Wednesday, January 23, 2019

The effect of Tai Chi on four chronic conditions—cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease


Background Many middle-aged and older persons have more than one chronic condition. Thus, it is important to synthesise the effectiveness of interventions across several comorbidities. The aim of this systematic review was to summarise current evidence regarding the effectiveness of Tai Chi in individuals with four common chronic conditions—cancer, osteoarthritis (OA), heart failure (HF) and chronic obstructive pulmonary disease (COPD).
Methods 4 databases (MEDLINE, EMBASE, CINAHL and SPORTDiscus) were searched for original articles. Two reviewers independently screened the titles and abstracts and then conducted full-text reviews, quality assessment and finally data abstraction. 33 studies met the inclusion criteria. Meta-analyses were performed on disease-specific symptoms, physiological outcomes and physical performance of each chronic condition. Subgroup analyses on disease-specific symptoms were conducted by categorizing studies into subsets based on the type of comparison groups.
Results Meta-analyses showed that Tai Chi improved or showed a tendency to improve physical performance outcomes, including 6-min walking distance (6MWD) and knee extensor strength, in most or all four chronic conditions. Tai Chi also improved disease-specific symptoms of pain and stiffness in OA.
Conclusions The results demonstrated a favorable effect or tendency of Tai Chi to improve physical performance and showed that this type of exercise could be performed by individuals with different chronic conditions, including COPD, HF and OA.
The body of the research paper can be found at the doi link shown at the end. Omitted here for simplicity. We only show the discussion section here: 


The most important findings of this systematic review and meta-analyses on 33 studies and 1584 participants were that Tai Chi showed favorable effects or modest trends on improving 6MWD, knee extensor strength and quality of life in most or all four chronic conditions: cancer, OA, HF and COPD. Our findings support the results of a previous systematic review that showed the effectiveness of Tai Chi on health outcomes in older patients with chronic conditions.25 These findings also complement previous systematic reviews that only examined the effect of Tai Chi in a single chronic condition.59–62 Moreover, Tai Chi provided greater improvements than comparison groups in other physical performance measures including decreased TUG times and shorter sit-to-stand times in participants with OA. Finally, Tai Chi was more effective for improving pain and stiffness in OA compared with other interventions or controls.
Meta-analyses demonstrated that Tai Chi was more effective or showed modest trends compared with controls or other intervention groups towards improving the 6MWD in four chronic conditions. The 6MWD is a common primary outcome measure that is considered to evaluate functional exercise capacity.63 It shows moderate-to-high correlations with outcomes from peak cardiopulmonary exercise tests in participants with cardiac diseases64 and COPD63 and has also been shown to increase after resistance training in participants with chronic HF.65 The positive effect and trends of the 6MWD in all four conditions provide evidence that the exercise overload induced by Tai Chi was sufficient to improve functional exercise capacity in these chronic conditions.
Tai Chi improved the knee extensor muscle strength in participants with HF and COPD, but only showed a tendency towards improvement in participants with OA compared with other comparison groups and was not measured in participants with breast cancer. Although participants with knee OA have lower knee muscle strength,66 this impairment might be less than the weakness demonstrated in participants with HF67 and COPD,68 and thus a greater overload may be required than that provided by Tai Chi. Hence, Tai Chi appears to improve knee extensor strength in HF and COPD with more marginal benefits in OA. Further study is required to realise its impact on knee extensor strength in cancer survivors.
Other physical performance measures that require knee extensor strength improved more so after Tai Chi than other comparison groups in participants with OA. Most notably, TUG and sit-to-stand times showed greater improvements after Tai Chi than comparison groups in participants with OA. These findings may be attributed to the multifaceted training stimuli of Tai Chi that is directed towards improving balance and postural alignment in addition to strength.5 Although Tai Chi provides a minimal strength training stimulus, its positive influence on TUG and sit-to-stand times provides strong evidence of its clinical impact on important functional measures in participants with OA.
The effect of Tai Chi on quality of life within a particular condition was less consistent. The most positive effects of Tai Chi on quality of life were shown in participants with OA. This is somewhat similar to a systematic review that examined participants with OA that showed improved physical quality of life, but not quality of life related to mental health.69 The differing results can be explained by the small sample sizes in the previous systematic review, which only included two studies and 84 participants versus 181 respondents in our systematic review. A strong trend was shown in participants with COPD, and the inclusion of RCTs that were written in other languages may have resulted in a significant overall effect towards improving quality of life in participants with COPD similar to another systematic review.60
In addition to the improvement in physical performance measures, symptoms either improved or did not differ after Tai Chi compared with the other treatment or a control group. Pain and stiffness in OA showed greater improvements after Tai Chi and dyspnoea showed a trend towards improvement in participants with COPD. Improved pain and stiffness in participants with OA may be attributed to increases in muscle strength, balance and/or postural alignment.70 From a clinical perspective, this evidence provides some assurance to the health professional that prescription of Tai Chi to persons living with OA and COPD has the potential to improve functional exercise capacity, but not at the expense of aggravating pain or causing undue dyspnoea.

