
ABSTRACT
Problem: Taiji practice is known to have health benefits. As a therapeutic exercise, it may have potential applications in cardiopulmonary physical therapy (PT). Methods: To explore this possibility, a systematic critical review of the topic-related literature was conducted. Results: One hundred fifty-six original articles were examined, yielding 7 controlled clinical studies with primary relevance to cardiopulmonary practice. Critical review of these studies revealed that regular practice of taiji has potential cardiovascular benefits in the areas of improved submaximal activity tolerance, blood pressure control, and enhanced immune response. Discussion: Sufficient research evidence is available to explore programming options in PT cardiopulmonary practice. Additional potential applications may exist in the areas of pulmonary rehabilitation, peripheral vascular insufficiency, diabetic management, and early mobilization post medical or surgical event. Implications: Information presented should help inform PT clinicians of the potential benefits of integration of taiji practice with more traditional cardiopulmonary rehabilitative modalities. It also should provide impetus for innovational program planning and consideration of inclusion of taiji as a therapeutic exercise as part of professional or continuing education curricula.
INTRODUCTION
Research is emerging that substantiates what the Chinese have known for centuries: regular practice of taiji promotes health. Touted as the 'perfect exercise," it is safe; it is fun; it is social. Research supports that taiji practice has both physiologic and psychosocial benefits.2 As such, taiji may have potential physiotherapeutic applications in cardiac and pulmonary rehabilitation and related cardiopulmonary physical therapy (PT) clinical practice. Featured media attention1 and medical research interest3 attest to the growing popularity of taiji in the Western world.
Taijiquan or T'ai Chi Chuan [translated as supreme ultimate boxing] encompasses both a profound and varied Chinese martial art and a health regimen with a common set of core principles, movements, and exercises.4 Taiji practice is recognized by its characteristic dance-like, slow, circular, fluid movement patterns. While there are a number of schools of taiji, health-promoting forms are distinguished from other taiji forms by the absence of explosive or high impact movements. In practice, movement sequences are combined into choreographed forms for group performance. Short-forms, combinations of 10 to 48 movements developed for easy learning, are generally derived from the longer forms such as the Yang-style 108 form.4
The corner stones of this soft (internal) art are rootedness (balance), connectedness (coordination), and centeredness (concentration and body awareness). The mental intention and the dynamic relationship between selective muscle relaxation and applied tension (the yin and yang of it) make taiji a mindful exercise. Many movement patterns or sequences have engaging descriptive names such as wave-hands-like-clouds, fair-maid-works-shuttle, and needle-at-sea-bottom. Others have animal reference, such as grasp-bird's-tail, snake-creeps-down, high-pat-on-horse, golden-rooster, stork-cools-wings, and mount-the-tiger. While still other movement names reflect martial arts origins, such as punch, heel kick, and double-strike-to-theears. Regardless of the individual movement name, when patterns are combined in a slow, flowing dance-like form, the activity is observed and experienced as aesthetically beautiful and mentally calming.5
PURPOSE
It is the intent of this paper to explore potential clinical applications of taiji as a therapeutic exercise. It offers a critical review of the literature, purposely limited to exploring therapeutic applications of taiji within a defined scope of physiotherapeutic cardiopulmonary clinical practice. For information on the breadth of research supporting therapeutic effect, interested clinicians are referred to a recent report published in the Archives of Physical Medicine and Rehabilitation.2 For information on psychological benefits of Taiji practice, interested clinicians are referred to a comprehensive literature review by Sandlund and Norlander.6
Information presented in the current report identifies the potential physiologic benefits of inclusion and integration of Taiji practice within more traditional cardiopulmonary rehabilitative interventions. Once informed, PT clinicians, program administrators, clinical researchers, and educators can make their own judgments as to the potential value of Taiji as an adjunct, complementary, or mainstream treatment option within their clinical practice and identify areas of application and evaluation focus.
