15 Tai Chi Use and the Elderly

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1 15 Tai Chi Use and the Elderly SJ.Forrel/ Complimentary medicine use in western societies continues to increase. Part of this gaining acceptance includes the use of eastern movement theories. Eastern movement therapies have been practiced for many hundreds of years in order to enhance physical and emotional well being as well as for prevention and treatment of disease. These theories have been especially helpful to the elderly due to ease of program development and enactment, lack of significant side effects, and generally low cost. Tai chi is such a program that will be discussed here. The following is a summated review of the concepts of tai chi including applicable published reports of the benefits to the elderly. General Tai Chi is also known as T'ai ch' uan, Tai chi chuan, Tai chi quan, and Taijiquan [1,2]. Tai chi carries the meaning of "supreme ultimate" while chuan carries the meaning of "fist". The exact origin of tai chi is unclear but most believe it was developed as a martial art. Many reports declare that the origin lies in the Ming dynasty greater than 300 years ago. One legend attributes the origin to a Taoist priest named Chang San Feng. Reportedly he developed tai chi after viewing an altercation between a snake and a crane [1]. Others have said the movements of tai chi are based on similar movements exhibited by the snake, crane, tiger, and dragon [3]. Irrespective of the origin, most agree that tai chi began as a martial art that continues today. One report states that tai chi was originally considered a form of shadow boxing and later evolved into a way to combat enemies [2]. Nowadays, the practice of tai chi is also used in prevention and treatment of health disorders. The principle of tai chi lies in a source of internal energy called the chi. The chi originates in the dan tien or tan tien [1,3]. This area is located a few inches below the umbilicus [1]. The energy flows throughout the body in channels in a harmonious way. The alteration of this energy flow is the basis for the use of tai chi in health concerns and martial arts practice. By practicing tai chi movements, the chi is stimulated and redirected to promote health and well being as well as to help prevent disease. With regard to martial arts practice, the movements also stimulate the chi, which in turn is translated into effective pushes and kicks. Tai chi has been practiced for many hundreds of years according to many schools of thought such as the Chen, Yang, Yin, and Sun approaches [2]. Many of these approaches utilize sets or forms of low impact routines. In 1956, the tai chi masters met E. P. Cherniack et al. (eds.), Alternative Medicine for the Elderly Springer-Verlag Berlin Heidelberg 2003

2 Tai Chi Use and the Elderly in China and adopted a simplified and condensed form of tai chi that brought together many of the principles of the approaches mentioned previously. Although the short form of tai chi remains quite popular today, many practitioners still adhere to the original long form tenets. The routines, also called sets or forms, involve coordinated movements of such body parts as the head, neck and spine, hands, wrists, knees, hips, and ankles [3]. The practitioner attempts to remain relaxed throughout the routines. They must be conscious of body position and trunk alignment [2]. Deep breathing also helps create a relaxed state. The mind must remain alert and calm to enhance propioceptive feedback relating to body position and movement. Once these criteria are met, the practitioner can then perform the coordinated and sequenced movements that are inherent to tai chi. In order to gain expertise in tai chi many years of practice is needed. Tai chi has been prominent in Asian culture for many decades. Even today it is included in many martial arts organized competitions [1]. Not all use is in such an organized environment. Across Western cultures, tai chi is gaining momentum in popularity. The elderly have in many ways been in the forefront of the increase in popularity. As chronic disease persists in an ever-increasing population, individuals are looking to less traditional methods in addressing health care needs. Tai chi is an excellent way to address these needs from perspectives of prevention and treatment of chronic illness and disability. The following is a review of the literature with regard to the benefit and uses of tai chi in the elderly. Cardiopulmonary System Cardiopulmonary disease is known to be quite prevalent in the older population. From coronary artery disease to cerebrovascular disease, cardiopulmonary illness and disability have a great effect on healthcare costs both direct and indirect. Tai chi has been shown to exhibit a positive influence on the cardiopulmonary system via a number of studies. While these studies vary somewhat in opinion as to whether tai chi provides for a level of light or moderate exercise intensity, little debate is present when discussing the benefits of tai chi. Brown et al. wanted to examine the effects of the long form of tai chi on certain pulmonary parameters [4]. Experienced tai chi practitioners were tested using tai chi methods compared to cycle ergometry. Similar exertion levels were maintained by monitoring oxygen consumption. Results showed that under tai chi conditions, subjects had both lower ventilatory frequency and ventilatory equivalent. The ratio of dead space ventilation to tidal volume was more favorable. Schneider et al. found similar results in comparing tai chi practitioners to another martial art wing chun [5]. Wing chun reports a greater level of exercise intensity based on metabolic equivalents. Yet, results of each test group after treadmill testing did not show appreciable differences in maximum oxygen consumption or heart rate. The ventilatory equivalent was also lower in the tai chi group.

