 to 2007, 181 articles appear
with tai chi in their titles.
Study Selection
The following inclusion criteria were used to select previous-
ly published studies: (1) must be longitudinal study, including
randomized controlled trials, quasirandomized trials, and
preintervention and postintervention analyses; (2) TC had to
be one of the interventions investigated; (3) the subjects had
to be 60 years or older; and (4) outcomes measured included
one or a combination of strength, balance, activity perform-
ance, fear of falling, and rate of falling. All of these studies
were first screened by one of the authors (H.L.) before further
data extraction by both authors (H.L
. and A.F.).
Quality Assessment
The quality of selected articles was ensured using the follow-
ing criteria: (1) subjects were randomly selected; (2) no pop-
ulation group with a mixture of different ages (
60 years
old and
60 years old) was presented in the study; (3) in the
randomized controlled trials and quasirandomized trials, the
groups had similar baseline characteristics and equal oppor-
tunity to receive the interventions; (4) outcomes were
assessed blindly; and (5) statistical methods were applied
appropriately.
Data Analysis
All data were extracted by the 2 authors and summarized
with an analysis of the information presented from each
study (Table 1). The analysis focused on 3 categories:
recruited subjects and their functional status, parameters of
TC intervention (style, forms, duration, frequency, and ses-
sion length), and outcome measurement (balance, function-
al performance, lower extremity strength, fear of falling,
and rate of falling).
RESULTS
From January 2000 to July 2007, 18 studies (with 20 arti-
cles published), including 15 controlled studies and 3 pretest
and posttest (within subjects) studies, met selection criteria
(Table 1).
Who Can Benefit from TC?
Tai chi could be practiced by older people (Table 1) who
live independently in a community11-13,16-1 9,22,24,25,28,29 or
104
in senior living facilities (congregated housing, retirement
centers, and/or assisted living facilities)14,15,20-22,26 or in
nursing homes.15,30 However, the ability of TC to improve
balance seems to be based on the subjects’ functional status.
Speechley and Tinetti31 proposed 9 frail attributes (age
80,
abnormal gait/balance, infrequent [
1/wk] walking activ-
ity for exercise, decreased shoulder strength, decreased knee
strength, lower extremity disability, depression, taking
sedatives, and near-vision loss) and 4 vigorous attributes
(age
80, intact cognition, frequent exercise, and good
near-vision) for the assessment of functional status.
Vigorous is defined as possessing at least 3 vigorous attrib-
utes and fewer than 2 frail attributes;
frail
is defined as pos-
sessing a minimum of 4 frail attributes and fewer than 1
vigorous attribute
. Transitional frail is defined as possessing
attributes between the vigorous and the frail
. With these
definitions in mind, we evaluated all selected studies and
found that, based on the subject selection criteria among
these studies, subjects in 4 studies22-24,26 could be catego-
rized with Speechley and Tinetti’s definition. Among these 4
studies, balance improvement was identified in subjects
with a vigorous status23,24 or with a transitional frail
status.22,26 Also, using this categorization, Wolf et al26
reported that TC did not decrease the risk ratio of falling in
older people who were transitional frail prior to the study.
When both the TC and the control groups contained both
transitional frail and frail subjects, no significant difference
could be identified in fall rate between the groups.14,30
Furthermore, Fried et al32 developed another categoriza-
tion of older people using 5 attributes (unintentional weight
loss, weakness, exhaustion, slowness, and low physical
activity) primarily based on Short Form 36 (SF-36) sub-
scores to categorize them into frail (3 or more of 5 attrib-
utes), prefrail (1 or 2 of 5 attributes), and nonfrail (none of
5 attributes) phenotypes
. During our review, we did not
analyze the subjects in each reviewed study by using Fried
et al’s categorization, because the SF-36 scores were not
available from these reviewed studies. However, using this
categorization, Faber et al15 reported that TC exercise has
positive effects in regards to falling and physical perform-
ance in prefrail but not frail older people.
The “frail” in
Fried et al’s categorization is not exactly the same as the
frail in Speechley and Tinetti’s categorization, but individu-
als in both categorizations with the lowest functional level
are considered frail. Considering this evidence, improve-
ment of balance and physical performance could be demon-
strated among vigorous older people but remains a topic of
debate among transitional frail subjects26 and might not be
apparent in frail older people.15,30
Whether or not a TC participant had to use an assistive
ambulatory device during TC practice seemed to play a role
in affecting the rate of falling and the fear of falling among
the elderly14,15,18,2 2,26,30 who were frail or transitional frail
(prefrail), living either in senior living communities14,18,22,26
or in nursing homes.15,30 None of the studies in this review
included wheelchair users or those who are unable to stand
up during TC practice, although some TC learning books
are available to these people.33,34
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TC Styles & Forms
Yang, form undescribed
Yang, 10 forms (note: 1-2 forms a week
for 8 wk, then perform the whole 10
forms for 4 wk)
Sun, 12 forms (music background)
Yang, 7 forms
Yang, 24 forms
Chen, 13 forms
Yang, 5 forms
Yang, 12 forms
Yang, 24 forms
Yang, 6 forms
Yang, form undescribed
Wu (Ng), 108 forms
Mix of Yang and Sun, no standardized
forms mentioned
Yang, 6 forms
Yang, form undescribed
Yang, 24 forms for practice with
instructors and first 11 of the 24
forms for self-practice at home
Yang, 24 forms
No description for style and form
Table 1
.
