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

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

Komagata, Sachiko

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.

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.

The purpose of this critical review was to examine the evidence-based support forTai Chi as an effective adjunct to traditional physical therapy interventions to improve balance and reduce falls in older adults. The examination involved 2 methods of critical review: the use of the Ql27 and the MR scores.

METHODS

The search strategy was based on the method described by Sackett and colleagues (Figure I).23,28,29 We searched MEDLINE, EMBASE, the Social Sciences Citation Index, and PsyclNFO, using keywords Tai Chi$, fall$, and therapy$ (where $ indicates truncation of the word). Additional searches were performed by combining the keywords. We also used the Cochrane Database of Systematic Reviews. Studies were screened by reviewing the title and abstract and by applying the following inclusion criteria: (1 ) the article contained original research data (reviews and summaries were excluded), (2) Tai Chi was used as the therapeutic intervention for balance training, and (3) the article included at least 1 outcome measure of balance or falls. Summary data included research questions and/or variables, study design, and the main findings of 11 studies selected for review.

Of 40 articles identified in the searches, 11 met our criteria for review. Each study's methodological quality was assessed using the Ql" and MR instruments.5

Quality Index

Qaulity index is a 27-question instrument, developed and tested by Downs and Black, that can be used to review critically both randomized and nonrandomized studies." The questions are subdivided into 5 categories: reporting (10 items), external validity (3 items), internal validity-confounding (selection bias,6 items),internal validity (bias,7 items),and power (1 item). Reporting assesses the objectives of the study, main outcomes, characteristics of the subjects, interventions, distribution of the confounding factors in each group, main findings, estimates of random variability, adverse events, follow-up, and actual probability values (eg, 0.035 rather than

The scores of each category indicate whether the key items are clearly described in the study. All items, except for power and 1 item in the reporting subscale,are scored on a 0,1 basis. Zero indicates "no"or"unable to determine"and 1 indicates "yes" or "able to determine." Power was scored on a O to 5 scale and 1 item in the reporting subscale scored on a O to 2 scale. The maximum number of points attainable is 32 and is termed Ql in order to quantify the overall methodological quality of each study.

Psychometric properties of the Ql have been assessed.27 High internal consistency has been demonstrated for both randomized and nonrandomized studies (Kuder-Richardson 20 = 0.89).27 Good test-retest reliability (r = 0.88), interrater reliability (r = 0.75), and criterion validity (r = 0.90) have been shown. Downs and Black indicated that raters required an average 20 to 25 minutes to assess each paper.27

Methodological Rigor

The second tool for assessing the methodological quality was MR, an 18-item check list created by Chan and Barlett.5 Thirteen of the items in the checklist had a 3 point score and the remaining 5 items had a 2 point score for a maximum of 49 points. Of the 11 articles reviewed, 6 had been critically analyzed by Chan and Barlett.5 The relationship between the MR scores assigned by Chan and those assigned by the author (SK) was determined by calculating the Pearson Product correlation coefficient. Then the same coefficient was calculated for correlation analysis of 5 additional articles reviewed by the author (SK) using both Ql and MR.

Analysis of outcome involved the effect size d-index.5 The effect size is defined by Cohen as "the degree to which the phenomenon is present in the population on the degree to which the null hypothesis is false."31lp325) An effect size of 0.2 is considered small, 0.5 is moderate, and greater than 0.8 is large.32 In meta-analysis, the d-index is used as an estimate of the effect size. The d-index, therefore, is a relative value that allows the investigator to compare the effects of the intervention between the groups or within the group over time in a standard unit (scale-free measure). The d-index was calculated for the outcome measures of interest.

