Tai chi chuan

Abstract

Tai chi chuan (TCC) is a Chinese conditioning exercise and is well known for its slow and graceful movements. Recent investigations have found that TCC is beneficial to cardiorespiratory function, strength, balance, flexibility, microcirculation and psychological profile. The long-term practice of TCC can attenuate the age decline in physical function, and consequently it is a suitable exercise for the middle-aged and elderly individuals. TCC can be prescribed as an alternative exercise programme for selected patients with cardiovascular, orthopaedic, or neurological diseases, and can reduce the risk of falls in elderly individuals. The exercise intensity of TCC depends on training style, posture and duration. Participants can choose to perform a complete set of TCC or selected movements according to their needs.

In conclusion, TCC has potential benefits in health promotion, and is appropriate for implementation in the community.

Full text

Tai Chi Chuan
An Ancient Wisdom on Exercise and Health Promotion
Ching Lan, Jin-Shin Lai and Ssu-Yuan Chen
Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital,
Taipei , Taiwan
Abstract Tai chi chuan (TCC) is a Chinese conditioning exercise and is well known for
its slow and graceful movements. Recent investigations have found that TCC is
beneficial to cardiorespiratory function, strength, balance, flexibility, microcir-
culation and psychological profile. The long-term practice of TCC can attenuate
the age decline in physical function, and consequently it is a suitable exercise for
the middle-aged and elderly individuals. TCC can be prescribed as an alternative
exercise programme for selected patients with cardiovascular, orthopaedic, or neuro-
logical diseases, and can reduce the risk of falls in elderly individuals. The exer-
cise intensity of TCC depends on training style, posture and duration. Participants
can choose to perform a complete set of TCC or selected movements according
to their needs.
In conclusion, TCC has potential benefits in health promotion, and is appro-
priate for implementation in the community.
LEADING ARTICLE Sports Med 2002; 32 (4): 217-224
0112-1642/02/0004-0217/$25.00/0
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Set your body straight,
See everything as one,
And natural harmony will be with you
Chuang-Tzu ( 369-286 B.C.)
Tai Chi Chuan (TCC) [boxing of the highest
ultimate] has developed since the 17th century in
China.[1] The slow, supple movement of TCC is
deeply rooted in Taoism (a branch of Chinese phi-
losophy). The central doctrine of Taoism is focused
on mind tranquility, and its goal is to achieve lon-
gevity by meditation and lifestyle modification. TCC
differentiated into many styles in the process of
development. Among them, Chen style is the old-
est, while Yang style is the most popular.[1] The
classical Yang TCC consisted of 108 forms and takes
about 3 months to learn. To shorten the learning
period, many simplified TCC techniques have been
developed. In recent years, TCC has gradually be-
come a popular exercise in the Western world and
investigations are flourishing. The purpose of this
article is to review the existing literature of TCC,
and to introduce its effect on health promotion. The
literature search for articles published between 1966
and 2001 was performed using the Medline database
(key words: Tai Chi Chuan, Tai Chi, Tai ji Quan
and Tai Chi Quan).
1. Tai Chi Chuan (TCC) Training
1.1 Training Characteristics
TCC is a low-speed and low-impact exercise.
During the practice, diaphragmatic breathing is co-
ordinated with graceful motions to achieve mind
tranquility. TCC is practised in a semi-squat pos-
ture, and exercise intensity can be easily adjusted

by controlling the angle of the knee. A high-squat
posture and short training duration are suited to
those with low levels of fitness or elderly partici-
pants; a low-squat posture and longer durations are
suited to healthy or younger participants.
Classical Yang TCC includes 108 postures, with
some repeated sequences (figure 1). Each training
session includes 20 minutes of warm up, 24 min-
utes of TCC practice, and 10 minutes of cool down.
Warm up exercise is very important because it may
enhance TCC performance and prevents injury. It
usually includes 10 movements (range of motion
exercises, stretching and balance training) with 10
to 20 repetitions.
