Evaluating the Health Effects of T'ai Chi

Betty Chewning, Ph.D.
Tricia Yu, M.A.
Jill Johnson, M.S., P.T., G.C.S.

Authors

Betty Chewning, Ph.D., is director of the Sonderegger Research Center and is an associate professor, School of Pharmacy, University of Wisconsin-Madison. Her research addresses patients' health behaviors and decision-making related to prescribed regimens and self-care. She has practiced T'ai Chi for 25 years.

Tricia Yu, M.A., is director of the T'ai Chi Center in Madison, Wisconsin, one of the oldest and largest schools in the United States. She provides training nationwide on simplified versions of T'ai Chi for health professionals and fitness instructors. She has practiced T'ai Chi for 29 years and studies with Yang Style T'ai Chi masters Benjamin Pang Jeng Lo and William C.C. Chen. She is certified by Master Chen.

Jill Johnson, M.S., P.T., G.C.S., is a geriatric clinical specialist in physical therapy at the New England Center for Integrative Health. Jill has published numerous research articles on geriatric rehabilitation and has received a grant from the Physical Therapy Foundation to study falls in the elderly. She practices both yoga and T'ai Chi and leads T'ai Chi Fundamentals workshops nationwide.

This is the second article of a two part series on T'ai Chi. This article outlines basic principles of T'ai Chi and summarizes recent research on the health effects of T'ai Chi suggested in preliminary, randomized studies. Although there are over 25 published research studies in peer reviewed publications on T'ai Chi, early research tended not to use a randomized, controlled design to study its benefits. Thus it was difficult to disentangle effects of T'ai Chi from pre-existing differences between the experienced T'ai Chi practitioners and comparison non-T'ai Chi practitioners.

Recently a small number of randomized, controlled studies have begun to document the positive effects of T'ai Chi practice on cardiovascular systems, physical balance, and emotional health. In addition, a preliminary study suggests that the practice of T'ai Chi may have a positive impact on the immune system at the cellular level. This article presents findings from these studies and suggests resources that interested readers can pursue for further information. Finally, implications for future research are discussed.

T'ai Chi Principles

T'ai Chi is an ancient Chinese exercise form that combines relaxed, slow movement with a calm, alert mental state. T'ai Chi practice focuses on certain principles or guidelines that foster natural postural alignment and reinforce proper body mechanics inherent in virtually all physical activity (see figure 1). The T'ai-Chi Classics, written by the old masters, states, "The movement is rooted in the feet, propelled by the legs, guided by the torso and expressed in the fingers" (1). The practitioner keeps the body relaxed and upright, focusing on natural diaphragmatic breathing throughout the sequence.

Health Impact of T'ai Chi

As more people in the West practice T'ai Chi, medical researchers have begun to study its effects on physical and emotional health. In the past decade numerous studies have reported positive health effects from T'ai Chi.
Blood Pressure

A growing number of controlled studies found positive cardiovascular effects of T'ai Chi similar to moderate exercise. Channer and colleagues (2) reported changes in blood pressure during an exercise program for cardiac rehabilitation following myocardial infarction. Three weeks after they were discharged from the hospital, a sample of 126 patients (90 males and 36 females; average age 56 years, ranging from 39 to 80 years) were randomly divided into three groups: T'ai Chi , aerobic exercise , and a non-exercise support group. Patients attended sessions twice weekly for three weeks, then once weekly for another five weeks. Heart rate and blood pressure were recorded before and after each session. At 11 weeks post-discharge, diastolic blood pressure had decreased only in the T'ai Chi group ( p<.01). Significant reductions in systolic blood pressure occurred in both exercise groups (both p<.05) compared to a control support group. Consistent with this finding, a second study by Wolf and colleagues also found blood pressure decreased more for subjects randomly assigned to T'ai Chi than for comparison groups (3). Young and colleagues also found systolic and diastolic blood pressure reduction for older, sedentary T'ai Chi participants as well as for aerobic exercise program participants (4). This study with 62 sedentary adults 60 years or older found blood pressure reduction in participants randomized to a T'ai Chi exercise group. The adults, 45% of whom were African-American and 79% women, had systolic blood pressure readings between 130-159 mm Hg at baseline. At 12 weeks systolic blood pressure had fallen an average of 7 mm Hg in the T'ai Chi group, comparable to the 8.4 mm HG reduction in a second exercise group receiving moderate aerobic exercise instead of T'ai Chi.

Balance/Falls

Falls are a major concern among older adults. T'ai-Chi has been identified as a potential strategy for reducing falls in a meta-analysis of the results from an eight-site FICSIT randomized, clinical study (Frailty and Injuries: Cooperative Studies of Intervention Techniques) (5). At one of the FICSIT study sites, Wolf and colleagues randomly assigned individuals aged 70 and over to T'ai Chi, individualized balance training, or exercise control education groups for 15 weeks (3). This study found that T'ai Chi reduced the onset of falls by 47.5% after adjusting for fall risk factors, reduced the fear of falling and increased participants' sense of being able to do all that they would like to do more than was true for the exercise and control groups.

