Ancient Exercise for Modern Rehab

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March 2005

By Sandra Matsuda, OTR/L, PhD, Diane Martin, PT, and Tricia Yu, MA

Tai Chi Promotes Wellness and Fitness Among a Wide Range of Patients.

Research confirms that tai chi is a movement therapy well suited for a number of conditions. A systematic review of tai chi research reports that “Tai Chi appears to have physiological and psychosocial benefits and also appears to be safe and effective in promoting balance control, flexibility, and cardiovascular fitness in older patients with chronic conditions.”¹ As medical research validates the benefits of tai chi practice,² health professionals are exploring this exercise as a therapeutic modality as well as a wellness regimen.

The Tai Chi Fundamentals program (TCF)³ offers a clear system for learning basic tai chi moves that are natural, efficient, and safe, and have applications for therapy, function, and wellness. Developed by tai chi instructor and article coauthor Tricia Yu, MA, in collaboration with Jill Johnson, MS, PT, GCS, it features instruction in tai chi’s movement patterns, their biomechanics, therapeutic and functional applications, and guidelines for documenting tai chi as a therapeutic modality. The program includes instruction in the mind/body integration components of tai chi, with focus on diaphragmatic breathing, and provides guidelines for staying relaxed and alert while in motion. The movement sequence follows a motor development progression and can be used as tools for both patient assessment and intervention.

ACCESSIBLE EXERCISE
TCF is accessible for individuals of all ages with a wide range of abilities and conditions, including the medically complex. Designed with discrete, measurable increments in difficulty, it can be used as a standard for researching outcomes for individuals whose abilities range from severely limited function to advanced athletic skills. TCF has applications for balance dysfunction, orthopedic and neurological rehabilitation, pain management, cardiovascular and respiratory disorders, as well as individuals with chronic fatigue and fibromyalgia. It can be taught individually or in groups, and used in a variety of settings including hospitals, sub-acute care, outpatient clinics, and home care, and in community wellness classes, senior centers, and long-term care facilities.

EAST MEETS WEST

Tips for Starting a Tai Chi Program

Attend a course offered for Tai Chi Fundamentals or other simplified tai chi programs.
Find local tai chi teachers who are willing to customize movements to accommodate individual differences and levels of conditioning.
Network/train with local tai chi practitioners in exchange for helping them with modifications for joint protection and simplification.
Invite a qualified tai chi practitioner to provide an in-service or workshop for staff.
Purchase videotapes and books3,13 to do self-study of tai chi forms.
Form an interest group with area therapists and wellness group leaders to incorporate tai chi into existing programs.
Market your tai chi program beyond patients to include employees, support group members and their spouses, and the community.

So how can tai chi be incorporated into rehabilitation programs? First, recognize that tai chi is a complementary approach to enhance, not replace, medical care and therapy. Physical and occupational therapy researchers have described how tai chi practice is being applied in therapy and wellness programs. Jennifer Bottomley, PhD, a physical therapist and tai chi practitioner, describes how tai chi can be used as a movement modality in orthopedics.⁴ Florence Clark, PhD, OTR, demonstrated how tai chi could be used effectively as a wellness intervention in her study of the well elderly living in the community.⁵ Studies also report the effect of using tai chi to improve aerobic capacity in patients recovering from acute myocardial infarction and other chronic conditions.^6,7

GERIATRICS
Steven Wolf, PhD, PT, a leading tai chi researcher, says that “The data strongly support the use of tai chi as an exercise form for older adults” provided that medical professionals assure that movements are graded and avoid aggravating existing musculoskeletal problems. The data from his landmark study on reducing frailty and falls in older persons suggest that regular practice of tai chi significantly influences older individuals’ functioning and well-being.⁸ In a review by Verhagen et al,⁹ evidence suggests that tai chi is effective in reducing falls and blood pressure in older adults.

The Tai Chi Fundamentals program is taught to seniors for wellness, for fall prevention, and to improve concentration, balance, and relaxation. Gail Janz, a PT practicing in Wisconsin, teaches TCF classes to seniors and those who have arthritis or pulmonary or cardiovascular diseases. She reports that elderly clients enjoy the challenge of continuous slow movement, and that “regular practice will result in a beneficial training effect including improved endurance and tolerance to daily activities.” Older patients with speech or breathing difficulties as well as people with varying degrees of conditioning and endurance have also been able to engage in TCF safely.

MUSCULOSKELETAL
Therapists in outpatient rehab use TCF movement patterns as a closed chain mode of leg strengthening. These patterns facilitate kinesthetic awareness of weight shifting that enhances single leg stance and balance. Total knee arthroplasty patients often exhibit gait deviations after regaining their strength and flexibility postoperatively. Introducing the weight shifting done in the Bear Rooting movement helps them regain a normal gait pattern.