The exercise intensity of TCC depends on train-
ing style, posture and duration.[2-4] Vari ations in train-
ing approaches result in substantial differences in
intensity and training effect. Participants may prac-
tise selected movements instead of a complete set
of TCC to improve balance or flexibility. However,
if the training goal is to increase cardiorespiratory
function or muscular strength, a complete set of
classical TCC movements is recommended.
In a recent study,[5] Lan and colleagues used a
K4 telemetry system to measure heart rate (HR)
responses and oxygen uptake (V
.O2) while perform-
ing classical Yang TCC. The HR during TCC prac-
tice was 58% of the HR range, and the V
.O2during
practice was 55% of the maximal oxygen uptake
(V
.O2max). The result implied that classical TCC is
an exercise with moderate intensity and is aerobic
in nature. The training characteristics of TCC fulfil
the recommendations of the American College of
Sports Medicine (ACSM) regarding exercise to de-
velop and maintain cardiorespiratory fitness.[6]
TCC is an everyday exercise in the Chinese com-
munity. Most practitioners practise TCC in a nearby
park in the early morning before they start a day’s
work. For some participants, exercise frequency may
be less owing to problems with accessibility. Exer-
cise frequency of at least three times per week is
needed to fulfil ACSM recommendations.[6]
1
567
23 4
Fig. 1. An example of a typical tai chi chuan for m (push down and stand on one leg) [reproduced fro m China Sports,[1] with permission].
The sequential motions are performed in a semi-squat posture.
218 Lan et al.
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1.2 Exercise Adherence
For novice practitioners, the adherence rate was
82% in a 6-month TCC programme which was con-
ducted twice a week in an elderly US population.[7]
In our study,[8] the adherence rate in a 12-month
TCC programme was 72%in an elderly population
in Taiwan, and the mean exercise frequency was
4.6 times weekly. Because the transportation and
programme accessibility varies in different regions,
a suitable exercise frequency must be set to fit the
participants’ demands and cultural differences to
facilitate adherence. Participants who develop higher
perceptions of efficacy have better exercise adher-
ence.[9]
1.3 Cost
TCC is a low-cost practice because little equip-
ment and few facilities are needed. It can be prac-
tised anytime and anywhere. In the Chinese com-
munity, most of the instructors are volunteers and
participants usually do not need to pay any tuition
fee. In the US, a recent study[7] reported that the
direct cost of a TCC programme was about $US3.5
per person per session (year of costing unknown).
This cost appears to be affordable for most partic-
ipants.
2. TCC and Health Promotion
2.1 Cardiorespiratory Function
Long-term TCC training is beneficial to cardio-
respiratory function. In cross-sectional studies,[10,11]
a middle-aged TCC group showed a 15.6 to 26.8%
higher V
.O2max than the control group,[10] while el-
derly TCC practitioners showed an increase of 18
to 19% in V
.O2max compared with their sedentary
counterparts.[11]
Long-term TCC training also delays the age-re-
lated decline in cardiorespiratory function. Lai and
co-workers followed a TCC group for 2 years, and
found that the annual decrease in V
.O2max was only
half that of the control group.[12]
To evaluate the training effect for novice TCC
participants, Lan and colleagues designed a 12-
month TCC programme for elderly individuals.[8]
After 1 year of training, men practising TCC showed
a 16.1% increase in V
.O2max, while the correspond-
ing increase for women practising TCC was 21.3%.
2.2 Strength
TCC is performed in a semi-squat posture, and
various degrees of concentric and eccentric con-
tractions are needed in this unique posture. In the
Frailty and Injuries: Cooperative Studies of Inter-
vention Techniques (FICSIT) study in Connecticut,
US,[13] a TCC programme can preserve the strength
gains from a 3-month strength training programme.
The results implied that TCC could maintain mus-
cular strength in the lower extremities.
Jacobson et al.[14] reported that a 12-week TCC
programme could improve the muscular strength
of knee extensors. In a recent study, Lan and co-
workers found that a 6-month TCC programme was
effective in enhancing the strength of knee exten-
sors.[15] After training, men who practised TCC ex-
perienced a 13.5 to 24.2% increase in isokinetic
strength in concentric contractions, and a 15.1 to
23.8% increase in eccentric contractions.