The formula is d = (me - mc)/[sigma] where: me = means of the outcome measure in the experimental group (or post-test in the same group); me = means of the outcome measure in the control group (or pretest in the same group); [sigma] = The mean standard deviation between the two groups (or pretest and post-test in one group).5(p6)

Categorization of Outcome Measures

To examine the effectiveness of Tai CM on balance, we used the same categorization of balance as described by Chan and Barlett/' These outcome measures are categorized into 3 groups: static conditions (eg, velocity of sway in AP in static condition, lateral body stability), internal perturbations (eg, single leg stance, eyes closed, reach testing), and external perturbations (eg, dispersion toes, up/eyes open, loss of balance during sensory organization testing). These categories are intended to describe no movement of the center of mass; voluntary movement of the center of mass, or involuntarily movement of the center of mass. A one-way ANOVA was used to determine the differences in the d-index among the above 3 categories.

RESULTS

Our search resulted in 40 journal articles published between 1981 and 2001. No studies were found in the Cochrane Database of Systematic Reviews. Limiting the search to 'randomized studies' and/or 'qualitative studies' yielded only 1 article.16 Out of 30 potential articles5-19,33-46 to review, 11 (Table 1)6,9,13-19,41,42 met our inclusion criteria and were fully evaluated for their methodological quality using the Ql and MR checklists (Table 2).27 The Ql scores of the 11 articles ranged from 8 to 22 out of a maximum of 32 points.

A total of 495 subjects participated in the 11 studies, with 250 participating in Tai Chi intervention. The number of subjects per study ranged from 11 to 110 subjects with an age range of 20 to 92 years. With the exception of 2 studies that used younger adults (ranging in age from 20 to 45 years),13,17 all of the studies used subjects who were healthy community-dwelling elderly ranging from 65 to 92 years old.To minimize the effects of gender, Hong etal15 studied male subjects, while Judge et al6 exclusively studied women. The remaining articles included both men and women.

Tai Chi was used as one of the main interventions for balance or postural control in most of the studies.9,13,14,17-1941 An exception is the study of Wolfson et al16 in which Tai Chi was used as a maintenance program after the main balance training program was completed. Hong et al15 and Tse and Bailey12 compared the balance abilities of Tai Chi practitioners and nonpractitioners. The intensity, duration, and frequency of the Tai Chi training varied from 8 to 16 weeks, 45 to 60 minutes per session, and once a week to 3 times per week. Most of the Tai Chi training was conducted in a group setting. The instructor's qualifications were not indicated in all studies under review.

Table 3 lists MR and Ql assigned by the author (SK) and MR reported by Chan and Barlett. All 3 are positively correlated to each other. The effect size d-index was calculated for 33 out of the potential 35 outcome measures (Table 4). Ross et al14 did not report the means or standard deviations, thus the dindex was not determined. The overall mean d-index was 1.99 (SD = 2.8) (Table 5). The mean d-index of measures corresponding to the static conditions, internal perturbation, and external perturbations was 0.52 (SD = 0.8), 2.48 (SD = 3.53), and 0.34 (SD = 0.39), respectively (Table 5). No statistically significant difference in the d-index occurred among the 3 outcome categories (F (2, 32) = 0.60, p>0.05). The relationship between the d-index and the Ql score has moderate negative correlation at r = - 0.52, and the relationship between the d-index and the MR score was r = - 0.28.

DISCUSSION

The movement pattern of Tai Chi is unique among other therapeutic interventions for people with balance impairments. The movement is slow but continuous, so the individual learns how to move most effectively within the postures and forms. Tai Chi is 'posture' or 'form-oriented' so that the person learns to use his or her visual or kinesthetic frame of reference throughout the movement. Therefore, the learner's behavior emerges from a self-organizing function of various subsystems.47 It is also hypothesized that the Tai Chi movement patterns facilitate specific breathing patterns, which in turn trigger the autonomie nervous system for self-adjustment, ie, homeostatis.48 Unlike some therapeutic interventions that have little kinesthetic demands, Tai Chi is postulated to improve kinesthetic awareness. By performing slow, continuous, and fluid patterns, the individual becomes aware of his or her own postural limitations. Such kinesthetic awareness could decrease the incidence of falls.18,43 This review suggests that that activities incorporated intoTai Chi appear to be capable of favorably influencing balance. This influence does not seem to be specific to internal perturbation category as reported by Chan and Barlett.5

The majority of the articles reviewed selected a frequency of Tai Chi as once a week for approximately 1 hour each training session. Such a length of training may fail to show improvements in postural control. Many postures in Tai Chi are unintuitive at first. For example, moving the right arm forward while the right foot is in front of the left can be an awkward movement to learn unless the person is familiar with boxing or fencing. If one has difficulty with overcoming the initial awkwardness of Tai Chi postures, the learner may feel discouraged to continue. Peer and instructor encouragement is one method to facilitate individuals to learn the forms.

