Relevant research into exercise and health conditions

Reviewed research appears here, but also research relating to each health condition can be found on that specific page

Tai Chi Exercise and Stroke Rehabilitation
Ruth E. Taylor-Piliae and William L. Haskell Top Stroke Rehabil 2007;14(4):9–22 © 2007 

Tai Chi (TC) is an ancient form of exercise,meditation, and self-defense, widely practiced in
China for thousands of years. TC is a low-impact moderate-intensity exercise, can safely be performed by persons with a chronic disease or disability, and is popular among adults of all ages. TC is viewed as a way of life to maintain or restore health and is a powerful centering activity in which an individual learns control over some bodily functions and quiets the mind. Little reported research has specifically examined the effectiveness of TC among stroke survivors. However, TC is associated with reductions in several risk factors for subsequent stroke or disability, including better balance, lower blood pressure, and
improved mood.

The most common application of the yin-yang principle (of Tai Chi) is balance. TC movements are performed without strain, while utilizing the principle of opposites
to maintain and promote harmony and balance in the body. Individuals are instructed
to feel the ground with their feet, sink their weight to the ground, and maintain good
body alignment to promote stability and balance. Movements flow from one to another, with body weight shifting from the right leg to left leg to balance the empty and full feeling.

The second principle is relaxation. Relaxation involves both the mind and body during TC. Active relaxation involves integrating mindfulness with physical relaxation and simultaneous awareness of all parts of the body. Each movement is slow and even, promoting the flow of qi throughout the body. The mind is alert, though calm and centered while performing TC.
Centering allows an individual to access the inner self, promoting relaxation and inner peace. The goal is a calmer, clearer, nonreactive state of mind and provides the person with an internal sense of control over stress.

The third principle is coordination. The body is upright, the head is erect, the spine is comfortably aligned, shoulders are balanced and relaxed, and body weight is evenly distributed on the soles of the feet. While moving, the body remains in an upright
position with the shoulders aligned over the hips. TC movements originate in the waist to turn the whole body in unison. The waist is the center or axis and directs the movement of the arms, legs, and eyes.The head, trunk, and pelvis rotate as a single unit, aligned over a stable base in the feet. There is no twisting of the spine. Among older adults, TC can initially be taught by repeatedly practicing a series of simpler movements, slowly building coordination. Once these movements are mastered, new movements with increasing difficulty and complexity and demanding greater coordination can be gradually introduced.

Review of Literature
Typical disabilities following stroke include poor neuromuscular control, hemodynamic imbalance, and negative mood state. TC is associated with better balance, lower blood pressure, and improved mood, which are important for stroke survivors. A review of relevant TC research literature follows, examining research designs, study populations, measurement of variables, and style and duration of TC. Finally, the potential application of TC to stroke rehabilitation is discussed.

Tai Chi and balance
During the practice of TC, balance is a vital principle that is rigorously followed. Over the
past decade, the number of studies examining the effectiveness of TC exercise for improving balance has greatly increased. The majority of studies have reported that TC significantly improves balance, despite different research designs, diverse study populations, a wide variety of balance measures, different styles of TC, and varied duration of TC practice/experience. The majority of studies have been conducted among healthy older adults, though study populations have included adults with osteoarthritis, balance disorders, multiple sclerosis, stroke, or cardiovascular disease risk factors.

Significant improvements in balance have been reported, regardless of the type of balance
measure used.

Despite study limitations, including few rigorously conducted studies, varied balance measures, and different styles and duration of TC exercise, TC significantly improved balance and was a safe and feasible exercise option for persons with chronic health conditions, including stroke survivors.

Tai Chi and blood pressure
High blood pressure (BP) following a stroke places stroke survivors at greater risk for a subsequent stoke.However, relatively few studies have examined the effect of TC on BP,
and no reported studies have specifically examined the effect of TC on BP among stroke survivors. Participants were mainly healthy middle-aged or older adults, though study populations included adults with cardiovascular disease risk factors, such as hypertension, or postmyocardial infarction.


Tai Chi and mood
Depression or negative mood are common feelings experienced by stroke survivors, further compounding recovery. The mental concentration or mindfulness associated with TC is thought to promote peacefulness or tranquility, reducing stress and tension, while improving overall mood.

All studies reported significant improvements in overall negative mood, while four
studies reported significant reductions in depression. Duration of the TC interventions ranged
from 8 to 16 weeks, making comparisons difficult. Rigorous studies using a randomized clinical trial design with sufficient sample size are needed to definitely determine if TC effectively improves mood or reduces depression.