2.3 Flexibility
TCC training is beneficial to trunk and ham-
string flexibility as a result of routine stretching
exercises in the warm-up phase. Hong et al.[16] re-
ported that long-term TCC practitioners had better
scores in the sit and reach test and total body rota-
tion test. Lan and colleagues also found that a 12-
month TCC training programme could significant-
ly increase participants’ thoracolumbar flexibility.[8]
2.4 Balance and Motor Control
During the performance of TCC, bodyweight
shifting, body rotation, and single-leg standing in
different postures are repeatedly practised. Delicate
joint control with muscle coordination is important
to maintain balance during motions. Therefore, TCC
practitioners display better balance function than
nonpractitioners. In studies using simple balance
tests (such as time duration in single-leg standing
Tai Chi Chuan and Health Promotion 219
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with eyes open or closed), older TCC practitioners
showed better postural control than sedentary indi-
viduals.[17,18] In studies using computerised balance
systems, TCC practitioners showed no differences
in simple conditions (such as postural sway when
standing with eyes open or closed) compared with
a control group.[19,20] However, in more complex
conditions, the TCC group demonstrated better re-
sults in eyes closed with sway surface, sway vision
with sway surface, and forward-backward body-
weight shifting test.[19]
TCC also improves balance function in novice
practitioners. In the FICSIT study in Connecticut,
US,[13] a TCC programme could preserve the bal-
ance gains achieved after a 3-month balance train-
ingcourse,andshowedatrendtowardsfurtherim-
provement in balance. In the FICSIT study in Atlanta,
US,[21] 15 weeks of TCC training increased the sway
in stance and decreased the fear of falling. How-
ever, sway in stance is not a direct measure of func-
tional postural stability, and dynamic balance may
be more important than static stance balance to pre-
vent falls.
TCC practitioners need to perform spiral move-
ments of the upper extremities with delicate con-
trol. Jacobson et al.[14] reported that a 12-week TCC
programme could increase participants’ shoulder
kinesthetic sense at 60°. In addition, an 8-week TCC
programme also significantly reduced movement
force variability in manual aiming tasks,[22] which
implies that TCC improves arm movement control
and might be beneficial for daily activities.
2.5 Endothelial Function and
Peripheral Circulation
Elderly TCC practitioners have been shown to
have higher skin blood flows and plasma levels of
nitric oxide (NO) than sedentary individuals at rest
andduringexercise.
[23] These results indicate that
TCC benefits cutaneous microcirculatory function
during exercise, and this change may be partially
mediated by enhancement of NO release.
The regular practise of TCC may enhance endo-
thelium-dependent dilation in the skin vasculature
of older individuals. In a recent study,[24] Wan g and
co-workers demonstrated that individuals who prac-
tise TCC had a higher acetylcholine-induced cuta-
neous perfusion than sedentary controls.
TCC training is also beneficial to the peripheral
circulation. By using impedance plethysmography,
Wang and colleagues found that elderly TCC prac-
titioners had higher hyperaemic arterial inflows,
venous capacity, and venous outflow than their sed-
entary counterparts.[24] These results indicate that
TCC training can delay the age-related decline of
venous compliance and hyperaemic arterial response.
2.6 Blood Lipid Profile
In a study reported by Jiang,[25] TCC partici-
pants showed unchanged total cholesterol (TC) levels
after 1 month of training. However, high-density
lipoprotein-cholesterol (HDL-C) levels and HDL-
C/TC increased significantly in the TCC group.
2.7 Thyroid and Immune Function
Xu and Wang[26] reported that older TCC partic-
ipants showed higher thyroid-stimulating hormone
(TSH), follicle-stimulating hormone (FSH) and tri-
iodothyronine (T3) levels than those observed in
the control group. A higher level of T3 in TCC par-
ticipants implied that they might retain a normal
metabolic rate and retard the aging process.
Sun et al.[27] used a rosette-forming procedure
to evaluate cellular immune function in 30 TCC par-
ticipants and 30 age-matched healthy participants.