THEORETICAL BASE
In traditional Chinese medicine, theoretical foundations for the therapeutic effects of taijiquan are explained holistically within the conceptual framework of freeing Qi or life energy.4,5 While the concept of Qi is fundamental to traditional Chinese medicine, it is a concept that is only peripherally explained in conventional Western medical theory. A bridge between the two seemingly disparate theoretical paradigms may be partially found in the field of psychoneuroimmunology7-9 which explains the phenomenon of the mind/body connection in healing and health maintenance.
In preparation for the ensuing discussion, some explanatory clarifications defining the similarities and differences between qi gong (also known as chi kung), hatha yoga, and taiji may be useful. Traditional hatha yoga is included in this discussion because, although East-Indian in origin,10 it is mindful exercise similar to qi gong and taiji. Qi gong, a part of traditional Chinese medicine, is an internal art used primarily to promote health and healing.11 Qi gong is integrated within Taiji practice but does not have origins in martial arts. Qi gong movement patterns and postures are designed to release the body's Qi, thus stimulating and restoring natural health and healing. Similar to qi gong , hatha yoga, compared to other forms of yoga, is generally practiced as an internal art with emphasis on posture, breathing, and relaxation. The definitive distinguishing characteristic of taiji from either qi gong or classical hatha yoga is that taiji is primarily a weight-bearing, dynamic-movement art. Neither taiji's origins as a martial art nor the religious or philosophical foundation of some styles of taiji have any primary relevance with regard to therapeutic effect.
METHODS
A systematic critical review of the topic-related literature was conducted. The search and selection process followed guidelines outlined by Ceyman, Deyo, and Ramsey12 and classifies level of evidence using the nomenclature of the Cochrane Collaboration (Level 1= randomized clinical trials (RCT), Level II = controlled clinical trials (CCT)). In early 2002, two concurrent and independent computerized searches of electronic databases were conducted. Electronic databases included MEDLINE and CINAHL accessed through both EBCOT and OVID search engines and PUBMED. Searches were limited by key words, 'Tai chi,' 'T'ai Chi,' 'Taiji,' 'cardiac,' 'respiratory,' 'pulmonary,' 'diabetes,' 'related topic words,' and 'English language.' Citation results of the searches were compared and combined to form a comprehensive bibliography. Then, identified article titles and abstracts were retrieved and screened for topic relevance and study independence. Only articles retrieved as full text publications were reviewed. The breadth and strength of research evidence was analyzed, and potential areas of physiotherapeutic application and future research were identified. Finally, research evidence was categorized as to level of evidence by research design. All studies meeting inclusion criteria of (a) being designed as either a RCT or a CCT, and (b) having direct relevance for health and wellness promotion or cardiopulmonary applications within the scope of physical therapy practice were critically analyzed. Ongoing surveillance of the body of published literature continued through article submission in July 2004. In discussion, the broader body of relevant research including both controlled, observational, and relevant scholarly discussions was addressed. Application focus is subcategorized as general health and wellness promotion and potential clinical applications.
RESULTS
Initial search of the literature identified over 300 citations. Following screening for study independence and potential relevance, 156 original articles (search activities concluded July 2004) were examined for level of evidence and contextual clinical relevance. Published reports (N=156) represented a diverse geographic distribution including the United Kingdom, the United States, Canada, Australia, the People's Republic of China, Taiwan, Israel, and South Korea. From this larger body of research, 7 Level I and Level II clinical studies13-19 were judged to meet selective inclusion criteria for critical review. In aggregate, a total of 412 subjects were observed. Clinical populations in the 7 studies, examined in the critical review, included community dwelling elders, individuals who had recently undergone coronary artery bypass grafting, individuals who recently experienced a myocardial infarct, and a cohort of individuals of Asian decent. Research questions examined immune response, activity tolerance, blood pressure management, home exercise persistence, and level of stress. Clinically significant evidence of physical and physiologic benefits was demonstrated in all 7 studies with no report of adverse response. Health benefits included improved management of hypertension, increased peak VO^sub 2^, evidence of reduced stress, and enhanced immune activity (Table 1).