Tai Chi and stroke survivors
To date, only one published study has examined the effect of TC among stroke survivors. A total of 18 subjects participated and were able to independently perform their activities of daily living and walk with assistance. All participants attended group-based exercise
classes twice a week for 12 weeks, randomly assigned to either TC or balance training (controls). Controls had a significantly greater increase in balance than TC, following the intervention. However, it is likely that both the TC and controls had similar balance training exercise conditions. Other possible explanations for the findings reported include the small sample and limited amount of TC instruction and practice that participants received. Additional research with a sufficient sample and rigorous study design for examining
TC as an alternative exercise in stroke rehabilitation is needed before firm conclusions
can be made. However, the study reported the safety and efficacy of TC as an exercise modality among stroke survivors; the study also noted that participants enjoyed TC.

Application of Tai Chi to Stroke Rehabilitation
Balance is an essential component of successful movements associated with activities of daily living (e.g., walking, reaching, bending) as well as fall prevention, which is important for stroke survivors. TC likely facilitates improvements in balance through
the development of proprioceptive awareness and kinesthetic sense.Proprioceptive awareness and kinesthetic sense are reported to diminish with age or following a stroke. Kinesthetic sense or the perception of movement is mediated by the body’s proprioceptive
mechanisms enabling it to receive stimuli from receptors originating in the muscles, tendons, and joints, through which these movements can be adjusted accurately for maintaining balance. Proprioceptive awareness and kinesthetic sense are important for coordinated movements, body posture, and motor learning (relearning), which are essential
to stroke survivors for adequate neuromuscular functioning.

Constant weight shifting, trunk rotation, a changing base of support, and an elongated central axis around which all movements occur are fundamental to TC exercise. The slow, rhythmic movements of TC are linked together in a continuous sequence, while body weight is continually shifting from leg to leg without compromising balance or stability. Shifting body weight during TC to different positions (e.g., forward, backward, side-to-side) in a smooth and coordinated manner challenges the balance control system to maintain the center of mass within the base of support. Repetitive demands of this balance control system occurs during the practice of TC and may help explain how TC facilitates better balance.30 Several TC movements are directly related to elements of balance. 

Impaired proprioception in older adults makes it difficult for them to detect changes in their body position until it is too late for compensatory movements to prevent falls. In older adults with hemiparesis following a stroke, proprioception and kinesthetic sense is likely impaired further. During TC, each movement is scrutinized for correct body position and foot placement, important for performing TC safely without injury, while subjects learn or relearn proprioceptive awareness and kinesthetic sense. Continual practice of TC among older adults develops and strengthens proprioceptive awareness and kinesthetic sense and may
also aid balance control in stroke survivors. In addition, during performance of TC the knees
are bent, which strengthens the quadriceps, knee extensor, and flexor muscle strength. Primary knee flexors are the hamstrings and gastrocnemius muscles, which are two-jointed muscles. The hamstrings cross the hip and knee joints, while the gastrocnemius cross the knee and ankle joints. During TC, bending the knee requires hip flexion and simultaneous dorsiflexion. Previous research among older adults has reported significant increases
in lower body strength and flexibility following a TC intervention. TC likely facilitates
improvements in both lower body strength and flexibility, further aiding in balance control.
TC exercise is often prescribed by Chinese doctors as a treatment for hypertension. The softness and low-impact nature of the movements without force or pressure are ideal for persons with hypertension. The muscle relaxation created by TC is thought to foster a conditioned relaxation reflex in the blood vessels, resulting in lower blood pressure.
 This BP response is important for older adults, as they often experience age-associated declines in physiological functioning, and for stroke survivors. In addition, the relaxation response that occurs is further enhanced through the mindfulness and active relaxation during TC.Mindfulness and active relaxation during TC focuses on body position (e.g., correct foot placement) and how the body feels (e.g., shoulders relaxed). It involves being alert and calm at the same time, while leading to improvements in mood or mental outlook, an important aspect of care and rehabilitation among stroke survivors.

