Effectiveness of Tai Chi on Improving Balance in Older Adults: An Evidence-based Review, The

Journal of Geriatric Physical Therapy, 2003 by Komagata, Sachiko, Newton, Roberta

ABSTRACT

Purpose: This paper provides a systematic critical review of the effectiveness of Tai Chi for balance improvement and fall reduction, and determines the effectiveness of the Quality Index (QI) as a critical review system. Methods: Eleven of 30 articles on Tai Chi met the criteria for systematic review. Both the QI and Methodological Rigor (MR) scores were used to evaluate the methodological quality. Results: Our review revealed moderate evidence of the effectiveness of Tai Chi on balance improvement. D-indices, calculated to determine the relative effect of the intervention on balance measurements, showed moderate negative correlations with the QI (r = -0.52) and minimal negative correlations with the MR score (r = 0.28). Conclusion: Tai Chi is effective for balance improvement but not effective for reduction of falls. This review is unique in demonstrating the feasibility of using the methodological QI designed for both randomized and nonrandomized studies.

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Key Words: Tai Chi, balance, fall, review, EBM

INTRODUCTION

Tai CM, a philosophy that originated in China several centuries ago, has gained the status of a cultural-historical treasure.1-2 Tai Chi Chuan is the martial art aspect of Tai Chi philosophy. Despite the various interpretations of the history of Tai Chi,13 current consensus indicates that the 3 main styles of Tai Chi Chuan are Chen, Yang, and Wu.1-2 Yang's style is the most commonly found in the United States, followed by the Chen style. Since a discussion of Tai Chi as a philosophy and the principles of Tai Chi Chuan are beyond the scope of this review, the term Tai Chi will be used throughout this review to denote any derivatives of the main styles of Tai Chi Chuan. The objectives of Tai Chi include harmony of the mind, promotion of health, and attainment of rejuvenation and longevity.' Tai Chi movements can be characterized as slow, controlled, and continuous weight shifting with various animal-like postures.4 However, when Tai Chi is performed with the intention to fight, the fluid soft forms easily turn into self-defense or fighting movements. There are 3 advantages of Tai Chi as an exercise program for older adults.1,5-8 Firstly,Tai Chi can be performed by anyone, regardless of age or gender, as long as the individual is able to stand. secondly, there is no need for special equipment or large space. Finally, the length of each session is flexible according to the individual's needs and tolerance. The paucity of qualified instructors in community-based or rehabilitation facilities presents a restriction to its true practice, because the practice of Tai Chi takes years to develop.2'9 Therefore,Tai Chi is performed in a variety of forms in fitness centers, health care practices, and research studies.29

Studies of the health benefits of Tai Chi have been accumulating slowly over the last decade. Studies have focused on the cardiorespiratory system,10'" muscular strength,7,2'13 flexibility,7'13 pain,14 mood,14 and balance.5,6,12'13,15-19 Various health care practitioners,such as physicians, nurses,and occupational and physical therapists, have published reports indicating the benefits of incorporating Tai Chi into their practice, particularly for older adults. It is critical for physical therapists working with older adults to be able to evaluate the effectiveness of Tai Chi in geriatric physical therapy practice.

Although nonrandomized studies or observational studies can yield valuable evidence,70 critical reviews in medical science often emphasize randomized controlled studies.2122 This emphasis is based in part on the concept of "strength of the evidence"introduced by Sackett and colleagues.21 Few meta-analyses assess the methodological quality of randomized studies.21 Therefore, the overestimation of the effectiveness of the intervention may occur among low quality randomized controlled studies within the meta-analysis.74 Chan and Bartlett published a meta-analysis of current studies to determine the effectiveness of Tai Chi as a therapeutic intervention to improve balance and postural control.1 Their analysis, based on Sackett and colleagues' guidelines for critical appraisal,25 revealed that Tai Chi appeared to influence balance abilities in response to internal (self-induced) perturbations but not external perturbations. This article represented the first critical review of Tai Chi's positive effect on balance that indicated the inverse relationship between studies' Methodological Rigor (MR) score and their effect size. However, the validity of their MR score sheet has not been established.5

In a search for a valid tool among 25 checklists available to judge the methodological rigor of clinical studies, none was applicable to assessing nonrandomized studies, such as cohort and case control studies.26 Downs and Black created and tested a checklist that measures the Quality Index (Ql), applicable for both randomized studies and nonrandomized studies.77 Subscales such as confounding factors and bias were added to assess the study's strengths and weaknesses in terms of the quality of reporting and internal validity. An external validity subscale also was added to the checklist to determine the study's generalizability to clinical practice. It is beneficial to use Downs' and Black's Ql to assess the methodological quality of Tai Chi studies because the majority of them are nonrandomized studies.

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Effectiveness of Tai Chi on Improving Balance in Older Adults: An Evidence-based Review, The

Journal of Geriatric Physical Therapy, 2003 by Komagata, Sachiko, Newton, Roberta

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