Studies Meeting Inclusion Criteria for Analysis
Method
RCT
TC vs education on balance and stress
Controlled trial
TC vs brisk walking
Quasiexperimental
TC vs routine daily activity
RCT
TC vs functional walking
RCT
TC vs stretching exercise
Controlled
TC vs education on fall prevention
RCT
TC vs routine daily activity
Controlled: TC vs combined balance
and step training
Pre-post
RCT
TC vs wellness education
Pre-post (case control)
RCT
TC vs general education
RCT
TC vs routine daily activity
Study
Gatts and Woollacott
11
Gatts and Woollacott
12
Audette et al13
Choi et al
14
Faber et al
15
Li et al16
Li et al17
Lin et al18
Maciaszek et al
19
Nnodim et al20
Richerson and Rosendale21
Sattin et al
22
Taggart et al
23
Tsang and Hui-Chan24
Voukelatos et al
25
Wolf et al
26
Wu and Keyes
27
Zhang et al28
Woo et al
29
Nowalk et al30
Subjects
22 elderly (Berg 44) with history of
operation on knee, hip, and back)
19 community sedentary older women
68 fall-prone older persons
278 subjects from 15 nursing homes
256 older physically inactive communit
y
dwellers
1200 in 6 rural villages (finally 88 TC
and 5 control)
49 older subjects with diagnosis of
osteopenia or osteoporosis in
community
213 older subjects from local senior
centers
18 healthy elderly and adults with
diabetes mellitus
311 community residents
Old women ( 65 yr)
49 healthy older subjects
702 older community dwellers
Duration/Frequency/Session Length
3 wk, 5 d/wk, 90 min/d
12 wk, 3 d/wk, 60 min/d (15-20 min
warm-up, and then 40-45 min TC)
12 wk, 3 d/w, 35 min/d (10
20
5)
20 wk, 1d/wk for 4 wk, then 2 d/wk for
16 wk, 90 min/d (30 for social activity
and 60 for TC), then follow-up for 52 w
k
26 wk, 3 d/wk, 40-50 min/d
52 wk, 6 d/wk, 60 min/d
18 wk, 2 d/wk, 45 min/d
10 wk, 3 d/wk, 60 min/d
26 wk, 1 d/wk, no session length
mentioned
48 wk, 2 d/w, 60-90 min/d
12 wk, 2 d/wk, 30 min/d
8 wk, 6 d/wk, 90 min/d.
Practiced in morning time
16 wk, weekly, 60 min/d, then follow-up
for 24 wk
48 wk, 2 d/wk, 60-90 min/d, then
follow-up for 4 mo
15 wk, 3 d/wk, 60 min/d
8 wk, daily, no session length
mentioned
12 mo, 2 d/wk, no session length
mentioned
3 d/wk, assessment every 6 mo for total
24 mo
.
No session length mentioned
RCT
TC vs balance training vs wellness
200 transitional frail
education
Pre-post
RCT
TC vs general daily activity
RCT
TC vs resistant exercise vs no exercise at al
l
RCT
TC vs strength training and conditioning
vs general education
17 independent living elderly
49 elderly community dwellers
180 elderly in community center
110 elderly residents in independen
t
living facilities and nursing homes
Abbreviations: RCT, randomized controlled trial; TC, tai chi.
Systematic Review
Styles of TC
The term “style” refers to sequences of TC movements gen-
erally differentiated by lineage names (Chen, Yang, Wu,
etc).
What is now known as Chen-style TC was the earliest
TC, originating around the middle of the 16th century in
China
. The term TC or TC chuan (supreme ultimate
boxing) does not appear in historical documents until the
late 19th century, but the “internalor “soft” martial art
styles that adopted the name can be documented as early as
the late 18th century.35 Besides Chen style, there are 4 other
styles of TC that are popular today (Yang, Wu, Sun, and
Wu/Hao) and claim their origins in Chen style, though this
is a matter of some debate among Chen-style practitioners.4
It should be noted that “Wu/Hao” TC bears no relation to
“Wu”-style TC
.
Wu, Wu, and Hao are family names, but
the 2 Wus are represented by different Chinese characters.
Today, Yang style is the most popular style practiced by
older populations.11,13,1 5,16,19-23,25-29 Its characteristics are
slow, large, graceful, sequential movements from one pose
to the next with an upright posture and high stance position
(knees bent slightly, less than 30 ). Chen style18,25,30 is
ostensibly more “martial” in appearance. It requires a
lower stance (knees bent more, around 30 -60 ) that may
require more energy expenditure during practice.36 Chen
also intersperses quick, explosive movements and stamping
with slow movements,5,36 which may explain why Chen
style was not as common as Yang style for older popula-
tions in the studies reviewed.
Other styles were reported in our review studies: 1 for
Sun style14 and 1 for Wu style,24 but no Wu/Hao style was
reported
. Almost all TC styles include slow and fast ver-
sions, weapons forms, and 2-person exercises. Slower forms
are generally learned first and weapons and 2-person exer-
cises added later. The Sun style features relatively fast hand
and slow leg movements.5 The Wu style set is slow, requir-
ing internal power to maintain the trunk in a constant
upright posture,4 whereas the Wu/Hao style requires a high
stance position (like Yang style) with relatively rapid execu-
tion of small movements.5
TC Forms
The term “formrefers to individual movements within
those styles.
Fourteen studies in this review reported the num-
bers of forms used by older people, as shown in Table 1.
These numbers range from 5 forms19 to 108 forms.24
Within this range are styles that include 6 forms,22,26 7
forms,15 10 forms,13 12 forms,14,20 13 forms,18 and 24
forms.16,21,28,29 The 24-form Yang style was the most fre-
quently reported
.
In 1956, the Chinese Sports Commission4
adopted Yang Style to develop a simplified 24-form TC for
ordinary Chinese to learn and practice
.