Conclusion
Stroke is the leading cause of serious, long-term disability among middle-aged and older adults in the United States. Typical disabilities following stroke include poor neuromuscular control, hemodynamic imbalance, and negative mood state. Reported research to date, indicates that TC exercise is associated with better balance, lower blood pressure, and improved mood, which are important for stroke survivors. TC is safe for older adults with chronic diseases or disabilities and may serve as an additional exercise modality for rehabilitation among stroke survivors. However, additional research with a sufficient sample and rigorous study design among stroke survivors is needed before widespread recommendations can be made for TC as an alternative exercise in stroke rehabilitation.

Parkinson's Disease

In 2003, the Parkinson’s Disease Society 
produced Keeping Moving, an exercise 
programme for people with Parkinson’s 
disease, devised by Bhanu Ramaswamy 
MCSP and Richard Webber MCSP, two 
senior physiotherapists in Sheffield. 

The evidence available to practitioners with 
regard to appropriate physiotherapy intervention 
for people with Parkinson’s up until the recent 
Rescue Project randomised control trial has either been of poor quality or absent. Physiotherapy has therefore had to rely on unsubstantiated anecdotal reports from professionals, people with Parkinson’s or carers regarding the effectiveness of input.

Clinical symptoms of Parkinson’s that may 
be influenced by physical therapies 
Considering the World Health Organization’s 
classification of consequences of disease 
(1980), physiotherapy has most effect on 
the management of disabilities (abilities),  
impairment (participation) and health of 
someone with Parkinson’s compared with 
anti-Parkinson’s medications that influence the 
disability. Physiotherapy is therefore advocated 
in combination with optimal timing of the effect 
of medications.

Underlying themes common to Alexander Technique, Pilates, Cunductive Education and Tai Chi 
all seemed to be the use of cognition to 
promote posture and body awareness or control of movement with emphasis on slow, flowing movements. All were timed with breathing to induce relaxation.  A person can  do these exercises in class or at home on an individual basis if a class is not available, which is why we have produced a DVD and booklet containing the programme.

The Keeping Moving programme has been based on this concept of action systems of motor control described above and three therapeutic models outlined as follows:
1 The Movement Enablement Through Exercise 
Regimes and Strategies (METERS) advocates 
the promotion, maintenance and use of quality
functional performance by focusing on four 
core areas of physiotherapy practice – gait, 
balance, posture and transfers outlined in 
Plant et al (2000) and detailed further in the 
Guidelines for Physiotherapy Practice in 
Parkinson’s Disease (Plant et al, 2001). 
2 A model put forward by Morris (2000) for 
physical therapists promotes a task-specific 
approach to training in the context of 
functional tasks.
3 A rationale for the management of individuals 
with Parkinson’s by Schenkman et al (1989 and 
1998), uses a systematic approach to evaluate, 
interpret and treat people with Parkinson’s. The Keeping Moving programme emphasises minimising musculoskeletal limitations and postural deformities in order to preserve the individual’s capability for independent function as long as possible. Clinically, the authors have found rotation useful in inducing relaxation and decreasing rigidity. It is also a necessary part of balance reactions and functional activities.

 The exercises progress through postural sets of lying, sitting and standing. Work on core stability and single limb range of movement in lying progresses to more complex sequences          involving bilateral or diagonal limb movements where the base of support is progressively decreased and the complexity of the movements increased. Elements of strengthening, balance, co-ordination of movements and flexibility are incorporated into the exercises and most of the exercises are synchronised with breathing. All are done at a cognitive level and with auditory cues Morris (2000) points out that there is little use in working on individual symptoms if the training does not relate to functions such as standing and walking, so the final exercises concentrate on aspects of stepping and sit-to stand control, hopefully resulting in modified or use of skills to gait and transfers.
No specific bed mobility or floor transfer 
exercises are done, as the task of getting on to 
and off the floor to perform the lying exercises 
requires similar skills. The therapist assists and 
instructs the person in how to get on or off the 
floor as necessary. 
All the exercises can be modified should the 
person with Parkinson’s experience difficulty 
in any one postural set. Some of the standing 
exercises are done with arm support if the 
person is very unstable, or sitting where their 
bottom becomes the base of support. 
Throughout the sitting and standing exercises, 
maintenance of best postural alignment 
is stressed.

Obtaining the programme/further information
The Keeping Moving programme is available from PDS.
The booklet is also available to download on
the PDS website at www.parkinsons.org.uk


Tai Chi for Cardiac Rehabilitation
We ran a Tai Chi for Cardiac Rehabilitation pilot program in south Birmingham starting in 2006 and measured patient improvement with the Dartmouth COOP score as recommended by BACPR.  The report is now complete and due to be published.