In addition to measuring falls, a follow-up evaluation at four months asked participants six questions:

1. Has participation in this program had any noticeable effect on your life?

2. Has participation in this program changed your sense of confidence in any area?

3. Are there any areas in which you feel less confident?

4. Has participation in the program affected your daily living activities in any way?

5. Has your normal physical activity changed as a result of your participation in this study?

6. Do you feel that you benefited from participating in this program?

Although both T'ai Chi and balance training subjects reported increased confidence in balance and movement, only T'ai Chi subjects reported that their daily activities and their overall life had been positively affected. The authors suggest, "When mental as well as physical control is perceived to be enhanced, with a generalized sense of improvement in overall well-being, older persons' motivation to continue exercising also increases."

Emotional Health

The practice of T'ai Chi may have a positive impact on the mental health as well as physical health (6). One study compared the psychological changes associated with 16-week moderate- and low-intensity exercise training programs with and without cognitive strategies. Subjects were healthy, sedentary adults, including 69 women (mean age 55) and 66 men (mean age 51). Participants were randomly assigned to a control group, moderate-intensity walking group, low-intensity walking group, low intensity walking group with Benson's relaxation response (7), or a T'ai Chi exercise group (T'ai Chi). The T'ai Chi activity was performed in a group 3 times a week for 45 minutes. Data for women and men were analyzed separately because baseline scores were significantly higher for women than men on several variables related to mood, trait anxiety, negative affects and neurotocism. Mean baseline scores, however were still within the average range of published scores.

At the end of the 16 week intervention, women in the T'ai Chi group reported reduced tension, depression, anger, confusion, and total mood disturbance and improved general mood. Women in the moderate-intensity walking group reported greater satisfaction with their physical attributes, and men in that group reported increased positive affect. No other differences were observed between groups on measures of mood, self-esteem, personality, or life satisfaction. In general, men in all groups showed improved psychological scores post-testing compared to pre-testing, but no differences between groups. Given the study's intention to compare exercise groups with and without a cognitive element it is interesting that T'ai Chi, but not exercise plus the relaxation response training, had a significant impact on psychological outcomes for women. These findings also underscore the importance of considering gender differences in planning and evaluating interventions meant to improve physical and emotional health.

It is worth noting that small but significant aerobic improvements (peak VO2) occurred in the moderate intensity walking and in low intensity groups for women, but not in the T'ai Chi group. For men, the same small but significant improvements occurred in the moderate intensity walking and low intensity walking plus relaxation response groups.

Immune Response

One non randomized study has attempted to trace the impact of T'ai Chi exercise at the cellular level, studying the effect of T'ai Chi exercise on T-lymphocytes in elderly subjects as an indicator of the immune response (8). The sample was composed of 60 healthy subjects (volunteers who were not receiving acupuncture treatments or taking drugs that could alter immunity). Researchers compared 30 healthy aged subjects who practiced T'ai Chi to 30 healthy age-matched subjects who served as a control group. Immediately after T'ai Chi, a marked increase of active T-lymphocytes occurred. At rest, the total number of T-lymphocytes and the number of active T-lymphocytes increased significantly in the T'ai Chi group compared with the controls. A randomized, controlled study design could strengthen the results of this study. More studies are needed to explore these findings.

Summary of Studies

Preliminary, randomized studies suggest T'ai Chi potentially has positive emotional and physical health outcomes with respect to blood pressure as well as balance (See figure 2). While more research is needed to delineate the conditions under which impact is most likely and for which patient populations it is most beneficial, initial findings suggest that T'ai Chi can be a useful addition to health and fitness programs. There is a need for more research with controlled study designs to evaluate the effects of T'ai Chi practice for a range of ages and health domains (i.e., respiratory system, immune system, psychological outcomes). Gender differences will be important to explore carefully in future work. Further, it would be useful for more research on the physiological dynamics hypothesized to underlay the outcomes identified. Lastly, there is a need for research to identify issues in the implementation and maintenance of T'ai Chi practice itself.

First author's Note:

In the summer of 1974 I was introduced to T'ai Chi in a class taught outside by the lake at 6:30 in the morning. Little did I know that 25 years later I would still be doing T'ai Chi outside by the lake at 6:30 in the morning even in the Wisconsin winter ! The beauty of the morning itself became a teacher as I adopted the moves our teacher originally demonstrated. Through the practice I came to feel more connected to my natural world by the lake, watching the seasons come and go as I relaxed and focused on my breath, my balance, my posture. In the midst of my young family, T'ai Chi became a haven. Over time, the flow of movements became more important than the details. It helped me get successfully through much professional travel, the stress of tenure review, organizational conflicts, and more. At age 53, I'm actually more committed to my practice now than at any time before. T'ai Chi goes with me to hotel rooms, ocean sand bars at sunset, my mother's living room as I dodge coffee tables, and to piers with pelicans watching languidly. When traveling, one favorite location is on golf putting greens at dawn! This quiet, mindful practice quite frankly has been my rock in a "fast track life. I look forward to the time when quiet spaces are available in mainstream fitness and sports medicine environments to support the practice of this meditative exercise for many others as well.