The 24 forms also
gained popularity in competition. Many other shorter
forms, most often based on the Yang style,13,15, 19,20,22, 26
were adopted or modified for the research studies consid-
ered in this review.
In most of these articles, the number of
forms was selected on the basis of the subject’s functional
level. Healthy, functionally independent subjects could
learn and practice 24 to 108 TC forms,16,21,24,27,29 whereas
106
those with lower functional levels might learn much short-
er forms.14,15,20,26 For example, subjects who were identi-
fied to be frail were provided only 6 forms26 or 7 forms.15
Only one study26 referred to a pre-2000 research37 that
described specific forms practiced by older subjects but did
not explain why the forms were selected.
Description of Interventions
The duration, frequency, and session length of TC exercise
prescribed to older people for balance improvement varied
among studies.
As shown in Table 1, the range in duration
stretched from 3 weeks12 to 8 weeks,24,28 10 weeks,20
12 weeks,13-15,23 15 weeks,27 16 weeks,25 18 weeks,19
26 weeks,16,21,30 48 weeks,22,26 52 weeks,18,29,30 and even
104 weeks (2 years).30 The frequency of TC practice in
these studies varied from once a week15,21,25 to twice a
week,15,19,22,23,26,29 3 times a week,13,14,16,20,27,32 and 5 to
7 times a week.11,18,24,28 The time length of each TC
practice session ranged from 30 minutes23 to 35 minutes,1 4
45 minutes,19 40 to 50 minutes,16 60 minutes,13,18, 20,25,27
60 to 90 minutes,22,26 and even 90 minutes.11 In summary,
most of the TC protocols required a duration of 12 weeks
or more, with a frequency of at least 2 times a week and
minimum of 45 minutes of TC session time.
Several points about the reviewed studies are notable.
First, a few studies mentioned warm-up (5-20 minutes) and
cooldown (5-10 minutes) times before and after TC practice.
The w
arm-up exercises included stretching, deep breathing,27
range of motion (ROM) exercise in a seated position,13,14 or
social activity.14 The cooldown exercises included ROM
exercises, resting,14 and social2 or visualization exercises.27
Second, short duration (
12 weeks), high frequency (on
daily basis), and long sessions (at least 60 minutes) were
usually reserved for vigorous and/or transitional frail older
subjects.11,20,28 From the research under review, such pro-
tocols seem ill-suited for people who fatigue easily or are
not able to stand for too long without assistance
. Longer
duration (12 weeks or more), lower frequency (2-3 times a
week), and session length of 45 minutes or more were most
commonly used for older adults, including older frail and
transitional frail subjects.13,15,16,19 ,22,2 6,27
Third, the studies under review appeared to use 2
primary mechanisms to avoid fatigue and learning frustra-
tion: (1) provide enough warm-up time, rest intervals, and
cooldown time to avoid fatigue and loss of interest;13- 15 and
(2) provide time for discussion during warm-up or
cooldown time.28
Fourth, some researchers agreed that a follow-up study
may be necessary to investigate adherence to TC exercise
after the period of training.15,25, 30
Fifth, the studies showed that it may take 5 minutes on
average to complete the 24-form Yang style (no age
restriction),36 while an older individual may need 2 con-
tinuous minutes to complete a 6-form Yang TC without
hesitating or stopping during performance.26 However,
no studies have reported how long (on average) a healthy
older ( 65) individual needs to learn to perform these
TC exercises independently.
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Sixth, for assistive ambulatory device users to practice
TC, it may require 3 months to progress from dependence
on an AAD to independence during the practice of TC.26
Outcomes of TC Intervention
Various measures were used to determine the effect of TC
intervention, including measurements of static and dynamic
balance, functional performance, muscle strength and flex-
ibility, and subjective measures (Table 2). After TC practice,
static balance has been measured with posturography, single-
leg standing (SLS) time, and tandem stance time. The results
Table 2
.
Outcome Measures Used in Studies Included in the
Systematic Review
Static balance
1.
Posturography: significantly improved with eyes open on a plat-
form
21,25,27
and on a mat
25
but was not identified in other studies
(on a platform).23,29
2. Single-leg stance: significantly improved,13,17,21.27,28 but not in
others.
14,2 0
3.
Tandem stance: improved,
20,25
but the improvement from TC prac-
tice was not better than with other balance exercise training.
20
Anticipatory dynamic balance
1. Posturography: significantly improved.10,19
2.
Functional reach.
16, 17,26
2.
Functional reach.
16, 17,26
3. Stepping reaction time: improved.25
4. Berg Balance Scale: improved,16,23 but not on a Berg component
(turn and pick up an object from floor).26
5.
Tinetti/Performance Oriented Mobility Assessment Balance Scale:
improved.18
Functional performance
1. Performance-oriented mobility assessment15
2. Gait velocity: improved on one 1 study on a 50-ft (15.24-m) distance,17
but not improved on others on a 8-m29 or a 10-m26,28 distance.
3. Improved maximal step length.20
4. Improved Timed Up & Go17,27,30
5. Chair rise: no difference compared with nonintervention group.26
6. Improved Tinetti Gait Scale.16,18
Muscle strength and flexibility
1. Strength improved on the knee11,13 and the ankle11,13,14 flexors and
extensors, but not on gripping strength.26
2. Trunk flexibility by bending toward floor improved,14,28 but not on
another.29
Subjective measures
1.
Fear of falling improved
14,17,22,23,27,28
but not on other studies.
18, 26
2. Groningen Activity Restriction Scale (for disability) improved.15
3.
