Exercise programs that 1) incorporate the practice of dynamic balance, and 2) involve motor adaptation according to task and environmental demands (Hu & Woollacott, 1994; Hirsch et al., 2003) can rehabilitate balance impairment. Habitual participation in physical activity, even begun late in life, has been shown to improve postural control in older individuals (Buatois, Gauchard, Aubry, Benetos, & Perrin, 2007). One form of balance and mobility exercise that has gained considerable attention in the last fifteen to twenty years is Tai chi chu’an (tai chi), an ancient Chinese martial art form involving strong mental engagement and focus upon the practice of slow, sustained movements.
Foci of Tai chi training include: vertical control of the trunk, step position, and strategies, flexibility, whole body coordination, somatosensory awareness, and kinesthetic attention to body position both in space and an internal sense of limb position. Tai chi is performed with flexed joints in a slow, continuous rhythmical flow while attending to accuracy of multi-joint paths, a vertical position of the head and trunk during weight transfer and balance on one leg. A Tai chi practitioner practices multiple configurations of their feet and hips given a particular form, and must coordinate upper and lower limbs in multiple directions. Frequent and dedicated practice of these movement forms has led to enhanced postural stability while moving and improved movement control in experienced practitioners (Hong, Li, & Robinson, 2000).
As early as 1993, tai chi began to be evaluated for its ability to reduce frailty in older adults, described in a publication by Dr. Steven Wolf in the Journal of the American Geriatrics Society (Wolf et al., JAGS 1993), with results of a seminal study appearing in 1996 (Wolf, Barnhart, Kutner, McNeely, Coogler, & Xu, 1996). This study demonstrated tai chi was effective at reducing fall incidence (Gillespie, Gillespie, Robertson, Lamb, Cumming, & Rowe, 2003). After this study, the floodgates opened, with multiple papers in succeeding years that described the beneficial effects of tai chi on balance and mobility, in older adults at first, and later in older adults with a myriad of co-morbidities, including Parkinson’s disease (PD).
Randomized controlled trials (the gold standard for clinical research), on the efficacy on tai chi have since been conducted in several different countries, e.g., Taiwan, Vietnam, Australia, New Zealand, Korea, China, Japan, and the United States, among others. These trials have demonstrated the international impact of this novel field of research regarding efficacy and mechanisms of improvement of this ancient martial art. Consistently, falls rates, falls efficacy and balance have improved, as well as aspects of function related to balance, e.g., quality of life, mental status, and cognition (Huang, Liu, Huang, & Kernohan, 2010; Li, Harmer, Fisher, & McAuley, 2004; Li, Harmer, Fisher, McAuley, Chaumeton, Eckstrom et al., 2005; Nguyen & Kruse, 2012; Takeshima, Rogers, Rogers, Islam, Koizumi, & Lee, 2007; Taylor, Hale, Schluter, Waters, Binns, McCracken et al., 2012; Voukelatos, Cumming, Lord, & Rissel, 2007).
As of yet, few studies have examined the beneficial effects of tai chi in those with PD, a progressive neurodegenerative movement disorder that affects more than 1 million individuals in the United States. Current pharmaceutical therapies are only partially effective, so other non-pharmaceutical interventions need to be examined, while better pharmacology and surgical techniques are being developed. Tai chi began to be evaluated as a complementary therapy for PD motor symptoms with a case study, which examined the progress of two 66-year-old males with PD. These individuals demonstrated balance improvements after a three month fitness program that involved balance, unsupervised activity at a fitness center, and sessions in Tai Chi two times weekly (Kluding & McGinnis, 2006). An intensive 5 day program in Tai Chi was completed by 17 individuals with mild to moderate PD, who experienced improvements in mobility and flexibility, as well as satisfaction and enjoyment with the program (Li, Harmer, Fisher, Xu, Fitzgerald, & Vongjaturapat, 2007).
Hackney & Earhart (2008) studied 13 individuals with PD who completed 20, one-hour lessons of Tai chi, in comparison to an untreated control group. Those who participated in Tai Chi demonstrated improvements in the Berg balance scale (a standard, clinical measure of balance function and fall risk in older de-conditioned adults), disease severity, mobility, standing balance, endurance and backward walking (Hackney & Earhart, 2008).
The strongest evidence that tai chi may improve motor impairments of PD has been provided by a randomized controlled trial, which assigned 195 participants to tai chi, resistance or stretching (24 weeks duration, 1 hour twice weekly). The tai chi group performed better than the stretching group in all secondary outcomes, and the tai chi group performed better than the resistance training group in stride length and functional reach. Tai chi also lowered falls incidence compared to the stretching but not in comparison to the resistance training. It is encouraging that the effects were maintained 3 months after cessation of tai chi training within the context of the study (Li, Harmer, Fitzgerald, Eckstrom, Stock, Galver et al., 2012).
A study examining the effects of tai chi on quality of life in PD found that compared to a control group, those participating in tai chi had improved their overall quality of life scores on the PDQ-39, a standard and widely used measurement for health related quality of life in people with PD. Results also indicated improved emotional well-being in this cohort (Nocera, Amano, Vallabhajosula, & Hass, 2013).