DISCUSSION
General Health and Wellness Promotion Applications
The number one priority in the US national initiative, Healthy People 2010(20) is to promote fitness through practice of regular exercise among all Americans. Recently, at the 4th International Symposium on Chinese Elderly, Beijing, October 2003, this same priority was identified as the major strategy for promoting healthy aging and containing health care costs among our aging global populations.21 The benefits of regular exercise for general conditioning and health promotion are well known.22 While there are many exercise options for health and fitness available to the general public, finding health promoting and fitness exercise regimens that are safe for individuals with exercise precautions due to physical limitations is a challenge. An estimated 43 million Americans have arthritis.23 These individuals are often reluctant to or precluded from access to fitness programs designed for more robust populations. Taiji practice has been found to be safe and have health benefits for seniors,24,25 individuals with osteoarthritis,26 rheumatoid arthritis,27 and fibromyalgia.28
Clinical Applications
Evidence of cardiovascular effect
Regular practice of Taiji has been associated with positive cardiorespiratory physiologic benefits.29,30 Achievement of this effect is consistent with goals of health and wellness exercise initiatives. As recently as January 2004, Taylor-Piliae and Froelicher31 reported findings of a metaanalysis of clinical studies assessing effect of taiji practice on aerobic capacity. Their analysis concluded that taiji practice provides many of the benefits attributed to conventional forms of aerobic exercise. These authors noted that greatest benefits were observed from practice of classical Yang style4 taiji exercise when performed for 1 year by sedentary adults.
Evidence of cardiovascular effect has been demonstrated in a randomized clinical trial. Young et al15 found that older, sedentary, community dwellers exercising regularly by performing taiji, with mean exercising heart rate of 75 beats per minute, had similar beneficial cardiovascular responses related to decreased resting systolic blood pressure (SBP) (mean change -7.0 mm Hg for resting SBP) as compared to a comparison group, who participated in a walking program at a mean heart rate of 112 beats per minute (mean change -8.4 mm Hg for resting SBP). The observation that similar cardiovascular benefits could be achieved with a low intensity taiji activity, as compared to a moderate intensity walking program, is most intriguing and may challenge previous beliefs defining training effect exclusively as a product of a positive linear relationship between exercising heart rate and training effect. The size of this effect is considered clinically significant, and nearly double the mean change in SBP (4.44 mm/hg) reported in a meta-analysis32 of RCTs assessing the effect of weight loss on blood pressure.
Two recently published studies provide controlled research evidence that taiji practice is both safe and effective for subacute cardiac populations. In a pilot clinical study conducted in Taiwan,43 individuals who had recently undergone coronary bypass graft surgery were nonrandomly assigned to either a taiji practice group (n=9) or a home-based exercise group (n=11 ). Both groups had completed an aerobic cycling cardiac Phase II exercise program prior to study entry. Graded exercise tests, performed before and after 1 year of exercise training, found that those in the taiji group showed a statistically significant increase in VO^sub 2^ peak (10.3%) and peak work rate (11.9%), as compared to the control group where no significant changes for these variable were found.
A multiple group, randomized-controlled, 8-week study evaluating the effect of taiji practice for individuals with recent Ml conducted in the UK found significant trends in lowering of systolic blood pressure in both exercise groups (Taiji group: n=38; aerobic exercise group: n=41)6 Descriptive data analysis regarding rates of program adherence for the 8-week trial were notable. Program completion rates were significantly higher (p < .001) within the taiji group (82%) as compared to the aerobic group (73%), and lowest (8%) among the nonexercising cardiac support group.
Evidence of immune response effect
Enhancement of immune response through regular exercise performance is also a desired effect of health and fitness promotion. In 1990, Xusheng et al19 suggested an immune response effect related to Taiji practice. Confirming clinical evidence is just emerging. In 2003, Irwin et al12 reported that varicella zoster virus (VZV) specific, cellmediated immunity (CMI) increased nearly 50%, in a randomly assigned Taiji (TCC) group consisting of older subjects, who were considered at risk of developing shingles, as compared to demographically similar, waited-listed controls. Knowledge of this enhanced immune effect may have clinical significance for the elderly who naturally experience some decline in immune response, as well as immune-suppressed individuals, and those with immuneassociated diseases.