In brief:
Project Aims
1. To provide access to a Phase IV Cardiac Rehabilitation program for patients who have been discharged from UHBIT following an acute cardiac event or intervention through the provision of a weekly Tai Chi Class in a community setting.

2.  To quantitively evaluate the Tai Chi programme using the established COOP charts as advocated by the British Association of Cardiac and Pulmonary Rehabilitation (BACPR), which measure functional status and quality of life.

3.  To qualitively evaluate the Tai Chi program by using case histories of participants.

Findings.

Significant inprovements were reported in the entire COOP dimensions analysed, the most evident being the positive change in health reported in 76% of the cohort.  Over half of the participants reported improvements in overall health (58%) and emotional status (50%).  A further 45% of patients reported improvements in their ability to undertake daily activities, and 41% in their ability to undertake social activities.  Improvement in physical fitness was reported in 32% or the cohort.

At initial COOP chart assessment none of the patients reported the least extreme dimension (ie score 1) for any of the COOP charts used. At endpoint 65% were fully integrating socially, 44% were able to undertake their daily activities with no difficulty at all, 29% reported their health was much better, 17% reported not being bothered by emotional problems and 5% reported they were able to undertake strenuous activity regularly.  COOP chart analysis suggested that Tai Chi had improved the general health and well-being of this cohort.

The improvements achieved by participating in Tai Chi were also reflected in improved quality of life for patients as evident in the case histories.  Patients were able to re-commence employment, avoid the need for planned orthopaedic surgery and actively participate in helping other cardiac patients; this was evident through speaking at support groups and education classes and also by offering individual support to patients during the Tai Chi classes themselves.

Balanced Approach/NHS UHBIT

Tai chi dramatically reduces fibromyalgia pain
25 August 2010
Tai Chi – the slow-motion ancient Chinese exercise – helps reduce the pain of fibromyalgia, a new study has discovered. The study worked with 66 fibromyalgia sufferers who practised the
exercise daily for 12 weeks. They all reported a reduction in pain levels, fatigue, physical functioning, sleeplessness and depression. The benefits continued for weeks after they stopped
exercising, and some said that there pain was dramatically reduced even three months later.

Researchers from Tufts University say Tai Chi could be an important way of treating fibromyalgia, especially as conventional medicine has few answers to this perplexing disease. 
(Source: New England Journal of Medicine, 2010; 363: 743-54).



Tai Chi the best exercise for arthritis
18 June 2009
Tai Chi, the slow movement exercise from the Far East, can help ease the pain of arthritis, and improve your overall health.  It’s the best exercise choice for people with arthritis and musculoskeletal pain, and is a better option than strengthening, stretching and aerobic exercise plans.

In a meta-analysis of seven studies, researchers from the George Institute in Sydney, Australia discovered that Tai Chi improves pain and reduces disability better than other exercises and health plans among arthritis sufferers.
(Source: Arthritis & Rheumatism, 2009; 61: 717).



Tai Chi: Balancing your energy
Researchers at UCLA have discovered that doing Tai Chi can promote better sleep compared with attending health-education classes that include advice on stress management, diet and
sleep habits. 

After 25 weeks, patients in the Tai Chi group reported greater improvements in self-rated sleep quality compared with the health-education group. Also, it appeared that the amount of 
benefit with Tai Chi was comparable to that with drugs, with better sleep efficiency and duration, as well as sleep quality—and no adverse side-effects (Sleep, 2008; 31: 1001–8).

These results mirror those of a previous study that compared Tai Chi with low-impact exercise. Those doing Tai Chi were more likely to improve their sleep quality compared with those doing low-impact exercise (J Am Geriatr Soc, 2004; 52: 892–900).

However, the benefits of Tai Chi go far beyond a good night’s sleep. It is a promising form of exercise for improving balance and preventing falls, a major cause of injury and even death in
older people (BMC Geriatr, 2006; 6: 6).

Indeed, it has been shown to improve the characteristics in older adults that place them at increased risk of falls such as poor balance, loss of strength, limited flexibility and fear of falling 
(Med Sport Sci, 2008; 52: 124–34). 

Eight to 16 weeks of Tai Chi training improved balance, flexibility and heart health  (Arch Intern Med, 2004; 164: 493–501), and reduced the risk of multiple falls by nearly half 
(J Am Geriatr Soc, 1996; 44: 489–97).