Rate of falling improved
17,25
but not on others.
14, 15,18, 20, 26,2 9
4. Time to first fall improved25 but not on another study.30
Compared with other exercises
a
1. TC is significantly better than education on wellness22,24 or on fall
prevention.
11, 18
2. TC is also more effective for balance improvement than routine
daily activity (nonintervention)14,19,25,28,29, or stretching.17
3. Balance improved but not significantly better than the resist-
ance strengthening exercise,29 functional balance training,20 or
walking.
13 ,15
Abbreviation: TC, tai chi.
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Systematic Review
from the measures seemed to be unclear. Some studies
demonstrated significant improvements in static balance as
measured by posturograph,21,25,27 SLS time,13,17,21.27,28 and
tandem stance time.20,25 However, other studies reported that
such improvements were not identified in posturography29
and SLS time,14,20 and the improvement in tandem stance
time after TC intervention was not better than with other
balance exercise training.20 Among these static balance
measures, 3 studies13,20,26 compared SLS time under the
conditions of eyes open versus eyes closed. The results
showed that TC improved the SLS time when the subjects’
eyes were open but not when their eyes were closed.
Dynamic balance improvement was not too contradic-
tory
. All measures of dynamic stance from the selected arti-
cles demonstrated significant improvement as examined by
posturograph,19,24 stepping reaction time,25 maximal step
length,20 and the Functional Reach Test.16,17,26 Measures
of combined static and dynamic balance, such as the
16,17,23
Tinetti Balance Scale18 and the Berg Balance Scale,
the Berg component of turning and picking up an object
Researchers saw significantly improved performance
velocity was reported significantly improved in 1 study17
measured chair rise.26
nificant increases in lower extremity muscle strength
were reported for the knee11 and ankle11,14 flexors and
seen in bending over toward the floor was documented in
Subjective measures were conducted and significant
improvements were revealed in fear of falling (measured
Confidence Scale),14,17,22,23,27,28 rate (number) of falling
(ROF),17,25 time to first fall,25 and self-reported health
status (Groningen Activity Restriction Scale).15 However,
ies in fear of falling,18,26 ROF,
and time to first
results, fear of falling
improvement
14,17,22,23,27,28
was
reported in more studies than the ROF.17,25 In many stud-
ies, the ROF was not reported to be significantly improved
5-month follow-up after a 15-week TC intervention.26
no additional instruments
or
equipment.13,15,20 As
shown in Table 2, TC practice can result in improve-
ments in many balance measures when compared with
daily activity.14,19, 25,28, 29 However, TC did not appear to
be better than other physical therapy interventions, such
or functional walking.13 ,15
107
demonstrated significant improvement as well.
However,
from floor did not improve.26
on the Performance Oriented Mobility Assessment,15
Timed Up and Go,17, 27, 30 and Tinetti Gait Scale.16-18 Gait
but not in others.26,28,29 Also, no difference was found
between the TC group and control group in a study that
Grip strength was reportedly not improved,26 but sig-
extensors.13 Significant improvement in trunk flexibility
2 studies14,28 but not in others.29
with Falls Efficacy Scale or Activities-Specific Balance
insignificant improvement was also reported in other stud-
14,1 5,18,20,2 6,29
fall.30 Taken together of these seemingly contradictory
at the end of the TC intervention14,15,18,2 0,26,29 or at the
Tai chi is a cost-effective intervention that requires
general
education,
11,18,22, 24
stretching,17 and routine
as resistance strengthening,29 functional balance training,20
Systematic Review
Quiet or Music Background
One study mentioned that a music background was used
during TC practice.14 However, TC is supposedly practiced
with total concentration and inner calm that helps to sus-
tain and maintain the circulation of “qi” (vital life energy in
Chinese philosophy).4 Sufficient and well-circulated qi is
the basic mechanism to maintain the balance of “yin” (soft-
ness, darkness, weightlessness, and femininity) and “yang”
(hardness, brightness, heaviness, and masculinity) inside the
body as well as between the inner world and the outside
environment.4 So, during practice, practitioners may need
to concentrate and feel each TC movement
.
On the basis of
this, TC instructors generally eschew listening to music as a
cue or reminder during performance of the exercise.
CONCLUSIONS
Based on the results summarized previously, many studies
have demonstrated that performance on balance measures
can be improved for older subjects by practicing TC
. The
benefits and general mechanism of how and why TC
improves the quality of life for older adults have been well
evaluated and reviewed by others.1-3 In this review article,
our discussion focused more on studies that reported unsuc-
cessful progress in one or more balance measures after TC
training
.
Explanations for these results might be attributed
to the following areas: (1) subject categorization, (2) TC
style and form selection, (3) selection of duration, frequency,
and session length, and (4) use of background music
. In
other words, these 4 areas might need to be considered by
clinicians before TC is provided.
In this review, results from 2 studies15,26 (which used
stratification to group subjects) indicated that older peo-
ple in frailty did not typically benefit, in terms of per-
formance on measures of balance, from TC
.
However, in
other studies without stratification (subjects from the
vigorous, transitional frail, and frail categories were
mixed together), it was uncertain whether the results
were significantly different between the TC group and
the control group. Many of these studies demonstrated
better results after TC practice,11-13,15-17,19,20,21,25,27,29 but
some showed no difference between TC practice and
non-TC practice18,20,28,29 in terms of static balance, fear
of falling, and rate of falling. Because we were not able
to determine how many subjects in each of these studies
could be categorized as frail, it might be reasonable for
us to inquire if the number of frail subjects in each of
these studies could alter the final measured results.