Potential clinical applications
Exercise is advocated as a therapeutic adjunct in the management of cardiac, pulmonary, peripheral vascular insufficiency, and diabetic conditions. In a case control study, delay of decline of microcirculation competence has been associated with regular taiji practice.33 This research conclusion has clinical implications for management of symptoms of intermittent claudication in peripheral vascular disease and diabetes. It has been suggested that taiji be considered as adjunct to traditional cardiac rehabilitation34,35 and for possible therapeutic use in individuals with congestive heart failure.35
Conclusions regarding therapeutic benefit common to both cardiac-based clinical trials14,16 are confirming evidence that Taiji is a safe, effective, low intensity alternative exercise regime with applications in cardiac rehabilitation. Similar to cardiac rehabilitation, guidelines for pulmonary rehabilitation identify general conditional exercises as part of conventional protocol.36 Although primary research is not yet available, it is logical to propose that individuals who are referred for pulmonary rehabilitation, exercise programs to assist in diabetic management and those with peripheral vascular insufficiency may benefit from taiji practice. Further, the potential immune enhancing effect combined with evidence of conditioning effect suggests that taiji or taiji-like exercises may also have utility in early rehabilitation post a major medical to surgical event. These propositions provide a measure of justification for future research.
Exercise adherence
Client willingness to follow therapeutic management recommendations and exercise regimen adherence are integral components to treatment efficacy.37 Adherence to exercise prescription and medically recommended home exercise regimen have been found to be disappointingly low in both cardiac and diabetic populations, with 1-year adherence rates reported to be as low as 10% and rarely above 50%.38 Three factors identified with exercise adherence that exist in taiji programming are expectation of benefit, self-efficacy, and social cohesion.39 The fact that individuals who engage in taiji practice are observed to gain therapeutic effect, combined with knowledge of empirical evidence that individuals chose to persist in their taiji exercising is consistent with the proposition that mind-body exercises such as tai chi are consistent with a philosophy of disease management focus on self-efficacy and decreased health care use.40 The combination of therapeutic effect and empowerment makes the option of taiji practice within conventional cardiac and pulmonary rehabilitation programs an intriguing one. The same reasoning supports potential applications in diabetic management.
IMPLICATIONS
While clinical research assessing therapeutic effects of taiji practice is growing rapidly, the major demand for taiji programming appears to be coming from sources other than the medical community: from community-center programming coordinators, from administrators of multi-level health care residences, and from individuals with health and exercise challenges. Critical analysis of clinical research reveals strong evidence of the effectiveness of regular taiji practice as a therapeutic modality for both health and fitness promotion and cardiovascular clinical applications. While the existing research supports use of taiji as a therapeutic exercise, knowledge of prescriptive and predictive validity is sparse. Many research questions remain unaddressed.
If taiji programming is increasingly accepted as adjunct to traditional therapies, the salient questions become: Who will deliver this complementary form of health care service? Is there a role for traditional Taiji instructors as health providers? And, is there a provider role for physical therapists as taiji instructors?
The Role of the Taiji Instructor
It is reasonable to believe that taiji was brought to the US with the first Chinese immigrants. However for many decades, taiji remained insulated within the Chinese community. It wasn't until the 1950s that master Taii instructors were known to share their knowledge with Westerners. A small cadre of Western taiji practitioners and instructors began to develop in the 1960s and 1970s, under the expert guidance of Cheng Man Qing, a renowned taiji master who emigrated from mainland China to the US. This core along with other taiji instructors, who either learned from masters or were themselves masters who immigrated to the US, are responsible for the majority of the current generation of taiji instructors in the US.