Group practice of the Stable and Open Move.

TCF is an appropriate modality for patients with spinal conditions because it shares the same principles that we teach in spinal stabilization: hip-width base of support, upright posture, bending the knees, holding an object in midline, and rotating at the hips with a neutral spine. Christine Zampach, MEd, PT, assistant clinical professor, School of Medicine, University of California-San Francisco, reported to the authors that “patients with spinal stenosis and other similar low back pain with radicular symptoms find the back position comfortable. It has opened up a new world of standing exercise for them.”

The movement patterns reinforce simple activities such as rising from a chair, pushing and pulling, and lifting. It can also be used to allow patients to complete more complex or demanding activities. For example, the Tai Chi Stance can build on leg strength to enhance functional activities such as sweeping, raking, vacuuming, bowling, and tennis. The Tai Chi Fold is useful for hip mobility and core movement, and can be used as a warm-up for functional and sports activities such as golf.

PAIN MANAGEMENT
The serenity and relaxation experienced while doing tai chi also add to the health and fitness benefits of regular practice. Zampach, whose practice focuses on chronic pain patients, told the authors that “[patients] have greatly benefited from Tai Chi Fundamentals’ slow, gentle movement patterns.” Judy Smith, a physical therapist from Madison, Wis, who uses the TCF with chronic pain patients, says, “Many of the movements are open and expressive and thus help elevate the mood. So many chronic pain patients are depressed, and the positive nature of the exercises makes a big difference.” Kate, an occupational therapist with terminal cancer, found that doing tai chi with a TCF instructor calmed her anxiety and helped her focus on something other than her pain and daily medical issues. Participants frequently experience relaxation, well-being, and focused attention that balance the stress of modern life and the effects of chronic illness.

NEUROLOGICAL
Shelly Vanness, an occupational therapist and biofeedback specialist in Appleton, Wis, teaches TCF to neurological and chronic pain patients for pain reduction, relaxation benefits, and neuromuscular reeducation. By connecting biofeedback machines to specific muscle groups while patients perform TCF movement patterns, they can see the sEMG graph simultaneously change to a more normal muscle tension level. She teaches relaxed arm swinging and progresses to Crane Takes Flight to help patients decrease upper extremity tension and use their arms more efficiently while performing daily activities. One Parkinson’s patient in Vanness’ program reported being able to shovel the snow from his driveway without pain using the TCF movement patterns and principles of relaxation and rest.

BALANCE AND FALLS
For those interested in balance and fall programs, tai chi programs can be customized for individual patients and can progress to group programs when the client can do so safely. Studies such as those of Wolf et al⁸ and Li et al¹⁰ have shown that tai chi practiced over as little as 15 weeks to 6 months improved participants’ functional balance and reduced the risk of falls significantly. Other benefits reported were decreased fear of falling, improved sleep, increased confidence, and improvement in daily function. In addition, with regular practice, participants maintained their level of safety for months after the studies were completed. Steven Wolf has reflected, “It is becoming very clear that the physical and behavioral benefits to be derived from learning tai chi among older adults can only be sustained with continued practice.”

The National Safety Council and the Centers for Disease Control and Prevention have established that the associated costs with fall injuries are leading to a public safety epidemic. As a result, new legislation, the “Keeping Seniors Safe From Falls Act of 2004,” will provide funding for research and public outreach projects to enhance awareness and promotion of fall prevention programs.¹¹ Studies by Li et al¹⁰ indicate that health care providers should consider tai chi as a balance retraining intervention as well as a component of a fall prevention program.

MOVING FROM INDIVIDUAL THERAPY

Free community classes in TCF sponsored by Group Health Cooperative HMO in Madison, Wis.

A rehab facility can offer a continuum of services by providing a tai chi program as a transition for those discharged from therapy who want an ongoing, gentle exercise program that they can sustain. In Fort Wayne, Ind, coauthor Diane Martin, PT, uses TCF individually in the clinic, then progresses patients to group classes offered in the community at a local women’s center and church. Participants have the opportunity to purchase the TCF book and videotape for home practice. Her participants report that they enjoy the atmosphere of group support, coupled with the instructor’s ability to facilitate their learning. This satisfaction leads them to return and bring others to class. A good program offers lifestyle changes and appeals to people of all ages, not just patients, but spouses, employees, support groups, and the larger community.

In a number of communities, both health care practitioners and tai chi instructors teach TCF in hospital- and community-based wellness classes, public housing, and retirement communities for seniors. Workshops and classes are also organized for people with specific diagnoses such as multiple sclerosis, cancer, or Parkinson’s disease. Often spouses attend and benefit along with patients. Other tai chi programs are also offered as follow-up classes for research studies done at the Health Connection, a community health, wellness, and research center in Columbia, Mo.

