Tai Chi Exercises Benefit Even Oldest Adults

Abstract

Low-impact exercises from the ancient Eastern martial art known as tai chi can deliver health benefits to many older adults, including those in long-term care, according to practitioners who conduct classes in the exercises and, increasingly, researchers. Some studies have indicated that tai chi can help reduce the risk of falls, lower blood pressure, relieve chronic pain, increase endurance, reduce depression, and improve cardiovascular fitness, said Karin M. Green, PT. But “traditional tai chi requires many months or years to learn well, and every detail is important,” said Ms. Green, a retired physical therapist. She said she has been teaching the exercise twice weekly for 8 years to a class of adults, mostly in their seventies and eighties, at Park La Brea, a large Los Angeles apartment community. A modified form of the ancient martial art, developed in 1996 by the Emory University department of rehabilitation medicine for research on falls prevention in the elderly, makes tai chi accessible to virtually anyone who can walk and stand, said Ms. Green. The simpler version consists of nine basic movements instead of the 24, 48, or 108 that make up traditional forms of the martial art. The modified tai chi can be easily adapted for settings including senior centers, assisted living facilities, and long-term care facilities, asserted workshop copresenter Kathryn Warner, OTR/L, an occupational therapist at the Swezey Institute, Santa Monica, Calif. It can even meet the rehabilitation needs of frail elderly patients, she said. Ms. Warner and Ms. Green presented their approaches to the exercises the joint conference of the American Society on Aging and the National Coalition on Aging last year. Ms. Green said she became interested in tai chi when she took a continuing education class in the 24-movement form. Nearing retirement, she wanted to teach some type of exercise to older adults, and her firsthand experience of tai chi's psychological and physical benefits impressed her, but “I realized how impractical that was [for older people],” she said. “There had to be a better way.” That better way came to her through Emory's tai chi–based program. “The researchers realized that traditional tai chi would take too long to teach” to the 70- to 97-year-old participants in the 48-week study, which compared tai chi training, computerized balance training, and wellness education in reducing falls. With assistance from a tai chi master, the researchers selected the movements they felt would be most beneficial in preventing falls, Ms. Green said. After adjustment for fall risk factors, tai chi reduced the risk of multiple falls by 47.5%, the most significant effect on fall prevention of the three interventions (J. Am. Geriatr. Soc. 1996;44:489-97). Ms. Green uses the Emory program as the basis of her free, outdoor Tuesday and Friday morning classes. She assesses new participants by two criteria: They must be able to walk to the class, and they must be able to stand with their feet close together with little or no swaying. Benches are nearby for rest, and Ms. Green said she keeps a cell phone on hand in case of emergency. Class size averages about 20 and typically includes participants ranging in age from the early twenties to the nineties. About half of the participants are in their seventies. Classes for continuing students include a warm-up, the nine basic movements, and a closing movement. A class for beginners immediately follows. Substitutes take over as needed, so Ms. Green never has had to cancel the class for lack of a leader. Park La Brea is a culturally diverse community, and about half of the students are immigrants. “I really like the idea that people from many different cultures and many different thought groups relate to tai chi,” said Ms. Green. For the class, she embraces an Eastern teaching philosophy that encourages participants to move their bodies naturally. Each person has his or her own style, and “that's fine. We do not teach perfection. No matter how participants perform, they are dressed, outdoors, socializing, and moving,” she said. The greatest reward “is the gratification of seeing people respond to the program, socialize with each other, and feel better, look better, and tell others how they benefited.” The program works because it is in a convenient and pleasant location, the participants are friendly, there is no pressure to perform correctly, and there is no cost. “I feel strongly that it should be free or very low cost because it's easy, it's effective, it's important, and I don't want to leave anybody out,” said Ms. Green. Ms. Warner said she has used tai chi as an adjunct to balance training for elderly osteoporosis patients, selecting movements that emphasize posture and lifting of the spine and rib cage. “We were really interested in finding new and important things that would be helpful for patients in terms of a group experience,” she said, adding that she has also had patients with balance or strength issues perform the movements while sitting in chairs. Elderly patients with chronic systolic heart failure who were enrolled in a 12-week tai chi program experienced significant improvements in quality of life, mood, and exercise self-efficacy, compared with patients who were enrolled in an education-only control group, more recent research revealed. “Exercise is a recognized important part of heart failure management,” Gloria Yeh, MD, said. “The focus of prior studies has been on aerobic training, with some new and recent emphasis on strength training. Little, however, is known about the potential value of integrative mind-body movement therapies in this population.” Tai chi is well suited for heart failure patients, she said, because the physical component “is low impact [and] nonstrenuous, and can easily be performed by the elderly or the more severely deconditioned patients, which may be important in enhancing exercise compliance and self-efficacy.” Reported cardiorespiratory benefits include an increase in peak oxygen uptake and ventilatory capacity, a decrease in blood pressure, and modulations of autonomic tone. Dr. Yeh and her associates at Beth Israel randomized 100 patients with systolic heart failure either to 12 weeks of tai chi classes that met twice weekly or to 12 weeks of an education class that met twice weekly. Testing at baseline, 6 weeks, and 12 weeks in both groups included questionnaires, functional tests, and cardiopulmonary exercise testing. The mean age of patients in this group was 67 years, and 72% were male. To be eligible for the trial, patients had to have a left ventricular ejection fraction of 40% or less, be on a stable medical regimen, and have New York Heart Association class I-III heart failure. Study exclusions included unstable angina, MI, cardiac surgery, or cardiac resynchronization therapy in the past 3 months, a history of cardiac arrest in the past 6 months, and unstable ventricular arrhythmia. The primary outcome measures were quality of life based on the