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Tai Chi to Prevent Falls Among the Elderly
By Dónal P. O'Mathúna, PhD, Dr. O'Mathúna is a lecturer in Health Care Ethics, School of Nursing, Dublin City University, Ireland; he reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
Part 1 of a Series on Tai Chi: Falls as Primary Outcome
Around the world, the proportion of those who are elderly (> 65 years of age) is growing and their life expectancy is increasing.1 Between one-third and one-half of elderly people fall each year, with those living in long-term care facilities having a higher incidence of falls than community dwellers.2 Although only about 20% of those falls require medical attention, and less than 10% result in fractures, less serious falls can be painful and reduce functionality. A fall can also lead to fear of further falling, although many elderly are afraid of falling even if they have not had an injurious fall. Approximately half of the elderly living in the community report experiencing fear of falling, which can lead to a debilitating spiral of loss of confidence, reduced physical activity and social involvement, further frailty, falling, and loss of independence.3
Effective fall prevention programs are therefore crucial to improving and maintaining health among the elderly. Several approaches have been examined, with tai chi (also called tai chi chuan) developing a significant reputation as a low-impact method of reducing the incidence of falls. Classes in its slow, graceful movements are commonly offered in many settings, including wellness programs and residential centers. Such classes also bring social benefits, but it can be practiced individually in almost any location. Its effectiveness is also being investigated actively, with several new studies published in 2007 alone. Part 1 will review the evidence from clinical studies of tai chi that directly measured the frequency of falls. Part 2 will review other studies that measured outcomes associated with falls, such as balance or fear of falling.
Tai chi literally means "supreme ultimate power." Originally developed to provide general physical fitness for the martial arts, it was influenced by Chinese Taoism and Buddhism. As such, it is believed to balance the flow of life energy (chi) within the body and promote healthy living.4 In the West, it has been modified to make the movements easier to learn and practice in shorter periods of time.4 Five major styles of tai chi have developed, with the Yang form being the most popular. The Chinese government made tai chi compulsory in many colleges and universities, promoting it as a national cultural activity and leading to millions of Chinese people practicing tai chi regularly.5
All forms of tai chi involve meditation, breathing exercises, and slow, graceful movements. Many of these represent animal and bird movements, as reflected in their names: "white crane spreads wings," "golden rooster stands on one leg," and "ride the tiger."5 Each session is composed of a series of specific postures combined into one long exercise. The movements are all considered circular with each session being viewed as one continuous, integrated circle. Sessions vary considerably from one another. For example, the traditional Yang style has 108 postures while simplified styles can have as few as six.1 Sessions can last anywhere from 10 minutes to more than an hour.
Mechanism of Action
The traditional explanation within TCM for how tai chi promotes health is by restoring a balanced flow of chi. Chi is a nonphysical "life energy" that is believed to pervade everything, with illness arising when its flow is hindered or imbalanced. Tai chi as practiced in Western society is a gentle form of exercise and "moving meditation."4 The movements are believed to improve balance, flexibility, fitness, and muscle strength, also leading to greater confidence and less fear of falling. The activity may also lead to general health benefits, which further reduce the risk of disability and falls.
Since the early 1990s, more than 30 studies have examined the effectiveness of tai chi for improving balance, muscle strength, or flexibility.1 Differing research designs involving participants of different ages and ability have led to conflicting conclusions. Three systematic reviews were published between 2003 and 2004, and all found only one randomized controlled trial (RCT) of tai chi where the primary outcome measure was incidence of falls among the elderly.6 A number of other studies used secondary outcome measures like balance and muscle strength, which can be predictors of risk of falling.7 The latter will be reviewed in a subsequent article.
The one RCT mentioned above was published in 1996 and republished in 2003 when named the best research paper from the 1990s by the American Geriatrics Society.6 Two hundred participants older than age 70 (average, 76 years) were randomly assigned to one of three groups: tai chi, computerized balance training, or a discussion group instructed not to change exercise activities. The tai chi subjects met with an instructor twice a week for approximately 20 minutes, and were encouraged to practice tai chi on their own twice daily for 15 minutes. The latter was not monitored. Outcomes were measured at baseline, after 15 weeks of training, and upon follow-up at four months by blinded assessors. The number of falls and fear of falling were substantially reduced in the group practicing tai chi, but not in the two other groups. After adjusting for all fall risk factors, tai chi reduced the risk of falls by 47.5%.
In a more recent RCT, 256 physically inactive people older than 70 years living in the Oregon area were recruited to participate.8 Subjects were randomly assigned to attend a one-hour class in either tai chi or stretching exercises. The classes met three times weekly for six months. Falls were recorded in a diary along with any resulting injuries. Both groups showed reductions in falls, but the reduction was significantly greater in the tai chi group (P = 0.007). Over the six months, the proportion of those falling in the tai chi group fell by 55%. Follow-up assessment occurred six months after the end of the study and the group differences remained significant (P < 0.001). The tai chi group also showed significantly better improvements than controls in balance, walk speed, and fear of falling (P < 0.001).