Return to Part 1 of this series

References

1. Lo, B., Inn, M., Amacker, R., and Foe, S. The Essence of T'ai Chi Ch'uan. Richmond, CA: North Atlantic Books, 1979.

2. Channer, K.S., Barrow, D., Barrow, R., Osborne, M., and Ives, G. Changes in haemodynamic parameters following t'ai chi chuan and aerobic exercise in patients recovering from acute myocardial infarction. Postgraduate Medical Journal 72: 349-51, 1996.

3. Wolf, S.L., Barnhart, H.X., Kutner, N.G., McNeely, E., Coogler, C., and Xu T. Reducing frailty and falls in older persons: an investigation of t'ai chi and computerized balance training. Atlanta FICSIT Group (Frailty and Injuries: Cooperative Studies of Intervention Techniques). Journal of the American Geriatrics Society 44: 489-497, 1996.

4. Young, D.R., Appel, L.J., Jee, S., Miller, E.R. The effects of aerobic exercise and T'ai Chi on blood pressure in older people: Results of a randomized trial. Journal American Geriatrics Society 47:2777-2284,1999.

5. Province, M.A., Hadley, E.C., Hornbrook, M.C., Lipsitz, L.A., Miller, J.P., Mulrow, C.D., Ory, M.G., Sattin, R.W., Tinetti, M.E., and Wolf S.L. The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. Journal of the American Medical Association 273:1341-47, 1995.

6. Brown, D.R., Wang, Y., Ward, A., Ebbeling, C.B., Fortlage, L., Puleo, E., Benson, H., and Rippe, J.M. Chronic psychological effects of exercise and exercise plus cognitive strategies. Medicine and Science in Sports and Exercise 27: 765-75, 1995.

7. Benson, H. The Relaxation Response. New York: William Morrow & Co., 1975.

8. Xusheng, S., Yugi, X., and Yunjian, X. Determination of e-rosette-forming lymphocytes in aged subjects with t'aijiquan exercise. International Journal of Sports Medicine 10: 217-219, 1989.

Recommended Reading

Kutner, N.G., Barnhart, H., Wolf, S.L., McNeely, E., and Xu, T. Self-report benefits of t'ai chi practice by older adults. Journal of Gerontology 52: 246-6, 1997.

Luskin, F.M., Newell, K.A., Griffith, M., Holmes, M., Telles, S., Marvasti, F.F., Pelletier, K.R., Haskell, W.L. A review of mind-body therapies in the treatment of cardiovascular disease: Part 1: Implications for the elderly. Alternative Therapies, 4:46-61, 1998.

Ross, C., Preswalla, J.L., The therapeutic effects of tai chi for the elderly. Journal of Gerontological Nursing Feb:45-47,1998.

Figure 1

T'ai Chi Principles

Postural Alignment

The body remains upright in proper postural alignment throughout the sequence. The head is uplifted at the crown and the occiput; shoulders stay relaxed.

Breath Awareness

Natural diaphragmatic breathing is maintained throughout the entire sequence. The belly expands with the inhalation and contracts with the exhalation. This allows the lungs to fill more completely with air. Breath awareness is a vehicle for bringing attention into the present moment.

Active Relaxation

Relaxation is often associated with being unfocused or sleepy. Active relaxation integrates physical relaxation with a calm mental alertness. This is considered to be an optimal state of functioning that promotes the flow of qi, or life force, within the body. T'ai Chi training reinforces this mind/body integration both while a person is still and in motion. It is a skill learned gradually through practice.

Minimal Effort

Most exercise programs focus on exertion and straining as a means to achieve increased strength and endurance. When practicing T'ai Chi, one conserves energy, using minimal effort so that the body actually feels heavier. This is called sung, a combination of relaxed and heavy.

Slow Movement

T'ai Chi's continuous slow movements are performed in a flexed stance, increasing endurance and load-bearing capacity. The knees remain bent and the body relaxed in proper alignment throughout the sequence. The slower and lower the movement, the greater the exercise benefit.

Separating the Weight

During transitions and weight shifts, the weight is balanced 100 percent on one foot, while keeping the body upright. Combined with the slow movement, this contributes to
better balance and increased leg strength.

Integrated Movement

The head, trunk, and pelvis initiate all arm movements. They rotate as a single "column" aligned over the stable base in the feet. There is no twisting of the spine. The upper body is relaxed and in proper alignment; the weight sinks directly into the legs and feet. When the upper body is tense, it is more difficult to sense this natural alignment.

Figure 2

Health Effects of T'ai Chi in Randomized, Controlled Studies

See T'ai Chi research Web site:

http://www.krapu4.com/taichi/research/