As demonstrated in this review, the style most com-
monly used for older TC practitioners is Yang style,
selected primarily because of its slow movements and the
decreased physical demand during the movements. As of
forms, 2 questions arise during form selection: (1) What
is
the appropriate number of forms? (2) What forms
should be selected? Various numbers of TC forms, from
short (5 forms19) to long (108 forms24), have been pro-
vided to the older population.
For individuals with bal-
ance deficits and decreased memory ability, the short TC
108
forms might be the best choice with which to begin. In
terms of which forms should be selected, each individual
TC form requires the practitioner to perform specific
body movements that can vary widely between forms.
Therefore, the TC providers’ choice of forms might
impact the subjects’ abilities to benefit from TC.
For
example, some forms (such as the Parting Wild Horse’s
Mane form) may require more weight shifting and pos-
ture changes than other forms (such as the Cloud Hands
form). As a result, it is possible that the forms selected for
practice might affect the outcomes measured after TC
training
. It might also be necessary for TC providers to
ju
stify why certain TC forms (particularly the short
forms) are selected.
In order to effectively provide TC as an exercise pre-
scription, a clinician needs to consider which TC param-
eters are the most appropriate for older individuals
.
Short
duration (
12 weeks) may be good for more functional-
ly independent individuals, but it usually required
increased frequency and session length.12,24 Long dura-
tion with less frequency and less actual TC practice time
might have favorable effects on those with a balance
deficit.26 The whole session time may include the warm-
up, the actual TC time (including rest intervals), and
cooldown.13,14,27 Doing so may reduce fatigue and learn-
ing frustration as well as increase interest and ability to
remember learned TC forms
.
Taken together, these results
suggest that the selection of TC exercise parameters can
likely affect the outcome measures after TC practice.
Also, a regimen of 12 or fewer forms, a duration of 12
weeks or longer, a frequency of 2-3/wk, and a session
length of at least 45 minutes might be an appropriate pre-
scription for older people with balance deficits in the
practice of TC.
The possible benefit or detriment of background music
during TC is questionable
. Use of music might affect the
benefit of TC for subjects by interrupting the inner focus
required during TC practice. Only 1 study14 from our
review reported the use of background music during TC
practice, and it found no improvement in the outcome
measures of SLS time, ankle strength, and rate of falling.
We could not conclude whether the lack of improvement
was a result of the background music, but use of music in
TC is worthy of discussion and future research.
The 4 areas discussed previously could affect the out-
come measures obtained after TC practice individually or in
combination
. However, the reviewed studies generally indi-
cate that TC may be an economic, effective, and safe exer-
cise program for balance training.
Further research that
incorporates more sophisticated research designs is neces-
sary.
To perform TC, one does not need additional exercise
equipment but only a small open area.4 The low (short
forms) to moderate (long forms) intensity and slow move-
ment of each form4 may minimize energy consumption and
risk of injury during performance
.
Although there are con-
tradictory results, improvements have been reported by
almost all of the reviewed longitudinal studies as measured
by one or more of the following: balance, performance,
Volume 33 • Number 3 • July-September 2010
Copyright © 2010 The Section on Geria tri cs o f t he American Physic al Th erap y As soci atio n. Una uthorized reprod uctio n o f this ar ticle is proh ibit ed.
Systematic Review
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muscle strength, and/or subjective evaluations. Results also
indicate that TC, commonly performed in groups, might be
more beneficial to the vigorous and likely the transitional
frail older adults
.
Older people in the frail category may
need an individually designed exercise program rather than
a group intervention, such as TC.30
For future studies, some factors that could affect the
outcome measurements may need to be considered
. These
factors include the following: stratification based on
frailty, validation of the specific TC style and forms
selected, the specific mechanics of each TC form, the con-
sistency among instructors in communicating the correct
performance of the TC forms, assurance of the quality of
movement in each form, use of light background music,
and a longer term of follow-up after TC training.
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Sarcopenia has become a key challenge for healthy aging in older adults. However, it remains unclear whether traditional Chinese medicine can effectively treat sarcopenia. This systematic review analyzes the current evidence for the effect of traditional Chinese medicine (TCM) on sarcopenia. We searched for articles regarding sarcopenia treated by TCM in Cochrane library, PubMed, SinoMed, Web of Science, Embase, and the China National Knowledge Infrastructure (from inception until 10 December 2021). Two researchers independently screened the literature in accordance with the inclusion and exclusion criteria designed by PICOS principles. The risk of bias was assessed by the Cochrane Risk of Bias (ROB) tool. The quality of evidence was assessed by the grading of recommendations, assessment, development, and evaluation (GRADE). Participants’ characteristics, interventions, and the relevant results of the included studies were extracted and synthesized in a narrative way. The total number of participants in the 21 included studies was 1,330. Most of the studies evaluated physical function (n = 20) and muscle strength (n = 18), and a small number of studies (n = 6) assessed muscle mass. Overall, it was found that TCM had a positive impact on muscle strength (grip strength, chair stand test) and physical function (6-m walking speed, timed up and go test, sit and reach) in patients with sarcopenia, inconsistent evidence of effects on muscle mass. However, the small sample size of the included studies led to imprecision in the results, and the presence of blinding of the studies, allocation concealment, and unreasonable problems with the control group design made the results low grade. Among these results, the quality of evidence for grip strength (n = 10) was of medium grade, and the quality of evidence related to the remaining indicators was of low grade. This systematic review showed that traditional Chinese Qigong exercises and Chinese herbal medicine have a positive and important effect on physical performance and muscle strength in older adults with sarcopenia. Future high-quality multicenter randomized controlled trials (RCTs) with large samples are needed to determinate whether acupuncture and other therapies are effective in treating sarcopenia.