INTRODUCING THE ART

Tai Chi Resources

ROM Dance (program materials), www.taichihealth.com, (608) 280-9730
T’ai Chi Chih, www.taichichih.org,
(701) 854-7459 or (888) 540-7479
Tai Chi Fundamentals (courses and materials), www.taichihealth.com,
(608) 280-9730
Seminar Solutions (courses), www.seminarsolutions55.com
Tai Chi for Arthritis (courses and materials), www.taichiproductions.com
Quest Seminars (courses), www.questseminars.com

Through academic institutions, TCF is being introduced to future and practicing therapists. At the University of Missouri-Columbia (UMC), occupational therapy students are introduced to the TCF Program in their complementary therapy course. They also learn the ROM Dance,^5,12 a range of motion and pain management program based on tai chi principles, for use in nursing homes. At the University of Saint Francis in Fort Wayne, physical therapist assistant students learn TCF in their Patient Care Skills class as an integrative modality. The nursing faculty has also requested that the principles of TCF be taught in their introductory nursing classes as a wellness tool.

TCF workshops were offered as part of a certificate in Interdisciplinary Geriatric Assessment through UMC’s outreach extension program. Participants included practicing physical, occupational, respiratory, and speech therapists as well as nurses who serve clients in rural nursing homes, home health, and outpatient clinics.

PROFESSIONAL WORKSHOPS
The skills learned in the basic course can be applied immediately in practice. The course includes review of research on tai chi, biomechanical analysis of tai chi movement, clinical applications, overview of mind/body research, and how to document tai chi as a therapeutic modality to help bridge this ancient exercise with the western medical model. Participants first learn TCF movement patterns and then progress to a simplified tai chi form. Therapists and tai chi practitioners can complete TCF certification through advanced workshops and regular practice.

The TCF program offers one option for rehab professionals interested in learning tai chi. Additional programs are available that may be useful for rehab professionals.

Sandra Matsuda, OTR/L, PhD, is an assistant professor of occupational therapy, University of Missouri-Columbia. Diane Martin, PT, is instructor of the Physical Therapist Assistant Program, University of St Francis, and is a practicing clinician at Integrity Physical Therapy, Fort Wayne, Ind; she has found the TCF methods to be beneficial in managing both her personal battle with arthritis/pain as well as her patients’ function/pain. Tricia Yu, MA, is director of the Tai Chi Center, Madison, Wis.

REFERENCES

Wang C, Collet JP, Lau J.The effect of Tai Chi on health outcomes in patients with chronic conditions: a systematic review. Arch Intern Med. 2004;164:493-501.
Chewning B, Johnson J, Yu T. T’ai Chi (part 2): effects on health. ACSM’s Health and Fitness Journal. 2000;4(3):1–5.
Yu T, Johnson J. T’ai Chi Fundamentals for Health Professionals and Instructors. Madison, Wis: Uncharted Country Publishing; 1999.
Bottomley J. The use of T’ai Chi as a movement modality in orthopaedics. Orthopaedic Physical Therapy Clinics of North America. 2000;9(3):361–373.
Jackson J, Carlson M, Mandel D, Zemke R, Clark F. Occupation in lifestyle redesign: the Well Elderly Study Occupational Therapy Program. Am J Occup Ther. 1998;52:326-336.
Channer K, Barrow D, Barrow R, Osborne M. Change in hemodynamic parameters following Tai Chi Chaun and aerobic exercise in patients recovering from acute myocardial infarction. Postgrad Med. 1996;72:349-351.
Taylor-Piliae RE, Froelicher ES. Effectiveness of Tai Chi exercise in improving aerobic capacity: meta-analysis. J Cardiovasc Nurs. 2004;19:48-57.
Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T; Atlanta FICSIT Group. Selected as the best paper in the 1990s: Reducing frailty and falls in older persons: an investigation of tai chi and computerized balance training. J Am Geriatr Soc. 2003;51:1794-803.
Verhagen A, Immink M, van der Meulen A, Bierma-Zeinstra S. The efficacy of Tai Chi Chaun in older adults: a systematic review. Fam Pract. 2004;21:107-13.
Li F, Harmer P, Fisher KJ, McAuley E. Tai Chi: improving functional balance and predicting subsequent falls in older persons. Med Sci Sports Exerc. 2004;36:2046-52.
Senate approves elder falls prevention act. PT Bulletin Online. December 3, 2004.
Harlowe D, Yu T. ROM Dance: A Range of Motion Exercise and Relaxation Program. St. Mary’s Hospital Medical Center and the Board of Regents of University of Wisconsin System. 3rd ed. Madison, Wis: Uncharted Country Publishing; 1997.
Yu T. Tai Chi Mind and Body. London: DK Publishing; 2003.