Australasian Journal on Ageing, Vol 24 No 1 March 2005, Research 9–13 9

Blackwell Publishing, Ltd.ResearchTai Chi in older people: balance and mobility

Tai Chi in Australia: acceptable and effective approach to improve balance and mobility in older people?

Keith HillPublic Health Division, National Ageing Research Institute (NARI), Parkville, Victoria, Australia

Whanseok ChoiDepartment of Family Medicine, Uijongbu St Mary’s Hospital, Catholic University, Seoul, South Korea

Robyn SmithAllied Health Research and EBP, Northern Health, Bundoora Extended Care Centre, Bundoora, Victoria, Australia

Joanna CondronCentre for Development and Innovation in Health, La Trobe University, Bundoora, Victoria, Australia

Objective: To evaluate the effects of 24 form Tai Chi Quan (TCQ) on balance and related measures, and factors associated with participation in the program.Methods: Twenty-three older subjects (mean age 71.0 years, SD 5.6 years) commenced the three times weekly 1 h TCQ sessions. Subjects were measured on balance (Functional Reach, Step Test), gait (velocity, double support phase duration), activity level, leg muscle strength, and the Modified Falls Efficacy Scale (MFES) before and following the 3 month program. Participants also completed a survey investigating participation and perceived benefit of the program.Results: Nineteen participants completed the program, averaging attendance at 68% of classes. There was significant improvement in balance (Step Test, P < 0.01) and non-significant improvement in gait double support duration (P = 0.04), Functional Reach (P = 0.04) and activity level (P = 0.06). Most participants incorporated some home practice as well as the formal program, and reported both the physical (balance) components and remembering sequences of movements as the most challenging aspects of the program.Conclusions: Twenty-four form TCQ is a practical form of exercise for older people that improves dynamic balance performance.

Key words: balance, older adults, physical activity, Tai Chi.

IntroductionTai Chi is gaining popularity as a form of exercise for olderpeople in Australia (Song HJ, Tai Chi Australia, 2004,personal communication). A number of styles of Tai Chideveloped from the 1600s. Under the direction of China’sgovernment in the early 1950s, a consensus meeting defined a

new style called the Beijing 24 Step Form, as a condensed ver-sion containing the essential elements of the Yang style [1].The development and national promotion of this style in Chinahad an underlying emphasis on improving people’s health.In addition to varying styles, Tai Chi programs also differ inthe number of forms or discrete movements used, includingshorter combinations of 8 [2], 10 [3] and 12 forms [4].

Several research reviews have investigated the effectiveness ofTai Chi in improving health outcomes for older people [5–6].The majority of research has been limited to cross-sectional orpre and post intervention studies. Although not consistentacross the studies, overall these studies have identified signific-ant improvements in leg strength [7–9], cardiovascular/cardi-orespiratory fitness [8,10], trunk flexibility [7,11], static standingbalance [9,12], dynamic standing balance [9,13–15], and painand mood [16]. Most commonly, samples have included rela-tively healthy older people as participants [17].

Four randomised controlled trials (RCTs) have been con-ducted in the community setting. One compared an abbrevi-ated 10 form Tai Chi with a balance platform training programand an education program [3], and achieved a significant low-ering of systolic blood pressure post exercise, reduced fear offalling and increased time to first fall. Interestingly, however,there was no significant improvement in balance measuresin the Tai Chi group [18]. Another RCT, using the 24 formBeijing style Tai Chi, identified significant improvements inself reported physical function and movement efficacy in olderpeople [19], with greater benefit achieved by participants withlower levels of function and lower levels of health perception[20]. Two RCTs have evaluated the effect of Tai Chi onosteoarthritis patients, with one identifying improvement inarthritic symptoms, balance and self perceived function [21]using the Tai Chi for Arthritis program [4], and the otherreporting significant improvements in self efficacy for arthritissymptoms, satisfaction with general health, and trends forimproved mobility and standing up from a chair [22].

One of the possible explanations for the lack of change in bal-ance performance in the randomised controlled trial by Wolfet al. [18], despite achieving reduced falls rates, may be thechoice of balance measure. Several Tai Chi studies measuringstatic balance have not identified any improvement in perform-ance [10,13]. Static and dynamic balance measures have beenshown to measure different underlying constructs [23]. Thereis a clear need for further well designed studies to morerigorously examine the effectiveness of Tai Chi in improvingbalance and related measures among older people.