Tai chi appears to be a safe and appropriate means by which falls incidence may be lowered and functional balance could be improved for those with PD. Likely, multiple other benefits of tai chi remain to be discovered for individuals with PD
- Buatois, S., Gauchard, G. C., Aubry, C., Benetos, A., & Perrin, P. (2007). Current physical activity improves balance control during sensory conflicting conditions in older adults. Int J Sports Med, 28(1), 53-58. doi: 10.1055/s-2006-924054
- Gillespie, L. D., Gillespie, W. J., Robertson, M. C., Lamb, S. E., Cumming, R. G., & Rowe, B. H. (2003). Interventions for preventing falls in elderly people. Cochrane Database Syst Rev(4), CD000340. doi: 10.1002/14651858.CD000340
- Hackney, M. E., & Earhart, G. M. (2008). Tai Chi improves balance and mobility in people with Parkinson disease. Gait Posture, 28(3), 456-460. doi: S0966-6362(08)00064-7 [pii]10.1016/j.gaitpost.2008.02.005
- Hong, Y., Li, J. X., & Robinson, P. D. (2000). Balance control, flexibility, and cardiorespiratory fitness among older Tai Chi practitioners. Br J Sports Med, 34(1), 29-34.
- Huang, H. C., Liu, C. Y., Huang, Y. T., & Kernohan, W. G. (2010). Community-based interventions to reduce falls among older adults in Taiwan – long time follow-up randomised controlled study. J Clin Nurs, 19(7-8), 959-968. doi: JCN2834 [pii]10.1111/j.1365-2702.2009.02834.x
- Kluding, P., & McGinnis, P. Q. (2006). Multidimensional exercise for people with Parkinson’s disease: a case report. [Case Reports Research Support, Non-U.S. Gov’t]. Physiother Theory Pract, 22(3), 153-162.
- Li, F., Harmer, P., Fisher, K. J., & McAuley, E. (2004). Tai Chi: improving functional balance and predicting subsequent falls in older persons. Med Sci Sports Exerc, 36(12), 2046-2052. doi: 00005768-200412000-00006 [pii]
- Li, F., Harmer, P., Fisher, K. J., McAuley, E., Chaumeton, N., Eckstrom, E., & Wilson, N. L. (2005). Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci, 60(2), 187-194. doi: 60/2/187 [pii]
- Li, F., Harmer, P., Fisher, K. J., Xu, J., Fitzgerald, K., & Vongjaturapat, N. (2007). Tai Chi-based exercise for older adults with Parkinson’s disease: a pilot-program evaluation. J Aging Phys Act, 15(2), 139-151.
- Li, F., Harmer, P., Fitzgerald, K., Eckstrom, E., Stock, R., Galver, J., . . . Batya, S. S. (2012). Tai chi and postural stability in patients with Parkinson’s disease. N Engl J Med, 366(6), 511-519. doi: 10.1056/NEJMoa1107911
- Nguyen, M. H., & Kruse, A. (2012). A randomized controlled trial of Tai chi for balance, sleep quality and cognitive performance in elderly Vietnamese. Clin Interv Aging, 7, 185-190. doi: 10.2147/CIA.S32600
- Nocera, J. R., Amano, S., Vallabhajosula, S., & Hass, C. J. (2013). Tai Chi Exercise to Improve Non-Motor Symptoms of Parkinson’s Disease. J Yoga Phys Ther, 3. doi: 10.4172/2157-7595.1000137
- Takeshima, N., Rogers, N. L., Rogers, M. E., Islam, M. M., Koizumi, D., & Lee, S. (2007). Functional fitness gain varies in older adults depending on exercise mode. Med Sci Sports Exerc, 39(11), 2036-2043. doi: 10.1249/mss.0b013e31814844b700005768-200711000-00020 [pii]
- Taylor, D., Hale, L., Schluter, P., Waters, D. L., Binns, E. E., McCracken, H., . . . Wolf, S. L. (2012). Effectiveness of tai chi as a community-based falls prevention intervention: a randomized controlled trial. J Am Geriatr Soc, 60(5), 841-848. doi: 10.1111/j.1532-5415.2012.03928.x
- Voukelatos, A., Cumming, R. G., Lord, S. R., & Rissel, C. (2007). A randomized, controlled trial of tai chi for the prevention of falls: the Central Sydney tai chi trial. J Am Geriatr Soc, 55(8), 1185-1191. doi: JGS1244 [pii] 10.1111/j.1532-5415.2007.01244.x
- Wolf, S. L., Barnhart, H. X., Kutner, N. G., McNeely, E., Coogler, C., & Xu, T. (1996). Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J Am Geriatr Soc, 44(5), 489-497.
[Editor’s Notes: (1) Members of the PD Gladiators Metro Atlanta Fitness Network offer Tai Chi class adapted for people with PD. (2) Dr. Hackney is currently recruiting for a research study on the effects of Tango and Health Education in people with PD on cognition, mobility and balance.]
Dr. Madeleine E. Hackney, Ph.D, is a Research Health Scientist at the Atlanta VA Center for Visual and Neurocognitive Rehabilitation and an Assistant professor of Medicine in the division of General Medicine and Geriatrics at the Emory School of Medicine. She holds a Ph.D. in Movement Science from Washington University and a BFA in Dance from NYU, Tisch School of the Arts and has also been an American Council on Exercise certified personal trainer since 2000. Dr. Hackney’s extensive research interests include inquiry into challenging exercise programs–traditional exercise, Tai Chi and partnered tango classes–designed to improve physical function and quality of life in people with PD, older adults and those with serious mental illness. In 2014, she co-founded MDT Education Solutions, which has trained almost 60 fitness and allied health professionals how to develop and lead safe, evidence-based exercise programs for people with PD at all stages of the disease, including almost all instructors in the PD Gladiators Metro Atlanta Fitness Network (including the YMCA of Metro Atlanta).
For more insights on this topic, listen to our podcast episode “A Western Perspective on PD: Understanding Complementary Medicine”.