3 Cardiopulmonary System 229 Other cardiopulmonary effects have been reported in the medical literature. Tai chi has been shown to be effective in lowering blood pressure. Young et al. examined the effect of tai chi compared to other randomized subjects that were involved in a 12-week moderate intensity aerobic exercise program of walking and low-impact aerobic dance. The study participants were at least sixty years old and had been sedentary prior to the study. None were considered to be hypertensive prior to the study. Results revealed a comparable reduction in blood pressure in both the tai chi group as well as the aerobic exercise group. Channer also looked at tai chi and blood pressure effects in patients that had experienced myocardial infarction [6]. Participants were randomized to tai chi, aerobic exercise, and support control groups. Both the tai chi and exercise groups showed decrease in systolic blood pressure. Therefore, a conclusion could be drawn that tai chi is as effective as moderate intensity exercise in lowering blood pressure. According to the American Heart Association, greater than 4.7 millions Americans are now alive with heart failure [7]. In 1997 alone, $3.7 billion dollars were paid to Medicare beneficiaries for costs incurred attributable to heart failure. Extrapolation of these numbers worldwide would indicate global cause for concern. Tai chi though may be used to address this concern in the geriatric population. Fontana et al. wanted to investigate the effects of tai chi on the heart failure population [8]. Prior to their study, the safety of tai chi in this population was assessed by comparing metabolic equivalents in healthy adults [9]. They found that the energy expenditure for tai chi was similar to that of many activities of daily living. Subsequently they studied tai chi and the effects in heart failure patients. Pertinent variables measured included heart failure symptom scores, dyspnea scores, and exercise tolerance. Subjects were placed in a biweekly class of tai chi. Results showed decreases in heart failure symptom scores and dyspnea scores. An increase in distance walked over six minutes after tai chi was shown. While this study did not only include elderly participants, it may indicate yet another method to combat heart failure and the associated disability in older individuals. Aging has been shown to be associated with a decline in body function related to exercise capacity and thermoregulatory response to environmental conditions [10,11]. At times this can ultimately affect mortality rates. Tai chi may have a positive effect in these areas. Lai et al. examined the two-year trends of exercise capacity after participation in tai chi exercise [10]. This study focused on older subjects (mean age 64 +/- 9 years) with no major co-morbidities in the areas of cardiovascular, pulmonary, or musculoskeletal disease. The test group performed tai chi on the average five times per week compared to sedentary activity of the control group. Results showed the tai chi group had a reduction in maximal oxygen consumption during cycle ergometry by % compared to % in the sedentary control group. Thus a conclusion was drawn that tai chi may help delay the decline in cardiorespiratory function in older populations. Wang et al. evaluated the effect of tai chi on the response of microcirculation in healthy geriatric men [11]. Test subjects were placed in tai chi protocols at least three times were week and were then assessed against sedentary controls that were age matched and body size matched. Outcome measures revealed improvement in skin blood flow, cutaneous vascular conductance, and skin temperature during exercise. Thus tai chi may help in supporting the thermoregulatory response that is needed by older individuals in response to heat stress.