Correspondence to: Dr Keith Hill, National Ageing Research Institute. Email: k.hill@nari.unimelb.edu.au

. H i l l K , C h o i W , S m i t h R e t a l .

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As with other forms of exercise, compliance with completingthe program is also an important issue, with up to 41% ofparticipants failing to complete Tai Chi programs of 3 to12 months duration [3,10,12,17,21]. Factors associated withsustained participation in Tai Chi community programs includethe gentle nature of the exercise, perceptions of improved per-formance, opportunities for social interaction, and easy accessto venues [17]. A potential barrier to participation was frustra-tion with the difficulty of learning the movement sequences[17]. Issues associated with sustained participation in this formof exercise warrant further exploration.

The aims of this pilot study were to investigate the effect of24 form Tai Chi Quan (TCQ) on a comprehensive test batteryof dynamic balance and related measures in a group of olderpeople, and to identify issues influencing participation andcompliance with the program.

MethodsSubjects were recruited through promotion of the programin local newspapers, newsletters and community displays inMelbourne, Australia. Inclusion criteria were: being aged65 years or older, living in the community, and being able towalk independently outside the home. Subjects were excludedif they had participated regularly in other Tai Chi programswithin the previous 12 months. Twenty-three subjects (7 maleand 16 female) commenced the classes. The project wasapproved by the Royal Melbourne Hospital Clinical ResearchEthics Committee, and all participants provided informedconsent.

ProceduresPrior to commencing classes, and at the completion of the TaiChi program, all subjects were assessed on a range of balance,mobility and related measures by one of the investigators (JC).All measures have moderate to high reliability and validityreported in samples of older people [24–29].

The Functional Reach (FR) test, a bilateral stance dynamicstanding balance task, was performed using the dominant armas described by Duncan et al. [24], except that the width of thebase of support was standardised to feet 10 cm apart.

The Step Test (ST) is a dynamic single leg stance balance taskthat involves stepping one foot fully on then off a 7.5-cm stepas quickly as possible in 15 s [25]. Each leg was tested sepa-rately, and the lowest score recorded.

Gait velocity and double support duration were measured atcomfortable speed over the middle 6 m of an 8 m walkwayusing a Clinical Stride Analyser [26].

Modified Falls Efficacy Scale (MFES) is a 14-item question-naire evaluating confidence in performing tasks without falling[27]. An average score across all completed items was reportedout of a maximum 10, with higher scores indicating greaterconfidence.

Activity level was assessed using the Human Activity Profile(HAP), a 94-item questionnaire with items organised in orderof increasing energy expenditure [28], and rated as ‘still doing’,‘have stopped doing’, or ‘never did’ the activity. The highestrated item listed as ‘still doing’ was recorded as the MaximalActivity Score (MAS), and the MAS less the number of lowernumbered items reported as ‘have stopped doing’ was recordedas the Adjusted Activity Score (AAS).

Muscle strength: Nicholas Manual Muscle TesterThe break test was used with the Manual Muscle Tester(MMT) to assess ankle dorsiflexor, knee extensor and hipabductor strength bilaterally in supine [29]. Each muscle groupwas assessed three times, taking the average for the last twotrials and standardising by dividing by body weight. A cumu-lative leg muscle strength score was calculated by summing theaverage standardised score for both ankle dorsiflexors, quadri-ceps and hip abductors.

Survey distributionAfter 2 months of Tai Chi classes a survey developed by theproject team was circulated to those still participating. Ques-tions related to reasons for participating in the program, easi-est and hardest parts of the program, perceived benefits, andhome practice. The survey was completed by 18 of the 19 par-ticipants still attending classes at that time.

InterventionClasses were conducted for 1 h three times weekly for3 months, and consisted of 10 min warm up exercises, 40 minpractice of the previously learned or new forms (24 formTCQ, based on the Beijing 24 form), and 10 min of warmdown exercises. An experienced Tai Chi practitioner (oneof the authors, WC) led the classes, together with a second(novice) trainer to assist and monitor participants’ perform-ance. Thirty-six classes were considered sufficient to learn 24forms. Dosage of twice or three times weekly for 3–4 monthshas been shown in other exercise approaches to be sufficientto achieve physical improvement [30]. There was no cost toparticipants.