Most tai chi research focusing on the elderly involves those living in the community; however, falls occur more frequently in residential facilities and are more likely to lead to serious injuries. One study enrolled 110 nursing home residents older than 65 years (average, 84.7 years).9 Participants were randomly assigned to either control, an exercise regimen, or tai chi. All received educational instruction on improving the quality of residential life, though not specifically on fall prevention. The exercise group received an individualized program involving a treadmill, exercise bicycle, and weight lifting. Structured sessions were held three times weekly. The tai chi group met three times weekly and also received instruction on various methods to reduce fear of falling. All but 11 participants were followed for 24 months before the study ended. There were no significant differences between any of the groups for number of falls or time to first fall. Adherence to the two regimens was poor, with adherence to tai chi being significantly worse than the general exercise program (24% vs. 56%; P < 0.001). No statistical differences were found in numbers of falls between those who adhered and those who didn't. The researchers noted that the participants in this study were older and frailer than in most other studies.
A Korean study involved two long-term care facilities, which were randomly assigned to be the tai chi or control site.2 Sixty-eight fall-prone residents participated, 29 in the tai chi site and 30 in the control. Sun-style tai chi classes were taught three times per week for 35 minutes for 12 weeks while the control site received no exercise intervention. During the 12 weeks, falls were reported by nine people in the tai chi group and 15 in the control, but the difference was not statistically significant. Those using tai chi had increased confidence that they could avoid falling, while the control group's score fell (P < 0.001). Outcomes for muscle strength, flexibility, balance, and mobility were significantly better in the tai chi group compared to control (P < 0.001).
A small number of other RCTs have examined the impact of tai chi on other outcomes regarded as indicators of risk of falling. These included recent studies on balance and stability, muscle strength, and fear of falling.3,10 Although the quality of earlier studies in this area was viewed as problematic, recent studies have been designed more rigorously and generally favor the tai chi group over control. These types of studies will be reviewed in detail in Part 2.
No adverse effects of tai chi were reported in the literature examined.
The number of tai chi RCTs involving the elderly has grown, but remains small. In general, that evidence supports tai chi as a program to reduce falls in those living in the community. Other trials measuring risk factors for falls also found evidence favoring tai chi. Although tai chi is practiced in many different ways, most studies use instructor-led sessions meeting three times a week for 30-60 minutes. The gentle nature of tai chi makes it particularly suited for elderly adults, but studies involving nursing home residents found tai chi no better than control. Modified versions of tai chi are being developed to accommodate frailer people.11 Whether the benefits of tai chi result from exercise more generally, or the unique combination of exercise, meditation, and breathing, remains unclear. One study found that elderly men who participated regularly in tai chi or golf had similar stability and joint movement as young men, and significantly better scores than elderly men who did not exercise.12
The evidence supports the use of tai chi to help prevent falls in elderly people living in the community. They may also reap the benefits of other physiological, psychological, and social interactions that accompany tai chi. As tai chi programs vary considerably in duration and rigor, the precise nature of the exercise should be understood before participating. All adults, especially the elderly, who are considering starting such a program should seek out medical advice to ensure they are physically ready to do so. People should remain alert to symptoms that could indicate overexertion. Keeping such cautions in mind, regular practice of tai chi may provide the elderly with protection against falls.
1. Taylor-Piliae RE, et al. Improvement in balance, strength, and flexibility after 12 weeks of Tai chi exercise in ethnic Chinese adults with cardiovascular disease risk factors. Altern Ther Health Med 2006;12:50-58.
2. Choi JH, et al. Effects of Sun-style Tai Chi exercise on physical fitness and fall prevention in fall-prone older adults. J Adv Nurs 2005;51:150-157.
3. Zijlstra GA, et al. Interventions to reduce fear of falling in community-living older people: A systematic review. J Am Geriatr Soc 2007;55:603-615.
4. Chen W, Sun W. Tai chi chuan, an alternative form of exercise for health promotion and disease prevention for older adults in the community. Int Q Community Health Edu 1997;16:333-339.
5. Jacobson BH, et al. The effect of Tai Chi Chuan training on balance, kinesthetic sense, and strength. Percept Mot Skills 1997;84:27-33.
6. Wolf SL, et al. Selected as the best paper in the 1990s: Reducing frailty and falls in older persons: An investigation of tai chi and computerized balance training. J Am Geriatr Soc 2003;51:1794-1803.
7. Verhagen AP, et al. The efficacy of Tai Chi Chuan in older adults: A systematic review. Fam Pract 2004;21:107-113.
8. Li F, et al. Tai Chi and fall reductions in older adults: A randomized controlled trial. J Gerontol A Biol Sci Med Sci 2005;60:187-194.
9. Nowalk MP, et al. A randomized trial of exercise programs among older individuals living in two long-term care facilities: The FallsFREE program. J Am Geriatr Soc 2001;49:859-865.
10. Li Y, et al. Effects of extended tai chi intervention on balance and selected motor functions of the elderly. Am J Chin Med 2007;35:383-391.
11. Chen KM, et al. The effects of a Simplified Tai-Chi Exercise Program (STEP) on the physical health of older adults living in long-term care facilities: A single group design with multiple time points. Int J Nurs Stud 2007 Jan 10; Epub ahead of print.
12. Tsang WW, Hui-Chang CW. Effects of exercise on joint sense and balance in elderly men: Tai Chi versus golf. Med Sci Sports Exerc 2004;36:658-667.