Tai Chi and Postural Stability in Patients with Parkinson's Disease
Fuzhong Li, Ph.D., Peter Harmer, Ph.D., M.P.H., Kathleen Fitzgerald, M.D., Elizabeth Eckstrom, M.D., M.P.H., Ronald
Stock, M.D., Johnny Galver, P.T., Gianni Maddalozzo, Ph.D., and Sara S. Batya, M.D.
N Engl J Med 2012; 366:511-519February 9, 2012
Background
Patients with Parkinson's disease have substantially impaired balance, leading to diminished functional ability and an increased risk of falling. Although exercise is routinely encouraged by health care providers, few programs have been proven effective.
Methods
We conducted a randomized, controlled trial to determine whether a tailored Tai Chi program could improve postural control in patients with idiopathic Parkinson's disease. We randomly assigned 195 patients with stage 1 to 4 disease on the Hoehn and Yahr staging scale (which ranges from 1 to 5, with higher stages indicating more severe disease) to one of three groups: Tai Chi, resistance training, or stretching. The patients participated in 60-minute exercise sessions twice weekly for 24 weeks. 

The primary outcomes were changes from baseline in the limits-of-stability test (maximum excursion and directional control; range, 0 to 100%). Secondary outcomes included measures of gait and strength, scores on functional-reach and timed up-and-go tests, motor scores on the Unified Parkinson's Disease Rating Scale, and number of falls.

Results
The Tai Chi group performed consistently better than the resistance-training and stretching groups in maximum excursion (between-group difference in the change from baseline, 5.55 percentage points; 95% confidence interval [CI], 1.12 to 9.97; and 11.98 percentage points; 95% CI, 7.21 to 16.74, respectively) and in directional control (10.45 percentage points; 95% CI, 3.89 to 17.00; and 11.38 percentage points; 95% CI, 5.50 to 17.27, respectively). The tai chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance-training group in stride length and functional reach. Tai chi lowered the incidence of falls as compared with stretching but not as compared with resistance training. The effects of tai chi training were maintained at 3 months after the intervention. No serious adverse events were observed.

Conclusions
Tai Chi training appears to reduce balance impairments in patients with mild-to-moderate Parkinson's disease, with additional benefits of improved functional capacity and reduced falls. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00611481.)  Supported by a grant (NS047130) from the National Institute of Neurological Disorders and Stroke.  Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. 



Tai Chi Lowers Blood Pressure
 Daily Telegraph 5th April 2012
Researchers found that older people who regularly performed the traditional Chinese “mind and body” technique were less likely to suffer high blood pressure and were physically stronger.
They concluded that the improvement of heart function combined with increased muscular power meant that the martial art should be considered the preferred technique for elderly
people to maintain good health.

Tai Chi, which has grown in popularity throughout the world, is typified by slow, deliberate repetitive movements and is based on co-ordination and relaxation rather than muscular
tension. It is believed that focusing the mind solely on the movements helps to bring about a state of mental calm and clarity.

In the Hong Kong study, pulse measurements showed that Tai Chi specifically improved expansion and contraction of the arteries — known as arterial compliance, an important
indicator of heart health — and increased knee muscle strength. A number of earlier studies have shown that strength training alone has been accompanied by a decline in arterial
compliance.

The findings were published online in the European Journal of Preventive Cardiology.

The study involved 65 elderly subjects from Hong Kong, 29 recruited from local Tai Chi clubs who had each practised the technique for at least 90 minutes a week for three years, and 36
controls with no such experience.

Initial results showed that the Tai Chi subjects were superior in almost all medical observations,including blood pressure, vascular resistance and pulse pressure. Measurements also showed that both large and small artery compliance was 40-44 per cent higher in the Tai Chi group.

Additional analysis showed that the Tai Chi subjects had greater average muscle strength.

The effect of Tai Chi training in lowering blood pressure has been documented previously. Dr William Tsang from the The Hong Kong Polytechnic University in Hong Kong, who led the
research, said: “However this is the first study to investigate the possible effects of Tai Chi on arterial compliance by comparing older Tai Chi practitioners with non-practitioners similar in
age and activity level.

“The improvement in arterial compliance could have resulted from a combination of aerobic training, stretching, mental concentration and calm meditation during Tai Chi movement,” he
said.  Dr Tsang said the added appeal of Tai Chi was that it could be practised any time and anywhere without the constraints of equipment or a gymnasium.