Statistical analysisDescriptive statistics were calculated for all outcome measuresand survey results. Changes in outcome measures between preand post intervention were assessed using repeated measurest-tests, with Bonferroni adjustment for multiple comparisons(adjusted P-value 0.01).

ResultsTwenty-three participants commenced classes, with an averageage of 71.1 years (SD = 5.6 years), 14 were married and sixlived alone. Seven participants were taking four or more medi-cations, and 16 reported no falls in the preceding 6 months.Nineteen participants completed the 3 months of classes(74% female, mean age 71.7 years [SD 6.1], range 65–88 years),averaging attendance at 68% of available classes. Four par-ticipants did not complete the program (17% dropout rate),

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mostly for health reasons unrelated to the Tai Chi (e.g. surgery,pneumonia and lower back pain). Those who withdrew fromthe program performed slightly worse on most of the baselinemeasures (P > 0.05).

All measures improved following the Tai Chi classes, exceptfor the MFES which remained unchanged and gait velocitywhich showed a small (6%) reduction (Table 1). Performanceon the Step Test improved significantly (P < 0.01), and therewere non-significant improvements in Functional Reach(P = 0.04), double support phase duration of the gait cycle(P = 0.04), and MAS (P = 0.06). The percentage improvementrelative to baseline ranged from −6.0% for gait velocity, to+20.4% for the Step Test. Of note, the average MFES scorewas 9.6 (SD 0.7) out of a maximum of 10 at baseline, indicat-ing high levels of falls efficacy (confidence) prior to commenc-ing the program, and a ceiling effect limiting scope for changeon this measure.

Most participants reported several factors as reasons for com-mencing the program, with involvement in research, improv-ing health status, no cost, and central location being mostcommon (Table 2). Participants reported fairly active lifestylesprior to commencing the program (also supported by highbaseline scores on the HAP). Seventeen participants reportedperceived benefits from participating in the program, particu-larly in the areas of confidence, agility and function. Ten ofthe 18 respondents considered remembering the movementsequences to be the hardest part of the program, and almost asmany considered the balance demands to be the hardest com-ponent. The warm up and cool down period of classes wereconsidered to be very enjoyable, and were the componentsmost commonly used in home programs. Sixteen participantsreported undertaking home practice as well as the groupclasses, the majority doing this at least twice weekly. Severalparticipants identified aspects of the program they suggestedcould be improved, including greater clarity in the booklet pro-vided with written description and graphics of each movementsequence for home practice, use of a video to support homepractice, and use of a larger venue.

DiscussionResults of this pilot study add to the growing literature sup-porting Tai Chi as a beneficial form of exercise for olderpeople. Of note, dynamic balance (the Step Test) improved sig-nificantly. This is in contrast to the one randomised controlledtrial investigating the effect of Tai Chi on falls, which identifieda significant reduction in falls, although no significant changein balance performance [3]. Several possible factors couldaccount for this difference in results. One important differencebetween the two studies is the type of Tai Chi practiced.

Table 1: Pre- and post-intervention measures and percentage change following Tai Chi (n = 19)

Outcome measure Pre-intervention mean (SD) Post-intervention mean (SD) Change (%)* P-value

Dynamic standing balanceFunctional Reach test (cm) 28.9 (7.6) 32.0 (5.8) +10.7 0.04Step Test (complete steps in 15 s–worst leg) 14.7 (3.9) 17.7 (5.1) +20.4 < 0.01

Fear of fallingModified Falls Efficacy Scale 9.6 (0.7) 9.6 (0.6) 0 0.95

GaitVelocity (m/min) 71.2 (17.3) 66.9 (16.5) −6.0 0.10Double support duration (% gait cycle) 27.4 (4.8) 24.8 (3.2) −9.5† 0.04

Human Activity ProfileMaximal Activity Score 75.4 (6.0) 76.6 (6.4) +1.6 0.06Adjusted Activity Score 69.0 (11.0) 71.0 (10.4) +2.9 0.19

Muscle strengthAverage leg strength score 0.169 (0.054) 0.183 (0.042) +8.3 0.30

*Percent change is calculated relative to baseline score ([t2 – t1] × 100/t1). For all measures a positive change score indicates improvement, except for †double support duration in which a negative score indicates improvement.