4 Tai Chi Use and the Elderly Balance Balance issues and falls in the elderly continue to be major health concern as the general geriatric population increases in number [12]. Significant sequelae of falls, most notably hip and wrist fractures, have placed great financial hardship on the healthcare industry [13]. Sheldon has shown that standing sway increases and one-legged standing ability decreases with age [14]. Wolson et al. has reported that up to fifty percent of the elderly may exhibit loss of balance due to decrease in visual, ankle, and foot inputs [15]. Many studies have examined the effect of tai chi on balance and falls. Tse et al. compared a test group of experienced elderly tai chi practitioners to elderly nonpractitioners. Results of five balance tests showed that the tai chi group attained significantly better scores indicating superior balance ability [16]. Twenty-two persons with mild balance disorders were studied by Rain et al. [17]. Three objective tests involving posturography, Romberg testing, and reach testing as well as two questionnaires focusing on dizziness and general health were utilized. Participants underwent eight onehour sessions of tai chi by a trained instructor. They were then to practice daily for at least thirty minutes. Support materials such as videotapes and written illustrations were provided. After eight weeks subjects were retested and found to have improvements in performance on the posturography and dizziness survey. Less significant improvement was noted in the Romberg test and general health survey. Reach testing showed no improvement. A more recent study by Wong et al. also showed an improvement in postural stability with tai chi [18]. Elderly subj ects who had practiced tai chi for two to thirty five years were compared to controls using six progressively more difficult balance tests. In more simple balance tasks no difference in the groups existed. With more difficult tasks of balance such as simultaneously altering visual and propioceptive conditions, the tai chi group tested to a much better degree. Not all literature though is as convincing in supporting the use of tai chi for balance enhancement and prevention of falls. In the Atlanta Frailty and Injuries: Cooperative study of Intervention Techniques (FISCIT) trials, subjects were randomized to 15 weeks of tai chi training, computerized balance training, or educational classes [2,19, 20]. While results showed that the tai chi group did experience fewer falls and that there was a delay in time before falls occurred, only the computerized balance training group exhibited actual improvement in postural stability. Conclusions drawn from this study indicate that the elderly test subjects did show less fear of falling compared to other test groups. Therefore, the overall improvement with regard to falls may be due to altered confidence and not directly to tai chi effects and postural stability. Other studies also show mixed results regarding the effects of tai chi training and practice in relation to balance and falls. Wolfson et al. wanted to determine if tai chi had an effect on maintenance of balance gains [21]. In this study, elderly subjects of mean age 80 were placed in balance and strengthening programs. These programs included equilibrium control exercises, biofeedback, and lower extremity weight lifting. Results over three months showed an improvement in all balance measures. Subjects tested at levels that placed them at levels comparable to individuals three to ten years younger. After this initial improvement in balance measures, participants were

5 Musculoskeletal System 231 then placed in a six-month tai chi program. After six months of tai chi, significant continued but decreased gains were noted in test subjects. Therefore one could draw the conclusion that tai chi was responsible for the continued gains in balance. One cannot state though that the gains were not attributable to the initial exercise and balance programs and not the tai chi. A less encouraging report was published recently by Nowalk et al. [22]. This study encompassed two years and looked at older individuals in long term care facilities. Participants were randomized to a resistance and endurance exercise group, a tai chi exercise group, or to a control group. Exercise classes were held three times per week over a two-year period. All subjects were monitored periodically for cognitive and physical functioning. Fall reports within the long-term care facility reporting system were also monitored. Outcomes measured included time to first fall, time to death, number of days hospitalized, and incidence of falls. Overall, no statistical significance was noted between the exercise groups and the control groups. Musculoskeletal System Surprisingly, limited work is available concerning tai chi effects on the musculoskeletal system. Much anecdotal evidence abounds but the literature lacks peer reviewed publications [23]. Lan et al. has produced evidence that tai chi may improve flexibility and strength in separate studies [24-26]. Both elderly men and women were compared to control groups in looking at thoracolumbar spine flexibility as measured by