Limitations and strengths

This meta-analysis has some limitations. First, only studies published in English were included due to the lack of two reviewers who were fluent in other languages. Second, with the exception of OA, there were limited numbers of RCTs in the other chronic conditions, especially regarding the availability of raw data that could be included in the meta-analyses. Third, the sample sizes of included RCTs were quite small, contributing to limited power in most studies and in the aggregated data examined by meta-analyses. For example, the conflicting findings of the effect of Tai Chi on blood pressure in participants with HF are difficult to interpret because both reports had a small sample size.22 ,58 A fourth limitation is that participants in most studies represented patients who had one primary condition and may have excluded individuals with multimorbidity. Further study examining the effects of Tai Chi on multimorbidity is required to substantiate its benefits in this potentially complex patient group. Finally, the diversity of the type and parameters of Tai Chi in the included studies also limits the ability to make firm conclusions regarding the recommended Tai Chi exercise prescription for each chronic condition.
A key strength of this meta-analysis was the examination of the evidence regarding Tai Chi by reporting the symptoms, physiological and exercise outcomes of four common chronic conditions. Individuals with different chronic conditions may have different mechanisms that contribute to symptoms, impaired physical performance or quality of life. However, in people with multimorbidity, these underlying factors may also be inseparable or difficult to identify. Therefore, this systematic review offers a reasonable starting point to begin the quest for determining alternative exercise protocols, such as Tai Chi, for individuals who live with multimorbidity. Most of the included studies were moderate-to-high quality in terms of methodology (PEDro=4–7). Only one included study had poor quality32 and was excluded from quantitative syntheses due to missing data. This systematic review provided a quantitative synthesis of important physical performance outcomes, symptoms and quality of life. For some measures, evidence was limited due to the diverse outcome measurements among the conditions and small sample size. More rigorous RCTs with larger sample sizes are required to confirm the inconsistent findings among the included studies. Also, studies that examine patients with a broader range of diagnoses are required. For example, all of the studies examining cancer in this systematic review involved participants with breast cancer. It would be worthwhile to assess the effectiveness of Tai Chi on other types of cancer.
In conclusion, the results provided evidence regarding a favourable effect or tendency of Tai Chi on improving the performance of 6MWD, knee extensor strength and quality of life in people with cancer, OA, HF and COPD. Additionally, the meta-analyses showed the favorable effects of Tai Chi versus other interventions or no treatment on several disease-specific symptoms, including pain and stiffness. Taken together, Tai Chi demonstrates improvement in functional exercise capacity in individuals with different chronic conditions without aggravating symptoms of pain and dyspnoea. To summarize, Tai Chi appears to provide an adequate exercise stimulus and it could be a suitable exercise to prescribe for people with several co-morbidities that include COPD, HF and OA.

What are the findings?

  • Tai Chi can improve some physical performance outcomes in four chronic conditions (cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease) but not at the expense of worsening pain or dyspnoea.
  • Tai Chi may provide a suitable exercise stimulus for people with several co-morbidities.

How might this impact on clinical practice in the future?

  • It is possible to consider prescribing Tai Chi in people with multi-morbidity.
  • Tai Chi is an exercise that is suitable to improve physical performance in middle-aged and older adults.
  • Tai Chi can be a complementary therapy in some chronic conditions.
Chen YHunt MACampbell KL, et al. "
The effect of Tai Chi on four chronic conditions—cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: a systematic review and meta-analyses"

Friday, January 18, 2019

The Health Benefits of Tai Chi

This gentle form of exercise can help maintain strength, flexibility, and balance, and could be the perfect activity for the rest of your life.

Tai chi is often described as "meditation in motion," but it might well be called "medication in motion." There is growing evidence that this mind-body practice, which originated in China as a martial art, has value in treating or preventing many health problems. And you can get started even if you aren't in top shape or the best of health.

In this low-impact, slow-motion exercise, you go without pausing through a series of motions named for animal actions — for example, "white crane spreads its wings" — or martial arts moves, such as "box both ears." As you move, you breathe deeply and naturally, focusing your attention — as in some kinds of meditation — on your bodily sensations. Tai chi differs from other types of exercise in several respects. The movements are usually circular and never forced, the muscles are relaxed rather than tensed, the joints are not fully extended or bent, and connective tissues are not stretched. Tai chi can be easily adapted for anyone, from the most fit to people confined to wheelchairs or recovering from surgery.

Tai Chi movement

A tai chi class practices a short form at the Tree of Life Tai Chi Center in Watertown, Mass.
"A growing body of carefully conducted research is building a compelling case for tai chi as an adjunct to standard medical treatment for the prevention and rehabilitation of many conditions commonly associated with age," says Peter M. Wayne, assistant professor of medicine at Harvard Medical School and director of the Tai Chi and Mind-Body Research Program at Harvard Medical School's Osher Research Center. An adjunct therapy is one that's used together with primary medical treatments, either to address a disease itself or its primary symptoms, or, more generally, to improve a patient's functioning and quality of life.