Minnesota Living With Heart Failure Questionnaire (MLHFQ) and exercise capacity based on the 6-minute walk test and peak oxygen consumption (VO2max). Secondary outcome measures included mood based on the Profile of Mood States (POMS), exercise, self-efficacy based on the Cardiac Exercise Self-Efficacy Instrument (CESEI), and serum B-type natriuretic peptide (BNP). The tai chi class included five basic movements and warm-up exercises that emphasized relaxation, breathing, mind-body awareness, cardiovascular endurance, and a 45-minute videotape for home practice. The mean age of patients in this group was 68 years, and 56% were male. The education class was led by a nurse practitioner and was based on published Heart Failure Society of America education modules that covered standard heart failure topics such as diet, activity, medications, heart arrhythmia problems, and advance care directives. Dr. Yeh reported that over the course of the 12-week study, 75% of participants in the tai chi group attended all classes, compared with 67% of participants in the education group. Tai chi group participants reported a mean of 10 hours of home practice over the study period. At 12 weeks, patients in the tai chi group significantly improved their median MLHFQ scores by 19 points (from 28 at baseline to 9 at week 12), but there was no significant change in scores among those in the education group (21 points at baseline and 22 at 12 weeks). “This was quite a striking effect,” Dr. Yeh said. For the 6-minute walk, patients in the tai chi improved their walk distance by 35 m (from 391 m at baseline to 426 m), a nonsignificant improvement, whereas patients in the education group improved their walk distance by just 2 m (from 392 m to 394 m). Similarly, there was no significant difference in peak oxygen uptake between the two groups. In the education group, the VO2max dropped from 13.5 mL/kg per minute at baseline to 13 mL/kg per minute at week 12. In the tai chi group, the VO2max rose from 11.9 at baseline to 13 at week 12. The researchers observed clinically and statistically significant improvements in the tai chi group, compared with the education group, in the POMS total mood disturbance score and in the CESEI score over the 12 weeks. However, there were no differences in serum BNP between the two groups over the course of the study. Dr. Yeh reported the findings at the annual meeting of the Heart Failure Society of America in 2010. “There may be several potential mechanisms for tai chi's effect,” Dr. Yeh noted. “Observed effects may be due to the intervention's physical activity and associated training effect. Tai chi includes mild to moderate aerobic exercise as well as upper and lower extremity and core strength training. Some benefits may be due to relaxation and stress reduction components of tai chi acting on stress-related neuromodulators. Similarly, mediation and mind-body integration may favorably affect autonomic tone, and breathing retraining may decrease perceived dyspnea.” Dr. Yeh acknowledged certain limitations of the study, including its modest sample size, the potential for selection bias, and the fact that participants were not blinded to the intervention group. “We were also unable to isolate benefits to either physical activity or meditative components, or to a combination of both,” she said. The study was funded by the National Center for Complementary and Alternative Medicine. A form of tai chi can make a significant difference in older patients with major depression as an add-on to antidepressant medication, according to a pilot study presented at a 2010 conference in Boca Raton, Fla., sponsored by the National Institute of Mental Health. Researchers randomized 73 partial responders to escitalopram (Lexapro) to a conservative form of tai chi or health education for 2 hr/wk. Both groups demonstrated improvements in HAM-D (Hamilton Rating Scale–Depression) scores, but the tai chi cohort demonstrated significantly greater resilience to stress, as well as improvements in health-related quality of life and cognitive function. “I'm encouraged. This is a simple intervention available to everyone,” Helen Lavretsky, MD, said. “I am particularly excited about changes in memory and cognition, especially executive functioning.” This is the first randomized study to assess tai chi for geriatric depression, Dr. Lavretsky said. Studies in the literature already support tai chi in older populations for balance (Gait Posture 2007;25:205-14) and quality of life (J. Altern. Complement. Med. 2007;13:1077-83). The modified form was shorter and combined with breathing techniques for this population of people aged 60 years and older. “Some older people have arthritis, but this modified form was not difficult for them to do,” Dr. Lavretsky said in an interview. Keep in mind that seniors with severe pain are precluded from participation in traditional tai chi, she added. The group doing a form of what practitioners call tai chi chih reported increased energy levels. “Psychomotor retardation is very common in older adults who are very sedentary. Tai chi got them going,” said Dr. Lavretsky, a geriatric psychiatrist at the University of California, Los Angeles. The investigators proposed that this complementary mind-body intervention would reduce stress, improve physical functioning, and reduce the risk for polypharmacy in this population. They noted that fewer than 50% of elderly depressed patients who are treated with first-line antidepressant therapy achieve remission and functional recovery. An initial 112 participants with major depression were treated with 10 mg escitalopram per day for 6 weeks. The 73 partial responders then continued this regimen; of these, 36 were randomized to tai chi chih and another 37 to health education for 10 weeks. “The educational group did well, also. There was initial parallel improvement in HAM-D [24-item] scores,” Dr. Lavretsky said. Both groups experienced a mean improvement of 6.0 in scores on this measure. However, at week 16 the tai chi chih group demonstrated significantly greater improvements in resiliency, compared with the health education group, Dr. Lavretsky said. They also had a significantly higher mean score of 80 on the SF-36 Health Survey (an instrument that measures patient health), compared with 66 in the health education group. A higher score corresponds to a higher health-related quality of life. In addition, their executive cognitive function was better at 16 weeks than was that of the health education group. For example, the tai chi chih group had a mean Stroop test errors score of 0.03, compared with a mean 0.32 score in the education group. They also scored higher on the California Verbal Learning Test long-delayed recall at week 16 (a mean of 11.6), compared with 9.7 in the health education group. The study was funded by the National Center for Complementary and Alternative Medicine. Dr. Lavretsky said she had no relevant disclosures. Susan Birk is a freelance writer in Wheaton, Ill. Freelance writer Denise Napoli contributed to this article.