inclinometer and knee extensor and flexor strength as measured by peak torque dynamometer readings. Results showed test groups had overall better spine flexibility and muscle strength. Movement force variability of the upper extremities was examined by Yan [271. Previous studies have shown that the ability to perform arm movements decreases with age [28-32]. These movements tend to become less coordinated, slower, and more variable. Yan enrolled elderly subjects into a tai chi group or into a walking and jogging group. At the conclusion of the eight -week study, measurements were taken as to force variability of upper extremity movements. The tai chi group showed significant improvement in force variability compared to the other test group that only performed walking or jogging. Arthritis of varying types can affect older individuals causing great disability and secondary health problems due to lack of mobility [3]. Although the medical literature is limited on this topic, a few reports are available. With regard to rheumatoid arthritis, Kirsteins et al. wanted to investigate as to whether tai chi would be harmful to patients [33]. Over a ten-week period, a tai chi group that practiced one to two times per week was compared to controls. Results revealed no major difference between the groups with regard to increasing pain. Improvements were noted in joint edema, joint pain, walking time, and grip strength. The authors thus concluded that tai chi would safe as a weight bearing exercise for patients with rheumatoid arthritis. Van Deusen et al. compared a control group to dance group that incorporated tenets of tai chi [34]. Patients were randomized. The tai chi based dance group also incorporated elements

6 rai Chi Use and the Elderly of relaxation technique and group discussion. Results showed the tai chi test group possessed greater range of motion at the shoulder with greater perceived benefits while statistical benefit was noted with wrist and lower extremity range of motion. A more recent report looked at the effects of tai chi in conjunction with osteoarthritis. Hartman et al. conducted a randomized, prospective study that compared a tai chi group to controls [35]. Mean age was 68 years. The tai chi group had tai chi sessions twice per week for twelve weeks. At the conclusion, the tai chi group exhibited significant improvements in self-efficacy for arthritis symptoms, level of tension and general satisfaction with health status. No significant changes were noted for one-leg balance, walking speed over fifty feet, and sit-to stand transfers. Other Health Benefits Few other reports are available regarding the benefits of tai chi. Kutner et al. participated in the previously mentioned Atlanta FISCIT trials [36]. They reported after questioning participants that tai chi and balance training both increased confidence in balance and movement. Only the tai chi group though reported greater satisfaction with activities of daily living and overall general life satisfaction. Jin reported that tai chi showed comparable benefit in reducing emotional stress to brisk walking [37]. Outcome measures included cortisol levels and mood testing. Summary Currently, the general population continues to grow. Along with this growth come a greater percentage of older individuals. This fact may be attributable to longer lifespan due to improvements and advancements in medical treatment, and better prevention techniques of disease and disability. In the past Western medical practitioners have embraced fairly rigid ideas regarding this prevention and treatment of disease. Only more recently have Eastern thoughts and ideas made inroads into medical doctrine. Included in the category of complementary medicine is Eastern movement theory which is inclusive of tai chi. Tai chi utilizes the "mind-body" approach to health and well-being. Tai chi was originally practiced in China but now practitioners can be found worldwide in many environments from parks to formal classes. Tai chi has become especially popular with older generations for a number of reasons. Tai chi can be taught easily and relatively inexpensively. No major equipment is needed and almost any place can accommodate tai chi practice. The movements involved in tai chi are slow and coordinated and not ballistic in nature. This limits the impact on senior practitioners who may not able to tolerate high impact activities.

7 Summary 233 The medical evidence that generally supports the use of tai chi in the elderly is presented here. While the information is somewhat limited, as the popularity of tai chi continues to grow so will the medical evidence that will likely advocate it's use for personal health and well-being. References 1. Farrell S, Ross A, Sehgal K (1999) Eastern Movement Therapies. In: Schulman R, Cotter A, Harmon R (eds) Physical Medicine and Rehabilitation Clinics of North America Vol. 10, No.3: Wolf S, Coogler C, Xu T (1997) Exploring the basis for Tai Chi Chuan as a therapeutic exercise approach. Archives of Physical Medicine and Rehabilitation 78: Lumsden D, Baccala A, Martire J (1998) T'ai chi for osteoarthritis: an introduction for primary care physicians. Geriatrics 98: Brown D, Mucci