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Traditional, complementary, and integrative medicines include therapies of low cost, moderate intensity, low technology, and low impact and possibility of practice by aged people with chronic diseases. This evidence map identified 54 systematic reviews focused on the aged populations related to tai chi, tai chi chuan, qi gong, traditional Chinese exercise, acupuncture, meditation, and yoga interventions. These therapies have been evaluated on different health conditions, including positive effects to balance, quality of life, physical function, risk of falling, depression, anxiety, cognitive performance, stress, aerobic capacity, muscle strength, sleep quality, depression, kyphosis, cholesterol, dyspnea, body mass index, bone density mobility, insomnia. Acupuncture, Tai Chi, Tai Chi Chuan, Qi Gong, Traditional Chinese Medicine Exercises, Meditation, and Yoga have been applied in different areas and this map indicates more than 100 positive and promising effects for the aged population.
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Background Bipedal static posturography is widely used to assess postural control. However, standardized methods and evidence on the influence of footwear on balance in comparison to barefoot stance is sparse. Research questions Is bipedal static posturography applied in a standardized way with respect to demographics and the experimental set-up (systematic review)? Does habitual footwear influence postural control in comparison to barefoot condition during bipedal static posturography in adult patients and healthy subjects (meta-analysis)? Methods For this systematic review and meta-analysis, a comprehensive follow-up literature search was conducted from March 2009 until January 2020 according to the PRISMA guidelines. Original, research articles reporting on bipedal, unsupported, static posturography in adults (≥18 years) were included according to inclusion criteria (age, sex, height, weight, duration, repetitions, visual/foot condition, sampling frequency). Studies comparing habitual footwear with barefoot condition during bipedal static posturography were included for the meta-analysis. Center of pressure parameters (sway velocity, range, root mean square, paths lengths) with subjects having eyes closed (EC) or open (EO) were analyzed using random effects models. Results For this systematic review and meta-analysis, 207 and eight out of 5189 studies with 12,3414 and 156 subjects, respectively, were eligible. Most studies (89%) reported barefoot, 5% shod, and 6% barefoot and shod measurements. Less than half of studies (44%) included patients of which the minority (13%) suffered from neurological disease. Sway velocity in the anterior-posterior direction was higher in habitual shoes compared to barefoot with EC (SMD: 1.08; 95% CI: 0.68-1.48; p<0.01; I²=0%), with EO (SMD: 0.68; 95% CI: 0.11-1.26; p=0.02; I²=1%), and in the medio-lateral direction with EC (SMD: 1.30; 95% CI: 0.76-1.85, p<0.01; I²=37%). Significance Methodical heterogeneity of bipedal static posturography hampers studies’ comparability. Thus, we provide a standardized approach to increase knowledge whether habitual footwear decrease postural control in comparison to barefoot stance.
Background: Due to the low physical fitness of the frail elderly, current exercise program strategies have a limited impact. Eight-form Tai Chi has a low intensity, but high effectiveness in the elderly. Inspired by it, we designed an exercise program that incorporates eight-form Tai Chi, strength, and endurance exercises, to improve physical fitness and reverse frailty in the elderly. Additionally, for the ease of use in clinical practice, machine learning simulations were used to predict the frailty status after the intervention. Methods: For 24 weeks, 150 frail elderly people completed the experiment, which comprised the eight-form Tai Chi group (TC), the strength and endurance training group (SE), and a comprehensive intervention combining both TC and SE (TCSE). The comparison of the demographic variables used one-way ANOVA for continuous data and the chi-squared test for categorical data. Two-way repeated measures analysis of variance (ANOVA) was performed to determine significant main effects and interaction effects. Eleven machine learning models were used to predict the frailty status of the elderly following the intervention. Results: Two-way repeated measures ANOVA results before the intervention, group effects of ten-meter maximum walking speed (10 m MWS), grip strength (GS), timed up and go test (TUGT), and the six-minute walk test (6 min WT) were not significant. There was a significant interaction effect of group × time in ten-meter maximum walking speed, grip strength, and the six-minute walk test. Post hoc tests showed that after 24 weeks of intervention, subjects in the TCSE group showed the greatest significant improvements in ten-meter maximum walking speed (p < 0.05) and the six-minute walk test (p < 0.05) compared to the TC group and SE group. The improvement in grip strength in the TCSE group (4.29 kg) was slightly less than that in the SE group (5.16 kg). There was neither a significant main effect nor a significant interaction effect for TUGT in subjects. The stacking model outperformed other algorithms. Accuracy and the F1-score were 67.8% and 71.3%, respectively. Conclusion: A hybrid exercise program consisting of eight-form Tai Chi and strength and endurance exercises can more effectively improve physical fitness and reduce frailty among the elderly. It is possible to predict whether an elderly person will reverse frailty following an exercise program based on the stacking model.
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Résumé Introduction Les thérapies actives du mouvement corps-esprit sont pratiquées dans le but d’engager la personne à prendre soin de sa santé. Elles sont représentées par le qi gong, le tai-chi et le yoga. Elles comprennent toutes des postures, des exercices de respiration et de méditation. Utilisées conjointement avec la médecine traditionnelle, elles permettent une vision plus globale du patient, afin d’améliorer la qualité de vie. État des connaissances Ces thérapies ont été étudiées dans la bronchopneumopathie chronique obstructive, en comparaison de soins courants ou d’une activité physique de type marche, mais très peu dans le cadre de la réadaptation respiratoire. Les effets sont cliniquement significatifs sur la qualité de vie et la capacité fonctionnelle, et certaines des comorbidités peuvent également être impactées. Perspectives L’application de ces thérapies doit être étendue aux patients GOLD grade 1 et 4 tout en étudiant les effets sur la survenue des exacerbations bronchiques. Il reste à confirmer l’intérêt de les pratiquer en substitution d’une réadaptation respiratoire et à les évaluer en association de cette dernière. Conclusion Ces thérapies peuvent être utilisées pour faciliter le changement de comportement dans une optique thérapeutique et préventive, permettant de diminuer l’impact de facteurs aggravants de la maladie respiratoire.