The total E-rosette–forming lymphocytes formed
(Et) and active rosette (Ea) numbers in the TCC
group were higher than those in the control group.
In addition, the Et and Ea numbers were elevated
immediately after TCC practise. These results im-
plied that TCC was also beneficial to immune func-
tion.
2.8 Self-Reported Physical Function
Li et al.[7] reported that 6 months of TCC train-
ing could improve 65% of physical functions rang-
ing from daily activities (e.g. walking) to moder-
ate-vigourous activities (e.g. running). In contrast,
220 Lan et al.
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Kutner et al.[28] found no significant improvement
in physical function after TCC training. However,
the latter study only used ten Tai Chi movements
instead of a complete set of TCC, and its exercise
intensity may have been insufficient to induce a
significant improvement in physical function.
2.9 Psychosocial Function
Jin[29] reported that TCC training could increase
noradrenaline excretion in urine, and decrease sal-
ivary cortisol levels. These results implied that TCC
could reduce tension, depression, anxiety and mood
disturbance. In addition, the stress-reduction effect
of TCC was similar to moderate physical exerci se.[30]
Brown et al.[2] also reported that a 16-week TCC
programme could reduce mood disturbance and im-
prove general mood in women.
Kutner et al.[28] reported that TCC and balance
training could increase confidence in balance and
movement. In a recent article by Li et al.,[9] a6-
month TCC programme could enhance perceptions
of task-specific personal efficacy in older adults.
TCC might be valuable for older adults as a method
of improving and maintaining efficacy perceptions
in the face of functional and cognitive declines.
Hartman et al.[31] also reported that a 12-week TCC
programme could enhance self-efficacy, reduce ten-
sion and nervousness, and increase social support
in older patients with osteoarthritis.
3. Clinical Applications of TCC
TCC can be applied to patients with chronic
diseases as a therapeutic exercise programme. In-
dividualised programmes may be needed to con-
form to each patient’s condition. For frail patients,
tai chi–like exercises with breathing training can
be practised as a suitable programme.
3.1 Coronary Artery Disease
TCC is an aerobic exercise of moderate inten-
sity, and hence is suited for patients with coronary
artery disease. TCC can also lower blood pressure
(BP) in patients 3 weeks after discharge following
acute myocardial infarction.[32] Lan and co-workers
evaluated the effect of TCC training in patients
whohadundergonecoronaryarterybypassgraft-
ing (CABG).[33] Patients with CABG participated
in a 12-month classical Yang TCC programme af-
ter an outpatient rehabilitation programme. After
training, the TCC participants experienced increases
of 10.3% in V
.O2max and 11.9% in peak work rate.
The study indicated that TCC could be prescribed
as a suitable exercise alternative for low-risk car-
diac patients.
3.2 Hypertension
The FICSIT study in Atlanta, US, showed that
in older individuals, TCC training could lower sys-
tolic BP from 172 to 159mm Hg after a 12-minute
walk.[34] In a recent study,[35] 62 sedentary older
adults with a systolic BP of 130 to 159mm Hg and
adiastolicBPof<95mmHgwererandomisedtoa
12-week aerobic exercise programme or a TCC pro-
gramme. After training, individuals in the TCC group
experienced decreases of 7.0mm Hg in systolic BP
and 2.4mm Hg in diastolic BP, and these reduc-
tions in BP were similar to those observed in the
aerobic exercise group.
3.3 Prevention of Falls
TCC can improve balance, kinesthetic sense,
strength, and consequently can decrease the fear of
falling.[14] An 8-week TCC programme improved
the posturography test and dizziness scores in pa-
tients with mild balance disorders.[36] In the FICSIT
study,[34] the Atlanta group designed a randomised
clinical trial with three arms (TCC, balance train-
ing and education). The TCC group practised 10
selected postures for 15 weeks, and experienced a
reduced fear of falling. In addition, the TCC group
reduced the risk of multiple falls by 47.5% com-
pared with the education group.[34,37]
In a recent study,[38] TCC participants tended to
have a lower rate of falls. However, the statistical
power was insufficient because the adherence rate
of the TCC group was only 20%.