In addition, most of the studies reviewed here did not clearly state their confounding factors, such as gender, age, and lifestyle. GroupTai Chi sessions, rather than individual sessions, were used in most studies without addressing the potential effect of the group process or motivational factors on the outcome. Internal validity will improve by addressing these potential confounding factors. In addition, studies designed to address the participants' compliance status would improve the study's internal validity as well as the effectiveness of the program. To minimize selection bias, future studies should use randomized assignments when possible.

Only 4 studies clearly documented the subject's compliance with the intervention. The qualifications of Tai Chi instructors also play a major role in the effectiveness of Tai Chi in balance training. The instructors may affect the participants' levels of motivation,1053 compliance, and accuracy in performing the forms and postures. Observational studies investigating the quality of instruction and movement may provide the opportunity to discover a deeper understanding of Tai Chi's hidden effects on an individual's movement and wellness.

Since the effect of Tai Chi on balance has been tested in elderly subjects who have no history of neurological or musculoskeletal diseases, it may be beneficial to use this type of intervention to a specific disease population, such as stroke, Parkinson disease, or peripheral neuropathy. Physical therapists are skilled in analyzing people's movement patterns based on motor control and biomechanical theories. Therefore, they have the potential to determine through systematic study what specific characteristics of Tai Chi improve balance as compared with traditional physical therapy balance training techniques. The use of a sham-Tai Chi paradigm can be used to examine a placebo effect of Tai Chi.

Furthermore, due to the nationwide managed care trends, neuromusculoskeletal rehabilitation has been evolving to use more innovative formats. This usually entails fewer visits, a shorter length of treatment sessions, or the use of group sessions with more emphasis on education and home exercise programs. Tai Chi and other movement therapies can supplement a rehabilitation program and can be provided by health care professionals and practitioners other than physical therapists. A trend in current physical therapy practice is to offer post rehabilitation maintenance programs. Tai Chi may be an effective group therapy activity for people who undergo formal outpatient physical therapy programs for balance and gait training. When this review article was nearly completed, the authors found Wu's review article on Tai Chi's effectiveness for improving balance and preventing falls in the older population.49 Thus our recommendations for future studies overlap significantly with the study by Wu.

CONCLUSION

The majority of the studies reviewed here support the effectiveness of Tai Chi to improve balance. However, quality of studies requires further improvement in treating confounding factors, addressing compliance, and randomizing the assignments. Systematic review using Ql and d-index is warranted due to the existence of nonrandomized studies. Although the 3 balance outcome measure categories do not show a statistically significant difference in their effect size d-index, the internal balance perturbations category appears most suited to demonstrate Tai Chi's effect on the participants'balance. Demystifying the oriental martial art ofTai Chi through scientific studies and incorporating it in physical therapy practice, particularly aiming for balance improvement and fall prevention, can be justified.

ACKNOWLEDGEMENTS

We would like to acknowledge the support and valuable feedback provided by Susan L Michlovitz, PT, PhD, CHT and the editors and reviewers for the Journal of Geriatric Physical Therapy.

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Sachiko Komagata, PT1, Roberta Newton, PT, PhD2

1 PhD Candidate, Department of Physical Therapy, Temple University

2 Professor, Department of Physical Therapy,Temple University

Please address correspondence to: Sachiko Komagata, Department of Physical Therapy, Temple University 3307 N. Broad St., Philadelphia, PA 10140, Ph: 609-434-1077, Fax: 801-327-6832 (sachiko@komagata.net).