Opinions differ as to how long it takes to develop a taiji student into a teacher of taiji. There is an expectation of mastery of basic forms necessary for teaching demonstration and student correction. This mastery is important because the elicitation of therapeutic effect is thought to lie in the proper execution of the basic exercises.42 While students of taiji are often encouraged to share their knowledge with others, and short seminar courses introducing taiji as a therapeutic exercise option are available for health professionals, the consensus among expert taiji instructors is that instructor training time may range from 5 to 8 years.43 Efforts to validate teaching competence among taiji instructors are in progress but logistically difficult. While national and international taiji organizations exist, there is no single unifying body. As the public becomes more aware of the health benefits of taiji, not only the number, but more clinically meaningful, the demographics of individuals seeking taiji instruction may change from predominantly healthy individuals to individuals with some exercise precautions. This phenomenon further complicates the problem of identifying taiji instructors who are not only skilled in the art of taiji, but also competent to work with special needs' populations.
Exemplary models of adapted programs offered by traditional taiji instructors do exist.44,45 Programming has also originated from medical personnel. Dr. Paul Lam, from Australia is well-known for his work in adapted taiji programming to promote health.46 Dr. Lam's work includes offering seminars to prepare taiji instructors to lead adaptive programs. He has also authored and produced a number of videos specifically designed for individuals with clinical pathology including individuals with arthritis and individuals with diabetes. (For more information go to https://www.taichiproductions.com; accessed July 22, 2004.)
The Role of the Physical Therapist
Included in the definition of practice of Physical Therapy, as defined by the Model Definition of Physical Therapy (PT) for State Practice Acts, 1995, is care provided to ... promoting and maintaining fitness, health,... (Adopted by the American Physical Therapy Association (APTA Board of Directors in March 1995 (BOD 03-95-24-64)). The Guide to Physical Therapist Practice (APTA 2001 )47 identifies cardiac and pulmonary rehabilitation within established PT diagnostic practice patterns. As specialists in therapeutic exercise, physical therapists rank foremost among traditional health care providers as the discipline that could most easily integrate taiji exercises in their health and wellness and cardiopulmonary clinical practice. However, competence as a taiji instructor for health and wellness programming is not identified by the PT profession as an entry-level skill, and the profession does not have a designated section or Interest Croup in complementary and alternative health that might serve as a catalyst for educational and research initiatives.
The Ideal verses The Feasible
The ideal may be to have therapeutic Taiji programs delivered either by physical therapists cross-trained as a Taiji instructors or Taiji instructors cross-trained as a physical therapists. The obvious barrier to this proposition is that each respective training is extensive, and though highly desirable, the combination of the two competencies in one health care provider may be rare in practice. The feasible alternative may be to have collaboration for program development and continuing education between 2 disciplines (East meets West).
CONCLUSION
The demand for taiji programming as an exercise option is likely to escalate as evidence-based knowledge of the benefits of taiji is more broadly disseminated. While not exhaustive, there is sufficient research evidence supporting Taiji as a beneficial component in health and wellness promotion and having utility within the defined clinical scope of cardiopulmonary PT practice. There is preliminary controlled clinical evidence supporting the inclusion of taiji programming in cardiac rehabilitation. There is rationale for the evaluation of the benefits of taiji in pulmonary rehabilitation, peripheral cardiovascular insufficiency, diabetic management, and as part of early mobilization post major medical or surgical events. As proclaimed specialists in therapeutic exercise, physical therapists are in a unique position to explore integration of taiji into traditional practice. Interested PTs and PT educators should benefit from collaboration with taiji masters who are able and willing to integrate both Eastern and Western approaches to health and health care. Further, in planning research and considering expanding clinical practice and professional education into this area, it is imperative that new programming be delivered by competent instructors, and that any innovative programming be systematically evaluated for effect and utility.
[Reference]
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[Author Affiliation]
Penelope J. Klein, PT, EdD,1 William Adams, BA2
1 Associate Professor, D'Youville College, Buffalo NY
2 Taiji Master, Bill Adams Martial Arts and Fitness Centers, Elma, NY
[Author Affiliation]
Address correspondence to: Penelope J Klein, PJ, EdD, Associate Professor, D'Youville College, 320 Porter Ave, Buffalo NY 14201, (716) 515-0618 (kleinpj@dyc.edu).