Belief systems

You don't need to subscribe to or learn much about tai chi's roots in Chinese philosophy to enjoy its health benefits, but these concepts can help make sense of its approach:

Qi — an energy force thought to flow through the body; tai chi is said to unblock and encourage the proper flow of qi.

Yin and Yang — opposing elements thought to make up the universe that need to be kept in harmony. Tai chi is said to promote this balance.

Tai Chi in motion

A tai chi class might include these parts:

Warm-up.  Easy motions, such as shoulder circles, turning the head from side to side, or rocking back and forth, help you to loosen your muscles and joints and focus on your breath and body.

Instruction and practice of tai chi forms. Short forms — forms are sets of movements — may include a dozen or fewer movements; long forms may include hundreds. Different styles require smaller or larger movements. A short form with smaller, slower movements is usually recommended at the beginning, especially if you're older or not in good condition.

Qigong (or chi kung). Translated as "breath work" or "energy work," this consists of a few minutes of gentle breathing sometimes combined with movement. The idea is to help relax the mind and mobilize the body's energy. Qigong may be practiced standing, sitting, or lying down.

Getting started

The benefits of tai chi are generally greatest if you begin before you develop a chronic illness or functional limitations. Tai chi is very safe, and no fancy equipment is needed, so it's easy to get started. Here's some advice for doing so:

Don't be intimidated by the language. Names like Yang, Wu, and Cheng are given to various branches of tai chi, in honor of people who devised the sets of movements called forms. Certain programs emphasize the martial arts aspect of tai chi rather than its potential for healing and stress reduction. In some forms, you learn long sequences of movements, while others involve shorter series and more focus on breathing and meditation. The name is less important than finding an approach that matches your interests and needs.

Check with your doctor . If you have a limiting musculoskeletal problem or medical condition — or if you take medications that can make you dizzy or lightheaded — check with your doctor before starting tai chi. Given its excellent safety record, chances are that you'll be encouraged to try it.

Consider observing and taking a class. Taking a class may be the best way to learn tai chi. Seeing a teacher in action, getting feedback, and experiencing the camaraderie of a group are all pluses. Most teachers will let you observe the class first to see if you feel comfortable with the approach and atmosphere. Instruction can be individualized. Ask about classes at your local gym, senior center, or community education center. The Arthritis Foundation can tell you whether its tai chi program, a 12-movement, easy-to-learn sequence, is offered in your area. Check out the workshop in Golden Gate Bridge view with a master with 40-year teaching experience in San Francisco by visiting the event in the photo at the end.

If you'd rather learn at home, you can buy or rent videos geared to your interests and fitness needs. We now have materials in Chinese but plan to have materials in English in the future. Although there are some excellent tai chi books, it can be difficult to appreciate the flow of movements from still photos or illustrations.

Talk to the instructor. There's no standard training or licensing for tai chi instructors, so you'll need to rely on recommendations from friends or clinicians and, of course, your own judgment. Look for an experienced teacher who will accommodate individual health concerns or levels of coordination and fitness.

Dress comfortably. Choose loose-fitting clothes that don't restrict your range of motion. You can practice barefoot or in lightweight, comfortable, and flexible shoes. Tai chi shoes are available, but ones you find in your closet will probably work fine. You'll need shoes that won't slip and can provide enough support to help you balance, but have soles thin enough to allow you to feel the ground. Running shoes, designed to propel you forward, are usually unsuitable.

Gauge your progress. Most beginning programs and tai chi interventions tested in medical research last at least 12 weeks, with instruction once or twice a week and practice at home. By the end of that time, you should know whether you enjoy tai chi, and you may already notice positive physical and psychological changes.

No pain, Big gains

Although tai chi is slow and gentle and doesn't leave you breathless, it addresses the key components of fitness — muscle strength, flexibility, balance, and, to a lesser degree, aerobic conditioning. Here's some of the evidence:

Muscle strength. Tai chi can improve both lower-body strength and upper-body strength. When practiced regularly, tai chi can be comparable to resistance training and brisk walking.

"Although you aren't working with weights or resistance bands, the unsupported arm exercise involved in tai chi strengthens your upper body," says internist Dr. Gloria Yeh, an assistant professor at Harvard Medical School. "Tai chi strengthens both the lower and upper extremities and also the core muscles of the back and abdomen."

Flexibility. Tai chi can boost upper- and lower-body flexibility as well as strength.

Balance. Tai chi improves balance and, according to some studies, reduces falls. Proprioception — the ability to sense the position of one's body in space — declines with age. Tai chi helps train this sense, which is a function of sensory neurons in the inner ear and stretch receptors in the muscles and ligaments. Tai chi also improves muscle strength and flexibility, which makes it easier to recover from a stumble. Fear of falling can make you more likely to fall; some studies have found that tai chi training helps reduce that fear.

Aerobic conditioning. Depending on the speed and size of the movements, tai chi can provide some aerobic benefits. If your clinician advises a more intense cardio workout with a higher heart rate than tai chi can offer, you may need something more aerobic as well.