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Introduction: Elderly people in the society faces plenty of physical and medical problems, which make them more at risk of deconditioning and confined to their home due to impaired mobility and frequent falls.
Article
Tai Chi has been proven effective in preventing falls in older adults, improving the joint function of knee osteoarthritis patients, and improving the balance of stroke survivors. However, the effect of Tai Chi on human gait dynamics is still less understood. Studies conducted in this domain only relied on statistical and clinical measurements on the time-series gait data. In recent years machine learning has proven its ability in recognizing complex patterns from time-series data. In this research work, we have evaluated the performance of several machine learning algorithms in classifying the walking gait of Tai Chi masters (people expert on Tai Chi) from the normal subjects. The study is designed in a longitudinal manner where the Tai Chi naive subjects received 6 months of Tai Chi training and the data was recorded during the initial and follow-up sessions. A total of 57 subjects participated in the experiment among which 27 were Tai Chi masters. We have introduced a gender, BMI-based scaling of the features to mitigate their effects from the gait parameters. A hybrid feature ranking technique has also been proposed for selecting the best features for classification. The research reports 88.17% accuracy and 93.10% ROC AUC values from subject-wise 5-fold cross-validation for the Tai Chi masters' vs normal subjects’ walking gait classification for the “Single-task” walking scenarios. We have also got fairly good accuracy for the “Dual-task” walking scenarios (82.62% accuracy and 84.11% ROC AUC values). The results indicate that Tai Chi clearly has an effect on the walking gait dynamics. The findings and methodology of this study could provide preliminary guidance for applying machine learning-based approaches to similar gait kinematics analyses.
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Introduction : As an effective holistic therapeutic exercise program, Tai Chi has been widely used for patients with a variety of neurological disorders. In last 1-2 decades, there has been an increase in the number of research studies that examined the Tai Chi effects on biomarkers including inflammatory cytokines, oxidative stressors, and neurotrophic factors. Thus, the purpose of this article was to review such effects and their possible implication to neurorehabilitation. Method : In this systematic review, we searched Tai Chi-related articles from the last 15 years until July 2020 that had investigated changes of biomarkers after Tai Chi practice. The search identified 24 studies (21 randomized control trials, 2 cross-sectional studies, and 1 single group pre- and post- comparison) that were included in our analysis. Results: Tai Chi practice may be able to 1) reduce pro-inflammatory contributors (Interleukins -1, 6, 10, 12, tumor necrosis factor, the nuclear factor kappa-light-chain-enhancer of activated B cells, and the C-reactive protein) and increase anti-inflammatory cytokines (Interleukins -10 and 13); 2) decrease oxidative stress factors (like plasma 8-isoprostane, malondialdehyde, and protein carbonylation); and 3) increase neurotrophic factors (brain-derived neurotrophic factor, and N-Acetylaspartate). Conclusions : Tai Chi practice mediates anti-inflammation, anti-oxidative stress, and neural plasticity indicating its effect on modulating the pathophysiology of neurodegeneration and on potential effectiveness in neurorehabilitation.
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OBJECTIVE: To evaluate the effects of two exercise approaches, Tai Chi (TC) and computerized balance training (BT), on specified primary outcomes (biomedical, functional, and psychosocial indicators of frailty) and secondary outcomes (occurrence of falls).DESIGN: The Atlanta FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques), a prospective, randomized, controlled clinical trial with three arms (TC, BT, and education [ED]). Intervention length was 15 weeks, with primary outcomes measured before and after intervention and at 4-month follow-up. Falls were monitored continuously throughout the study.SETTING: Persons aged 70 and older living in the community.PARTICIPANTS: A total of 200 participants, 162 women and 38 men; mean age was 76.2.MEASUREMENTS: Biomedical (strength, flexibility, cardiovascular endurance, body composition), functional (IADL), and psychosocial well-being (CES-D scale, fear of falling questionnaire, self-perception of present and future health, mastery index, perceived quality of sleep, and intrusiveness) variables.RESULTS: Grip strength declined in all groups, and lower extremity range of motion showed limited but statistically significant changes. Lowered blood pressure before and after a 12-minute walk was seen following TC participation. Fear of falling responses and intrusiveness responses were reduced after the TC intervention compared with the ED group (P = .046 and P = .058, respectively). After adjusting for fall risk factors, TC was found to reduce the risk of multiple falls by 47.5%.CONCLUSIONS: A moderate TC intervention can impact favorably on defined biomedical and psychosocial indices of frailty. This intervention can also have favorable effects upon the occurrence of falls. Tai Chi warrants further study as an exercise treatment to improve the health of older people.