Table 2: Survey results (n = 18)

Measure n

Factors associated with commencing Tai Chi program(a) Keen to be involved in research 16(b) To improve aspects of health 15(c) Central location/accessible 15(d) No cost 12(e) OtherPhysical activities undertaken in last 12 months(a) None 4(b) Regular walking 14(c) Strength training 5(d) Exercise classes 2(e) Hydrotherapy 1(f ) Other 0Most beneficial part of the program(a) Improved perception of health status 7(b) Improved flexibility 2(c) Social/friendship aspects of the program 2(d) Relaxation 2Hardest part of the program(a) Remembering the components/learning 10(b) Balancing during the movements 9(c) Coordination 2(d) Relaxation 1Easiest part of the program(a) Warm up and cool down components 9Home practice(a) Yes 16(b) Frequency

Daily 44 times weekly 12–3 times weekly 6Once weekly 3Occasional/none 4

. H i l l K , C h o i W , S m i t h R e t a l .

12 Australasian Journal on Ageing, Vol 24 No 1 March 2005, Research 9–13

The 24 form Tai Chi used in the current study incorporates amore extensive range of movements which challenge balance,strength, coordination and flexibility. Although participants inthe current study reported the program to be very challengingfrom a balance and a memory perspective, it was nonethelessan appropriate form of exercise for this sample of relativelywell older people.

The other factor which may account for differences betweenthe studies is the choice of balance measures used. There isincreasing support for the use of dynamic measures of balancerelative to static measures in terms of responsiveness to change[23], reliability [31], and the association of falls with dynamictasks [29]. Although the current study did not investigate falls,improvement in one of the most important falls risk factors –balance – indicates the potential that this program has inreducing falls risk. However, a larger scale study incorporatinga randomised controlled trial design is required to investigatethe effectiveness of 24 form Tai Chi in preventing falls relativeto other types of Tai Chi, relative to other conventional formsof exercise such as group exercise or strength training, and rel-ative to less traditional forms of exercise such as Feldenkraisand yoga.

The MFES did not change with the program, however,participants demonstrated virtually no loss of confidence atbaseline, indicating limited potential for improvement on thisscale.

The survey results and the participation rates from this pro-gram indicate that 24 form Tai Chi is an enjoyable and practi-cal exercise option for relatively well older people. Other formsof Tai Chi, including the recently developed ‘Tai Chi for Arthri-tis’ [4,21], may be more appropriate for frailer older people. Itis unlikely that the same level of effect in terms of reduced fallsrisk and rate and degree of improvement in balance would beachieved with more gentle forms of Tai Chi, although furtherinvestigation is required. A recent randomised trial did notachieve a significant reduction in falls using an abbreviatedversion of Tai Chi for frailer older people in supported accom-modation [32].

Many factors interact to influence an individual’s participationin exercise. Intrinsic factors include pre-existing health condi-tions, level of preparedness for change in participating in physicalactivity [33], and personal preference [34]. Extrinsic factorsinclude access (e.g. central location, transport availability),cost, perceived level of benefit, and social opportunities. Inter-mittent measurement of performance for participants, withfeedback, can facilitate ongoing interest and personal satisfac-tion with the program. Refreshments and opportunities fornetworking and social interaction were provided after eachclass in the current program. These opportunities appeared tofoster development of social networks between participantsand supported ongoing participation. Clearly, if Tai Chi pro-grams are to become well established as a health promotionactivity for older people, options for accessing classes, and

each of the factors above, need to be considered by programdevelopers to ensure broad reach and participation levels.

Limitations of the study design include the potential for samplebias by relying on volunteer participants, the small sample size,and the lack of longer term follow-up to determine sustain-ability of outcomes. Additional outcome measures such asquality of life should also be considered in future studies.

SummaryA 3-month program of 24 form TCQ resulted in significantimprovement in balance in a small sample of older people. Theprogram was viewed positively by participants and achievedmoderately high participation levels. Results suggest that a largerconfirmatory study investigating the effectiveness of 24 formTai Chi across a broad range of health outcomes is warranted.

AcknowledgementsThe project team thank the Helen Macpherson Smith Trustfor providing funding for the project, and all participants whogave generously of their time.

Key Points• There are a number of different types of Tai Chi,

which may have differing health benefits.

• 24 form TCQ is associated with significant improve-ment in dynamic standing balance in independent,community ambulant older people.

• 24 form TCQ appears to be an appropriate andacceptable form of exercise for independent, com-munity ambulant older Australians.

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