Tai Chi Chuan and Health Promotion 221
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3.4 Arthropathy
Although TCC is performed in a semi-squat
posture, excessive stress to joints may be prevented
because most motions of TCC are performed in a
closed kinematic chain. Kirsteins et al.[39] reported
that TCC was safe even for patients with rheuma-
toid arthritis. Hartman et al.[31] also reported that
TCC could control fatigue and regulate pain during
activities, and could improve walking speed and
self-care activities in patients with osteoarthritis.
In addition, patients with haemophilia may safely
practise TCC as well as walking and swimming.[40]
However, the high-squat posture is recommended
for patients with arthropathy to prevent arthritis ex-
acerbation.
3.5 Neurological Diseases
TCC has been applied in selected neurological
patients and seems beneficial. Shapira et al.[41] used
TCC therapy in three patients with severe traumatic
brain injury. The time from injury to TCC therapy
was 1, 2 and 35 years, respectively. After 2 to 4
years of TCC training, all patients could walk with-
out assistance, rarely fell, and felt more secure while
walking. One patient could lead independent daily
activities and even returned to car driving.
Husted et al.[42] reported the results of 19 pa-
tients with multiple sclerosis who participated in
an 8-week TCC programme. After training, walk-
ing speed increased by 21% and hamstring flexi-
bility increased by 28%. These results may be at-
tributed to the effect of neuromuscular facilitation
during TCC practice.
4. Rationale for TCC Research
The training effect of an exercise programme
depends on its exercise mode, intensity, frequency
and duration. However, the training characteristics
in TCC studies are quite variable, and hence the
results are difficult to compare. In future research,
a standardised training programme should be utilised
according to the principles of exercise prescription.
Novice practitioners usually need 2 to 3 months to
learn a complete set of TCC movements if they
practise it everyday. During the familiarisation phase,
the exercise intensity and amount of training are
inconsistent. Therefore, 6 months of training may
be a minimum to evaluate the training effect of
TCC. Telemetric HR monitoring in selected indi-
viduals is needed to determine the exercise inten-
sity during TCC practice. The exercise frequency
should exceed three times per week to fulfil the
recommendations of the ACSM.[6] In addition, a
suitable exercise duration for a TCC programme is
40 to 60 minutes including warm-up and cool-down.
If a programme only utilises several TCC postures
instead of a complete set of TCC movements, ‘tai
chi-like exercises’or ‘tai chi movements’ are better
descriptions for the training mode. TCC should be
reserved for a complete set of motions that are prac-
tised continuously.
5. Conclusion
TCC is a ‘balanced’ exercise that integrates key
components of modern exercise training (cardiore-
spiratory function, strength, balance and flexibil-
ity). Recent studies have demonstrated that TCC is
beneficial to physiological and psychosocial func-
tions. The long-term practice of TCC can attenuate
the age decline in physical function and achieve
successful aging. Additionally, TCC can be pre-
scribed as an alternative exercise programme for
selected patients with cardiovascular, orthopaedic
or neurological disease, and can reduce the risk of
falls in elderly individuals. TCC merits further re-
search to broaden its application in health promo-
tion and disease prevention.
Traditional exercise studies focus on laboratory
training requiring expensive equipment. Although
a high-technology programme is effective in short-
term training, practising it in everyday life is diffi-
cult.[43] TCC is a low-technology exercise and can
be easily implemented in different communities.
In conclusion, TCC has potential benefits in health
promotion, and is appropriate for implementation
in the community.
222 Lan et al.
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Acknowledgements
The authors would like to thank Professor S.H. Tang
(School of Physical Education of the National Taiwan Nor-
mal University) for his assistance in training TCC practition-
ers in the past 12 years for our studies.
The authors have no conflicts of interest relevant to the
contents of this manuscript.
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Correspondence and offprints: Ching Lan, Department of
Physical Medicine and Rehabilitation, National Taiwan
University Hospital, No. 7 Chung-Shan South Road, Taipei,
10016, Taiwan .
E-mail: chinglan@seed.net.tw
224 Lan et al.
 Adis International Limited. All rights reserved. Sports Med 2002; 32 (4)