Article
Identification of different types of falls and fallers among elderly persons might aid in the targeting of preventive efforts. In a representative sample of 336 community elderly, subjects were assigned to Frail, Vigorous, or Transition groups based on observed patterns of clustering among demographic, physical, and psychological variables. The frequency and circumstances of falls in these three groups were then ascertained. As expected, the observed incidence of falling in one year of follow-up was highest in the Frail group (52%) and lowest in the Vigorous group (17%). However, 22% (5/23) of falls by vigorous subjects, but only 6% (5/89) of falls by frail subjects, resulted in a serious injury. Compared with frail subjects, vigorous fallers were somewhat more likely to fall during displacing activity (53% vs 31%), with an environmental hazard present (53% vs 29%), and on stairs (27% vs 6%). These findings suggest that fall-related injuries can be a serious health problem for vigorous as well as frail elderly persons. Injury prevention, therefore, should be directed at all elderly persons but tailored to expected differences in fall circumstances.
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For many centuries Tai Chi has been a martial art form, practiced primarily in Oriental cultures. For the past 300 years this movement approach has been used as an exercise form, practiced by millions of Chinese elderly people. To date, virtually no information exists about the therapeutic elements of this intriguing movement sequence. This article provides a historical review of existing documentation of reputed Tai Chi benefits. The 108 "forms" of Tai Chi Chuan are reduced to 10 composite forms for ease of application of these forms to older individuals within a reasonable time frame. An effort is set forth to identify the potential therapeutic elements within these forms.
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Tai chi chuan (TCC) is a traditional Chinese conditioning exercise, consisting of a series of graceful movements linked together in a continuous sequence so that the body is constantly shifting from one foot to the other. We propose that subjects practicing TCC will have better postural control and stability than will active non-practitioners. We compare static and dynamic postural controls in 14 TCC practitioners and 14 healthy active older adults using the Smart Balance Master System. The TCC group, containing 7 male and 7 female subjects (mean age, 70.9 +/- 3.3 years), had been practicing TCC regularly for 2 to 35 years. The control group included 4 male and 10 female healthy and active older subjects (mean age, 69.1 +/- 3.1 years), with age and body size matched to the TCC group. The results of static postural control tests showed no differences between the TCC and control groups under simple conditions (eyes open, eyes closed, swaying vision, and eyes open with swaying surface), but in the more complicated conditions (eyes closed with sway-referenced support and sway-referenced vision and support), the TCC group had significantly better results than the control group. In the dynamic balance test, the TCC group had significantly better results only in the rhythmic forward-backward weight-shifting test. Our data demonstrate that regular TCC practitioners have better postural stability, especially in the more complicated conditions with disturbed visual and somatosensory conditions.
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To evaluate the effects of coordination exercise on postural stability in older individuals by Chinese shadow boxing, Tai Chi Chuan (TCC). Cross-sectional study. Research project in a hospital-based biomechanical laboratory. The TCC group (n = 25) had been practicing TCC regularly for 2 to 35 years. The control group (n = 14) included healthy and active older subjects. Static postural stability test: progressively harder sequential tests with 6 combinations of vision (eyes open, eyes closed, sway-referenced) and support (fixed, sway-referenced); and dynamic balance test: 3 tests of weight shifting (left to right, forward-backward, multidirectional) at 3 speeds. Static and dynamic balance of Sensory Organization Testing (SOT) of the Smart Balance Master System. In static postural control, the results showed no differences between the TCC or control group in the more simple conditions, but in the more complicated SOT (eyes closed with sway surface, sway vision with sway surface), the TCC group had significantly better results than the control group. The TCC group also had significantly better results in the rhythmic forward-backward weight-shifting test. Duration of practice did not seem to affect the stability of elder people. The elderly people who regularly practiced TCC showed better postural stability in the more challenged conditions than those who do not (eg, the condition with simultaneous disturbance of vision and proprioception). TCC as a coordination exercise may reduce the risk of a fall through maintaining the ability of posture control.
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To assess the characteristic effects of Tai Chi Chuan (TCC) exercise on metabolism and cardiorespiratory response, and to measure its effect on cardiorespiratory function, mental control, immune capacity, and the prevention of falls in elderly people. A review of controlled experimental studies and clinical trials designed with one of two aims: either to assess physiological responses during the performance of TCC or to assess the impact of this exercise on general health and fitness. Metabolic rate, heart rate, blood pressure, ventilation, maximal oxygen uptake (VO(2)MAX), immune capacity, falls, and fall related factors. A total of 2216 men and women. Under review were 31 original studies, published in Chinese or English journals, that met the criteria for inclusion. Most of the papers written in Chinese had not been introduced into the Western literature. Nine of these studies showed that TCC can be classified as moderate exercise, as its does not demand more than 55% of maximal oxygen intake. When this form of exercise and others conducted at equal intensity were compared, TCC showed a significantly lower ventilatory equivalent (VE/VO(2)MAX). Evidence provided by cross sectional and longitudinal studies suggests that TCC exercise has beneficial effects on cardiorespiratory and musculoskeletal function, posture control capacity, and the reduction of falls experienced by the elderly. TCC is a moderate intensity exercise that is beneficial to cardiorespiratory function, immune capacity, mental control, flexibility, and balance control; it improves muscle strength and reduces the risk of falls in the elderly.
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One of the challenges faced by people with advancing age is decreased postural stability and increased risks for falls. There has been an increased interest over the last decade in using Tai Chi as an intervention exercise for improving postural balance and preventing falls in older people. Despite the increased number of studies in recent years relating Tai Chi to balance and fall prevention, results are scattered and inconsistent. There is wide variation in the use of balance measures, subject population, type and duration of Tai Chi exercise, and type of study. This paper provides a systematic review/analysis of currently available study reports. The goal of the review is to address the following concerns: how the effect of Tai Chi on balance or fall prevention has been evaluated to date, what level of evidence exists supporting Tai Chi as an effective exercise for improving balance or preventing falls, and what factors could possibly affect the benefit of Tai Chi on balance or falls. This review also helps identify directions for future research.