W, Hetzler R (1985) Cardiovascular and ventilatory responses during formalized T'ai Chi Ch'uan exercise. Research Quarterly for Exercise and Sport 60: Schneider D, Leung R (1991) Metabolic and cardiorespiratory responses to the performance of wing chun and t'ai chi ch'uan exercise. International Journal of Sports Medicine 12: Channer K, Barrow D, Barrow R (1996) Changes in haemodynamic parameters following T'ai Chi Ch'uan and aerobic exercise in patients recovering from acute myocardial infarction. Postgraduate Medicine 72: American Heart Association (2001) 8. Fontana J, Colella C, Baas L, Ghazi F (2000) T'ai Chi Chih as an intervention for heart failure. Nursing Clinics of North America 35: Fontana J, Colella C, Wilson B (2000) The energy costs of a modified form of rai chi exercise. Nursing Research 49: Lai JS, Lan C, Wong MK, Teng SH (1995) Two-year trends in cardiorespiratory function among older Tai Chi Chuan practitioners and sedentary subjects. Journal of the American Geriatrics Society 43: Wang JS, Lan C, Wong MK (2001) Tai Chi Chuan training to enhance microcirculatory function in healthy elderly men. Archives of Physical Medicine and Rehabilitation 82: Kessenich C (1998) Tai Chi as a method of fall prevention in the elderly. Orthopaedic Nursing 17: Ross M, Presswalla J (1998) The therapeutic effects of Tai Chi for the elderly. Journal of Gerontological Nursing 24: Sheldon J (1963) The effects of age on the control of sway. Gerontology Clinics 5: Wolson L, Whipple R, Judge J, Amerman P, Derby C, King M (1993) Training balance and strength in the elderly to improve function. Journal of the American Geriatrics Society 41: Tse SK, Bailey D (1992) T' ai chi and postural control in the elderly. American Journal of Occupational Therapy 46: Hain T, Fuller L, Weil L, Kotsias J (1999) Effects oft'ai Chi on balance. Archives of Otolaryngology-Head and Neck Surgery 125: Wong A, Lin Ye, Chou SW, Tang FT, Wong PY (2001) Coordination exercise and postural stability in elderly people: effect of Tai Chi Chuan. Archives of Physical Medicine and Rehabilitation 82: Wolf S, Barnhart H, Kutner N, McNeely E, Coogler C, Xu T (1996) Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Journal of the American Geriatrics Society 44: Wolf S, Barnhart H, Ellison G, Coogler C (1997) The effect of tai chi quan and computerized balance training on postural stability in older subjects. Physical Therapy 77: Wolfson L, Whipple R, Derby C,Judge J, King M,Amerman P, Schmidt J, Smyers D (1996) Balance and strength training in older adults: intervention gains and Tai Chi maintenance. Journal of the American Geriatrics Society 44: Nowalk M (2001) A randomized trial of exercise programs among older individuals living in two long-term care facilities: the FallsFREE program. Journal of the American Geriatrics Society 49: Luskin F, Newell K, Griffith M, Holmes M, Telles S, DiNucci E, Marvasti F, Hill M, Pelletier K, Haskell W (2000) A review of mind/body therapies in the treatment of musculoskeletal disorders with implications for the elderly. Alternative Therapies In Health and Medicine 6: Lan C, Lai JS, Chen SY, Wong MK (2000) Tai Chi Chuan to improve muscular strength and endurance in elderly individuals: a pilot study. Archives of Physical Medicine and Rehabilitation 81: Lan C, Lai JS, Wong MK, Yu ML (1996) Cardiorespiratory function, flexibility, and body composition among geriatric Tai Chi Chuan practitioners. Archives of Physical Medicine and Rehabilitation 77: Lan C, Lai JS, Chen SY, Wong MK (1998) 12-month Tai Chi training in the elderly: its effect on health and fitness. Medicine and Science in Sports and Exercise 30: Yan J (1999) Tai Chi practice reduces movement force variability for seniors. The Journals of Gerontology 54:

8 234 IS Tai Chi Use and the Elderly 28. Goggin N,Meeuwsen H (1992) Age-related differences in the control of spatial aiming movements. Research Quarterly for Exercise and Sport 63: Yan J (1998) Aging and rapid aiming arm control. Experimental Aging Research 24: Spirduso W (1975) Reaction time and movement time as a function of age and activity level. Journal of Gerontology 30: Welford A (1984) Between bodily changes and performance: some possible reasons for slowing with age. Experimental Aging Research 2: Cole K (1991) Grip force control in older adults. Journal of Motor Behavior 23: Kirsteins A, Dietz F, Hwang S (1991) Evaluating the safety and potential use of a weightbearing exercise, t' ai ch'uan, for rheumatoid arthritis patients. American Journal of Physical Medicine and Rehabilitation 70: Van Deusen J, Harlowe 0 (1987) Efficacy of the ROM dance program for adults with rheumatoid arthritis. American Journal of Occupational Therapy 40: Hartman C, Manos T, Wmter C, Hartman 0, Li B, Smith J (2000) Effects oft'ai Chi training on function and quality of life indicators in older adults with osteoarthritis. Journal of the American Geriatrics Society 48: Kutner N, Barnhart H, Wolf S (1997) Self -report benefits of t'ai chi practice by older adults. Journal of Gerontology 52: Jin P (1992) Efficacy of t'ai chi, brisk walking, meditation, and reading in reducing mental and emotional stress. Journal of Psychosomatic Research 36: