reviewarticle tai chi chuan in medicine and health...

Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2013 Article ID 502131 17 pageshttpdxdoiorg1011552013502131

Review ArticleTai Chi Chuan in Medicine and Health Promotion

Ching Lan1 Ssu-Yuan Chen1 Jin-Shin Lai1 and Alice May-Kuen Wong2

1 Department of Physical Medicine and Rehabilitation National Taiwan University Hospital7 Chung-Shan South Road and National Taiwan University College of Medicine Taipei 100 Taiwan

2Department of Physical Medicine and Rehabilitation Chang-Gung Memorial Hospital and Department of Physical TherapyPost-Graduate Institute of Rehabilitation Science Chang-Gung University Taoyuan 333 Taiwan

Correspondence should be addressed to Ching Lan clanntuedutw

Received 16 April 2013 Accepted 29 June 2013

Academic Editor WilliamW N Tsang

Copyright copy 2013 Ching Lan et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Tai Chi Chuan (Tai Chi) is a Chinese traditional mind-body exercise and recently it becomes popular worldwide During thepractice of Tai Chi deep diaphragmatic breathing is integrated into body motions to achieve a harmonious balance betweenbody and mind and to facilitate the flow of internal energy (Qi) Participants can choose to perform a complete set of Tai Chior selected movements according to their needs Previous research substantiates that Tai Chi has significant benefits to healthpromotion and regularly practicing Tai Chi improves aerobic capacity muscular strength balance health-related quality of lifeand psychological well-being Recent studies also prove that Tai Chi is safe and effective for patients with neurological diseases(eg stroke Parkinsonrsquos disease traumatic brain injury multiple sclerosis cognitive dysfunction) rheumatological disease (egrheumatoid arthritis ankylosing spondylitis and fibromyalgia) orthopedic diseases (eg osteoarthritis osteoporosis low-backpain and musculoskeletal disorder) cardiovascular diseases (eg acute myocardial infarction coronary artery bypass graftingsurgery and heart failure) chronic obstructive pulmonary diseases and breast cancers Tai Chi is an aerobic exercise with mild-to-moderate intensity and is appropriate for implementation in the community This paper reviews the existing literature on Tai Chiand introduces its health-promotion effect and the potential clinical applications

The weak can overpower the strong the flexible can overcome the rigid the whole world can perceive this but does not put itinto practice Tao Te Ching (Lao Tze)

1 Introduction

Tai Chi Chuan is a branch of Chinese martial arts and hasdeveloped since the 17th century in China The slow suppleand graceful movement of Tai Chi is rooted in Taoism Tao-ism is an ancient Chinese philosophy and has been taught byLao Tze in the 5th-4th century BC The Taoist doctrine isfocused onmind tranquility and its goal is to achieve longevi-ty by meditation and lifestyle modification In the processof development Tai Chi differentiated into five main stylesChen Yang Wu (Hao) Wu and Sun [1] Among them Chenstyle is the oldest while Yang style is the most popular Theclassical Tai Chi styles consisted of complex forms and theytake long time to learn and practice Therefore many sim-plified Tai Chi forms were developed to shorten the learning

period Variations in training approaches result in significantdifferences in exercise intensity and training effect Tai Chi isperformed in a semisquat position (Figure 1) and the exerciseintensity can be easily adjusted by controlling the speed andpostural height The characteristics of Tai Chi include (1)mind concentration with breathing control (2) whole-bodyexercise in a semisquat posture and (3) continuous curvedand spiral body movements [1] Tai Chi can be practicedalone or as a group exercise and it has significant benefitsfor physical emotional and social functions Participantsmay practice several Tai Chi movements instead of a wholeset to achieve specific health benefits such as flexibility andbalance However if they want to enhance aerobic capacityor muscular strength a complete set of classical Tai Chi isrecommended In the recent years Tai Chi has become a

2 Evidence-Based Complementary and Alternative Medicine

1 2 3 4

5 6 7

Figure 1 An example of a typical form of Tai Chi (push down and stand on one leg) The sequential motions are performed in a semi-squatposture (From [1] with permission)

popular exercise worldwide and researches are flourishingThe objective of this paper is to review the existing literatureon Tai Chi and to introduce the characteristics of training(exercise intensity and biomechanical aspects) the effecton health promotion (aerobic capacity muscular strengthbalance health-related quality of life and psychological well-being) and potential applications in medicine (eg neuro-logical diseases rheumatological diseases orthopedic dis-eases cardiopumonary diseases and cancers)

2 Training Characteristics of Tai Chi

21 Exercise Intensity The exercise intensity of Tai Chidepends on its training style posture and duration Varia-tions in training approaches result in substantial differencesin exercise intensity Lan and colleagues [2] have measuredheart rate (HR) responses and oxygen uptake while perform-ing classical Yang Tai Chi in middle-aged subjects Figure 2illustrates the heart rate response and oxygen uptake ( VO

2)

during the practice of Tai Chi In the 24 minutes of practicesubjectsrsquo HR increased rapidly in the first 12minutes and thenincreased slowly towards the end of the exercise By contrastsubjectsrsquo VO

2showed a sharp increase in the first three

minutes and then it achieved a steady state towards the end ofthe exercise In the steady state of Tai Chi practice the averageHR was 58 of the heart rate reserve (HRR) and the oxygenuptake was 55 of the peak oxygen uptake ( VO

2peak) HRR isthe difference betweenmaximum heart rate and resting heartrate HRR is typically utilized to establish HR-based trainingzones according to the heart rate reserve method The HRRmethod is demonstrated as follows Target HR = [(HRmaxminusHRrest) times intensity desired] + HRrest According to the

recommendations of American College of Sports Medicinemoderate-intensity (40ndash59 of HRR) aerobic exercise isrecommended for most of the adults [3] The HR during TaiChi practice is 50ndash58 of HRR in subjects aging from 25 to80 years (Figure 3) which indicates that the exercise intensityis similar across different ages [4] Previous studies reportedthat the energy cost during Tai Chi practice was between 3and 6 metabolic equivalents (METs) depending on differentstyles and training requirements Therefore a suitable styleof Tai Chi and selected movements can be chosen to fitparticipantsrsquo needs

22 Biomechanical Aspects Wu and Hitt [5] have examinedthe kinematics of Tai Chi gait (TCG) and normal gait byusing a motion analysis system and biomechanical forceplates TCG had a low-impact force an evenly distributedbody weight between the fore-foot and the rear-foot anda large medial-lateral displacement of the foot center ofpressure (COP) The low-impact force may be attributed tothe slow speed of Tai Chi and the coordinated muscularactivities of the lower extremities The activation duration ofleg muscles especially the knee extensors is significantlyaffected by the speed of Tai Chimovement Practicing Tai Chiat a different speed may alter the role of muscular functionin movement control [6] Additionally the spatial temporaland neuromuscular activation patterns of TCGwere differentwith normal gait Compared with normal gait Tai Chi gaithad (1) a longer cycle duration and duration of single-legstance (2) a larger jointmotion in ankle dorsiplantar flexionknee flexion hip flexion and hip abduction (3) a largerlateral body shift and (4) a significant involvement of ankle

Evidence-Based Complementary and Alternative Medicine 3

180

156

132

108

84

60

28

24

20

16

12

8

4

010

0Rest Rest

StartTCC Stop

StartTCC Stop

0 4 8 12 16 20 24Time (min)

Rest Rest0 4 8 12 16 20 24Time (min)

HR

(bpm

)

VO2

(mL

kgm

in)

Figure 2 Heart rate response and oxygen uptake during the practice of classical Yang Tai Chi in middle-aged men (values are mean plusmn SD)[2]

160

140

120

100

80

60

100

HR

(bpm

)

160

140

120

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(bpm

)

Men Women

0 4 8 12 16 20 24(min)

YoungMiddle-agedElderly

0 4 8 12 16 20 24(min)


Rest Rest

StartTCC Start

TCC

Stop Stop

Figure 3 Heart rate responses of men and women during the practice of classical Yang Tai Chi in different age groups (⧫ young group ◼middle-aged group and 998771 elderly group values are mean plusmn SE) [4]

dorsiflexors knee extensors hip flexors and abductors longerisometric and eccentric actions and longer coactivations ofmuscles [7] Normal muscle activation patterns are charac-terized by activation and relaxation related to the agonistand antagonist muscle groups during a specific activityCoactivation of muscle groups is a common strategy adoptedto reduce strain and shear forces at the joint [8]

Agemay affect the characteristics of Tai Chi performanceThe elderly people practice Tai Chi in a higher posturebecause of muscle weakness or degeneration of knee joints[9] Tai Chi gait has an increased shear force and frontal planetorque at lower extremity joints than normal gait but theshear force at lower extremity joints during TCG is lower inthe elderly subjects than in the young adults [10]

23 Cost Tai Chi is a low-cost exercise because equipmentand facility are not needed In the Chinese community mostof the instructors are volunteer and participants only need to

pay minimum tuition fees In the United States a study [11]reported that the direct cost of a Tai Chi program was about$35 per person per session and the cost was affordable formost participants In Taiwan a formal Tai Chi training coursefor novice participants usually costs $20ndash40 per month In arecent review to evaluate the strategies to prevent falls amongolder people [12] Tai Chi was the most cost-effectivenessstrategy to prevent falls

3 Tai Chi for Health Promotion

31 Aerobic Capacity The peak oxygen uptake is the bestindicator for aerobic capacity and is the strongest predictorof the risk of death among normal subjects and patientswith cardiovascular diseases [13] In cross-sectional studiesLan and colleagues [14] have reported that elderly Tai Chipractitioners showed 18-19 higher in VO

2peak than theirsedentary counterparts Furthermore long-term Tai Chi


practitioners displayed slower age-related decline of aerobiccapacity than sedentary individuals In a five-year follow upstudy [15] the annual decrease of VO

2peak in the Tai Chigroup was about 40 slower than in the sedentary controlgroup Lan and colleagues [16] also reported that the VO

2peakincreased 161 and 213 after one year of Tai Chi trainingin older men and women respectively According to a recentmeta-analysis [17] practice of Tai Chi may significantlyimprove aerobic capacity Middle-aged and older women andmen benefit the most with greater gains seen among thoseinitially sedentary

32Muscular Strength Tai Chi is performed in the semisquatposition and various degrees of concentric and eccentriccontractions are demanded in this unique posture In theFrailty and Injuries Cooperative Studies of InterventionTechniques (FICSIT) study [18] Tai Chi program might pre-serve the strength gains from a 3-month strength trainingprogram using instruments and significant gains persistedafter 6 months of Tai Chi

Twelve to 24 weeks of Tai Chi exercise appears to bebeneficial tomuscular strength of lower extremities Jacobsonand colleagues [19] reported that the 12 subjects aging 20ndash45years who performed 108-form Tai Chi three times per weekfor 12 weeks significantly increased the muscular strengthof their knee extensors Lan and colleagues [20] found thatTai Chi exercise enhanced strength of knee extensors atvarious angles After 6 months of Yang Tai Chi trainingmen increased 135ndash242of isokinetic strength in concentriccontractions and increased 151ndash238 in eccentric con-tractions Wu and colleagues [21] also reported that Tai Chiparticipants had higher concentric and eccentric strengthsof knee extensors and smaller foot center of pressure excur-sions in both eyes-open and eyes-closed conditions thanthe controls The degree of knee flexion during single-legstance of Tai Chi may be a key element for improving legmuscle strength [22] In a recent study Lu and colleagues[23]measuredmuscular strength of knee by isokinetic testingat 30∘s The Tai Chi group demonstrated greater eccentricmuscular strength in both knee extensors and flexors than thecontrol group

In elderly individuals Li and colleagues [24] reportedthat a 16-week Tai Chi program increased 199 of muscularstrength of the knee flexors and there was a significantdecrease in latency of semitendinosus muscle in the Tai ChigroupTheprevention of falls depends on the timely initiationof an appropriate postural response Tai Chi interventionsignificantly hastened the reaction time of the semitendi-nosusmuscle whichmay help older peoplemaintain posturalcontrol In a recent randomized trial a 16-week Tai Chiprogram three sessions per week also induced a significantincrease in eccentric knee extensor strength in senior femalesubjects [25]

33 Balance and Motor Control Standing balance is a com-plex process that depends on the integration of mechanicalsensory and motor processing strategies The visual propri-oceptive and vestibular systems are three sources of afferentinformation to influence the control of balance which is

termed ldquosensory organizationrdquo [26]The sensory organizationtesting (SOT) can be used to identify problems with posturalcontrol by assessing the subjectrsquos ability to make effective useof visual vestibular and proprioceptive information

During the performance of Tai Chi weight shiftingbody rotation and single-leg standing in different positionsare frequently practiced Delicate joint control with musclecoordination is required during motions and hence balancefunction may benefit from long-term practice of Tai ChiIn studies using simple balance tests (eg time duration insingle-leg standing with eyes open or closed) older Tai Chipractitioners showed better postural control than sedentarysubjects [27 28] In a study using computerized balancesystem Tai Chi practitioners showed no difference comparedto control group in simple conditions (such as posturalsway in standing with eyes open or close) [29] By contrastTai Chi participants showed better performance in complexconditions such as eyes closed with sway surface sway visionwith sway surface and forward-backward weight shifting test[29] Many studies have demonstrated the advantages of TaiChi on visual proprioceptive and vestibular functions andthey are described briefly below

331 Visual System In elderly people Tai Chi participantshad better postural stability at themore challenging conditionof sway-referenced vision and support than the control group[29] Tsang and colleagues [30] investigated elderly Tai Chipractitioners using the SOT and found that their visual ratiowas higher than that of nonpractitioners and even compara-ble with that of the young subjects The results implied thatlong-term practice of Tai Chi improved balance control inthe elderly population and there was an increased relianceon the visual system during stance Additionally elderly TaiChi practitioners attained the same level of balance controlas young subjects when standing in reduced or conflictingsensory conditions In a recent study Chen and colleagues[31] investigated the effects of Tai Chi for elderly personswith visual impairment and found that the Tai Chi groupshowed significant improvements in visual and vestibularratios compared with the control group

332 Proprioceptive System Tai Chi training puts a greatemphasis on exact joint positions and it may improve thesense of position of lower extremities Wong et al [32] andTsang and Hui-Chan [33] examined the knee proprioceptionin elderly subjects by using the passive knee joint repositiontest and found that Tai Chi practitioners had better kneejoint proprioceptive acuity than control subjects In anotherstudy Tsang and Hui-Chan [34] reported that both Tai Chipractitioners and golfers had better knee joint proprioceptiveacuity than the elderly control subjects and it was similarto that of the young subjects Similarly Xu and colleagues[35] reported that Tai Chi participants not only showedbetter proprioception at the ankle and knee joints than thecontrols but they also showed better ankle kinesthesis thanswimmersrunners

Training duration of Tai Chi may influence the accuracyof joint position sense Fong andNg [27] have compared long-term (practice for 1ndash3 years) and short-term (practice for 3


months) Tai Chi training for middle-aged and older individ-uals The results showed that both long-term and short-termTai Chi training improved joint position sense but only long-term practice could enhance dynamic standing balance

Tai Chi also improves proprioceptive function of upperextremities Tai Chi practitioners focus specific mental atten-tion on the body and upper extremities which may facilitatetactile acuity and perceptual function Previous study showedthat Tai Chi training could increase shoulder kinestheticsense and reduce movement force variability in manual aim-ing tasks Recent study also found that Tai Chi practitionersattained significantly better eye-hand coordination in fingerpointing than control subjects [36]

333 Vestibular System Elderly Tai Chi practitioners hadbetter maximal stability and average velocity than the con-trols under the condition of eyes closed and sway-referencedsupport (ECSS) which indicated improvement of balancefunction through vestibular mechanism [32 37] PracticingTai Chi involves head movements and thus stimulates thevestibular systemTherefore the elderly Tai Chi practitionerscould attain a higher vestibular ratio than the controls underthe condition of ECSS

Patients with dizziness and balance disorders may getbenefits from Tai Chi training Hain and colleagues [38]reported that patients with dizziness who practiced 8 Tai Chimovements every day for at least 30min showed significantimprovements in the SOT and the Dizziness HandicapInventory scores McGibbon and colleagues [39] found thatboth Tai Chi and vestibular rehabilitation improved balancein patients with vestibulopathy but through different mech-anisms Gaze stability is most improved in those who receivevestibular rehabilitation but Tai Chi training improveswhole-body stability and footfall stability without improvinggaze stability In a subsequent study [40] 36 older adultswith vestibulopathy were assigned to a 10-week program ofvestibular rehabilitation or Tai Chi exercise The improve-ments of the Tai Chi group were associated with reorga-nized neuromuscular pattern in lower extremities while thevestibular rehabilitation group only had better control ofupper body motion to minimize loss of balance In a recentstudy MacIaszek and Osinski [41] assigned 42 older peoplewith dizziness to either aTaiChi groupor a control groupTheTai Chi group practiced a 45-minute exercise twice weeklyfor 18 weeks and showed significant improvement in up toand go test forward deflection backward deflection and themaximum sway area

334 Prevention of Falls Balance function begins to declinefrom middle age deteriorates in older age and increases therisk of fall and injury Suitable exercise training may improvebalance function and prevent accidental falls Recent studiesfound that Tai Chi has favorable effects on balance functionand falls prevention in the elderly In the Atlanta subgroupof the clinical trial of FICSIT [42] a total of 200 participantswere divided into three groups Tai Chi balance trainingand education After 15 weeks of training the fear of fallingresponses were reduced in the Tai Chi group compared with

the education group and the Tai Chi group reduced the riskof multiple falls by 475

Li and colleagues [43] randomly assigned 256 sedentarycommunity-dwelling elderly people to a Tai Chi group or astretching control group After 6 months of training the TaiChi group showed significantly fewer falls lower proportionsof fallers and fewer injurious falls than the control groupTherisk formultiple falls in the Tai Chi groupwas 55 lower thanthat in the control group In another study Voukelatos andcolleagues [44] reported that 702 community-dwelling olderpeople participated in a Tai Chi class for 16 weeks The TaiChi group showed less falls than the control group and thehazard ratios of falls for the Tai Chi group were 072 and 067at 16 weeks and 24 weeks respectively

Tai Chi and conventional balance training appear tohave similar effects in falls prevention Huang and colleagues[45] assigned 163 older adults to three interventions groups(education Tai Chi and education plus Tai Chi) and onecontrol group Over a five-month intervention the educationplus Tai Chi group showed a significant reduction in fallsand the risk factors of falls After a one-year follow upparticipants who were receiving any one of the interventionsshowed a reduction in falls compared with the control groupIn a recent study Tousignant and colleagues [46] randomlyassigned 152 elderly subjects to a 15-week Tai Chi exerciseor conventional physical therapy and the results showed thatboth interventions were effective in falls prevention but TaiChi showed a better protective effect compared with physicaltherapy In a recent randomized trial [47] 684 community-dwelling older adults were assigned to 3 groups Tai Chi oncea week Tai Chi twice a week or a low-level exercise programcontrol group for 20weeks Over the 17-month period therate of falls reduced similarly among the 3 groups (meanreduction of 58)The results implied thatmultiple interven-tions could be used to prevent falls among older adults

Although many studies have reported favorable effects ofTai Chi on balance and falls prevention some studies did notfind positive evidence Woo and colleagues [48] randomized90 men and 90 women into 3 groups (Tai Chi resistancetraining and control) and found no significant changes inbalance muscle strength and flexibility for either exercisegroup compared with controls Logghe and colleagues [49]applied Tai Chi to 269 community-dwelling elderly peoplewith a high risk of fallingThe intervention group received TaiChi training one hour twice weekly for 13 weeks the controlgroup received usual care After 12 months the Tai Chi groupdid not display lower risk of falls than the control group

A meta-analysis including 9 trials (2203 participants)reported that Tai Chi participants had significant improve-ments in fall rates (2 trials included) and static balance (2trials included) compared with exercise controls [50] Com-pared with nonexercise controls however no improvementwas found for Tai Chi participants in fall rates (5 trials)or static balance (2 trials) but a significant improvementwas found for fear of falling In a recent meta-analysisLeung and colleagues [51] reported that Tai Chi was effectivein improving balance of older adults but it may not besuperior to other interventions Although many Tai Chistudies reported positive effects on balance function the


training protocols varied among these studies In futurestudies large randomized trials using a standardized Tai Chiprogram are required to prove the effect of falls prevention

34 Self-Report Physical Function and Quality of Life OlderTai Chi participants report higher physical function thantheir sedentary counterparts Li and colleagues [11] randomlyassigned 94 elderly subjects to either a 6-month Tai Chi group(60min exercise twice weekly) or a wait-list control groupAfter training the Tai Chi group experienced significantimprovements in all aspects of physical functioning The TaiChi group showed improvement in all 6 functional statusmeasures ranging from daily activities such as walking andlifting to moderate-vigorous activities such as running Theresults showed that Tai Chi might improve self-reportedphysical functioning limitations among physically inactiveolder individuals In the Atlanta subgroup of the clinical trialof FICSIT [52] elderly subjects were randomly assigned tothree groups (Tai Chi balance training or exercise educa-tion) After 4 months of training only Tai Chi participantsreported improvement in daily activities and overall life

Tai Chi exercise programs can slow down the decline inhealth-related quality of life (ADL) among elderly personsDechamps and colleagues [53] randomly assigned 160 insti-tutionalized elderly persons to a Tai Chi program (30min 4timeswk) a cognition-action program (30ndash45min 2 timeswk) or a usual-care control group After 12 months the TaiChi and cognition-action groups showed a lesser decline inADL than the control group Walking ability and continencewere maintained better in the intervention groups than inthe control group The total Neuropsychiatric Inventoryscore worsened significantly in the control group while itwas unchanged or improved in the intervention groups

35 Psychological Well-Being Jin [54] reported that Tai Chipractitioners had increased noradrenaline excretion in urineand decreased salivary cortisol concentrationThe increase inurine noradrenaline indicated that the sympathetic nervoussystem is moderately activated during the Tai Chi practiceThe decrease in salivary cortisol concentration denoted thatTai Chi is a low-intensity exercise and has similar effects ofmeditationThe results implied that Tai Chi could reduce ten-sion depression and anxiety and the stress-reduction effectof Tai Chi was similar to walking at speed of 6 kmhr [55] Itis also reported that a 16-week Tai Chi program could reducemooddisturbance and improve generalmood inwomen [56]For subjects with cardiovascular risk factors Taylor-Piliaeand colleagues [57] have reported that a 60-minute Tai Chiclass 3 times weekly for 12 weeks might improve mood statereduction in anxiety anger-tension and perceived stress

Wang and colleagues [58] reviewed the effect of Tai Chion psychological profile in 40 studies including 3817 subjectsTwenty-one of 33 randomized and nonrandomized trialsreported that regular practice of Tai Chi improved psycho-logical well-being including reduction of stress anxiety anddepression and enhanced mood Seven observational studiesalso demonstrated beneficial effects on psychological healthJimenez and colleagues [59] reviewed 35 Tai Chi interventionarticles in various populations and reported that Tai Chi

might provide health benefits to psychological functionIn those studies 9 out of 11 studies confirmed significantimprovements in mood and depressive symptoms 7 out of8 studies showed reduction in anger and tension and 6 out of10 studies displayed improvements in anxiety reduction

Tai Chi can be applied in patients with depression In arecent study Yeung and colleagues [60] randomly assigned 39patients with major depressive disorders to a 12-week Tai Chiintervention or a wait-list control group Compared with thecontrol group the results showed trends toward improvementin positive treatment-response rate and remission rate in theTai Chi group

4 Application of Tai Chi in Medicine

An optimal exercise program for adults should address thehealth-related physical fitness components of cardiorespira-tory (aerobic) fitness muscular strength and endurance flex-ibility body composition and neuromotor fitness [61] Previ-ous research suggests that Tai Chimay improve health-relatedfitness and psychosocial function Additionally Tai Chiincludes the warm-up and cool-down stretching exercisesand gradual progression of volume and intensity and it seemsto be helpful to reduce muscular injury and complicationsThe discussion below will focus on the clinical application inpatientswith neurological diseases rheumatological diseasesorthopedic diseases cardiopumonary diseases and cancers

5 Tai Chi for Neurological Disease

51 Stroke It is estimated that 15 million people experiencea stroke worldwide each year In the United States about795000 people experience a new or a recurrent stroke(ischemic or hemorrhagic) each year [62] Stroke results ina significant decrease in quality of life which is determinednot only by the neurological deficits but also by impairmentof cognitive function In a recent meta-analysis Stoller andcolleagues [63] reported that stroke patients benefited fromexercise by improving peak oxygen uptake and walkingdistance Stroke patients usually have impaired balance andmotor function thus Tai Chi exercise may have potentialbenefits in stroke rehabilitation

Hart and colleagues [64] assigned 18 community-dwell-ing stroke patients to a Tai Chi group or a control group Thestudy group practiced Tai Chi one hour twice weekly for12 weeks while the control group received conventionalphysical therapy After training the Tai Chi group showedimprovement in social and general functioning whereas thecontrol group showed improvement in balance and speed ofwalking The results implied that physical therapy should beserved as a main treatment program for stroke patients butTai Chi can be used as an alternative exercise program

Balance and motor skills in everyday life may benefitwhen stroke survivors do Tai Chi exercises Au-Yeung andcolleagues [65] randomly assigned 136 stroke patients to a TaiChi group or a control group practicing general exercisesTheTai Chi group practiced 12 short forms of Tai Chi for 12 weeksAfter training the Tai Chi group showed greater excursionin the center of gravity (COG) amplitude in leaning forward


backward and toward the affected and nonaffected sides aswell as faster reaction time in moving the COG toward thenonaffected side The result indicated that Tai Chi trainingimproved standing balance in patients with stroke

Tai Chi also shows benefits to the psychological functionWang and colleagues [66] randomly assigned 34 patients withstroke to Tai Chi exercise or conventional rehabilitation ingroup sessions once a week for 12 weeks After training theTai Chi group had improvement for sleep quality generalhealth score anxietyinsomnia score and depression scoreIn a recent study Taylor-Piliae and Coull [67] recruited28 stroke patients to participate in a community-basedYang Tai Chi training program Patients practiced Tai Chige150minutesweek for 12 weeks The results showed goodsatisfaction and the adherence rates were high (ge92)Therewere no falls or other adverse events in the training periodTai Chi appears to be safe and can be considered as acommunity-based exercise program for stroke patients

52 Parkinsonrsquos Disease Impaired mobility is commonamong patients with Parkinsonrsquos disease (PD) Normal senso-rimotor agility and dynamic control are required to maintainbalance during motor and cognitive tasks Gait changesinclude difficulty in initiating steps shuffling and freezingof gait and they are common in patients with PD Balancedifficulties are also prominent during turning and backwardwalking and thus patients with PD have high risk of falls[68] Tai Chi can improve balance kinesthetic sense andstrength and hence it may be prescribed as a sensorimotoragility program for patients with PD

Li and colleagues [69] designed a Tai Chi programfor 17 community-dwelling patients with mild-to-moderateidiopathic PD Patients participated in a 5-day 90mindaytraining program At the end of this intervention the pro-gram was well received by all participants with respect toparticipant satisfaction enjoyment and intentions to con-tinue Furthermore a significant improvement was observedin 50 ft speed walk timed up-and-go and functional reachThe results of this pilot study suggested that even a 5-day TaiChi programwas effective for improving physical function inpatients with PD

In another study [70] 33 patients with PDwere randomlyassigned to a Tai Chi group or a control group The Tai Chigroup participated in 20 training sessions within 10ndash13weeks After training the Tai Chi group improved more thanthe control group on the Berg Balance Scale the UnifiedParkinsonrsquos Disease Rating Scale the timed up-and-go thetandem stance test the 6-minute walk and the backwardwalking In a recent study Li and colleagues [71] randomlyassigned 195 patients with PD to one of three groups Tai Chiresistance training or stretching All patients participatedin 60-minute exercise sessions twice weekly for 24 weeksAfter training the Tai Chi group performed better than theother two groups in maximum excursion and in directionalcontrol The Tai Chi group also performed better in strengthfunctional reach timed up-and-go motor scores andnumber of falls than the stretching group Additionally theTai Chi group outperformed the resistance-training group instride length and functional reach This study revealed that

Tai Chi could reduce balance impairments in patients withPD with improved functional capacity and reduced falls TaiChi appears to be a safe and effective exercise for patientswith mild-to-moderate PD

53 Traumatic Brain Injury Traumatic brain injury (TBI) isa common disease in the young male population Howeverthe outcome is disappointing in severely injured patientsExercise therapy for patientswithTBImay improve themotorfunction and independence

Shapira and colleagues [72] reported the application oflong-term Tai Chi training in 3 patients with severe TBIAfter 2 to 4 years of training all patients can walk withoutassistance rarely fall and feelmore securewhilewalkingOnepatient can lead independent daily activities and even returnto car driving

To explore the effects of short-term Tai Chi training inpatients with TBI Gemmell and Leathem [73] assigned 18patients with TBI to a Tai Chi group (a 6-week course) ora control group The results showed that Tai Chi was asso-ciated with significant improvement on all Visual AnalogueMood Scales scores with decreases in sadness confusionanger tension and fear and with increases in energy andhappiness However therewere no significant between-groupdifferences in the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36) and Rosenberg Self-EsteemScale Recently Blake and Batson [74] examined the effectsof a short-term (eight weeks) Tai Chi Qigong program on 20patients with TBI Intervention participants attended a TaiChi Qigong program for one hour per week while controlparticipants engaged in nonexercise-based social and leisureactivities After the intervention mood and self-esteem wereimproved in the Tai Chi group when compared with controlsThere were no significant differences in physical functioningbetween groups

54 Multiple Sclerosis Husted and colleagues [75] reportedthat 19 patients with multiple sclerosis participated in an8-week Tai Chi program After training walking speedincreased in 21 and hamstring flexibility increased in 28The results may be attributed to the effect of neuromuscularfacilitation during Tai Chi practice

6 Tai Chi for Rheumatological Disease

There are more than 21 of adults in the United Statesliving with rheumatological diseases conditions that affectthe joints and bones and cause chronic joint pain swellingand stiffness [76] Studies have shown that patients withrheumatological diseases can benefit from Tai Chi exerciseAlthough Tai Chi is performed in a semisquat posture jointpain can be prevented because most motions of Tai Chi areperformed in a closed kinematic chain and in very slow speed[20] However patients with arthropathy should performTai Chi in high-squat posture to prevent excessive stress onlower extremities In a recent review Tai Chi may modulatecomplex factors and improve health outcomes in patientswith rheumatologic conditions Tai Chi can be recommendedto patients with rheumatoid arthritis osteoarthritis and


fibromyalgia as an alternative approach to improve patientrsquoswell-being [77]

61 Rheumatoid Arthritis Rheumatoid arthritis (RA) is achronic inflammatory and systemic disease which affectsthe musculoskeletal system In a Cochrane database systemicreview including 4 trials and 206 patients with RA [78] TaiChi does not exacerbate symptoms of RA In addition Tai Chihas significant benefits to lower extremity range ofmotion forpatients with RA

Recently two studies reported the benefits of Tai Chi forpatients with RA Wang [79] randomly assigned 20 patientswith functional class I or II RA to Tai Chi or attention controlgroup After 12 weeks of training half of patients in the TaiChi group achieved a 20 response of the American Collegeof Rheumatology but no patient in the control group showedimprovementThe Tai Chi group had greater improvement inthe disability index the vitality subscale of the SF-36 and thedepression index Similar trends to improvement for diseaseactivity functional capacity and health-related quality of lifewere also observed In another study [80] 15 patients withRA were instructed on Tai Chi exercise twice weekly for 12weeks The result showed that the Tai Chi group improvedlower-limb muscle function at the end of the training andat 12 weeks of follow up Patients also experienced improvedphysical condition confidence in moving balance and lesspain during exercise and in daily life Others experiencedstress reduction increased body awareness and confidencein movingThese studies indicated that Tai Chi was a feasibleexercise modality for patients with RA

62 Ankylosing Spondylitis Ankylosing spondylitis (AS) isa chronic inflammatory disease of the axial skeleton withvariable involvement of peripheral joints and nonarticularstructures In a recent study [81] Lee and colleagues assigned40 patients with AS to Tai Chi or control group The Tai Chigroup performed 60min of Tai Chi twice weekly for eightweeks followed by 8 weeks of home-based Tai Chi Aftertraining the Tai Chi group showed significant improvementin disease activity and flexibility compared with the controlgroup and no adverse effects associated with the practice ofTai Chi were reported by the participants

63 Fibromyalgia Fibromyalgia syndrome is a chronic con-dition characterized by widespread pain multiple tenderpoints nonrestorative sleep fatigue cognitive dysfunctioncomplex somatic symptoms and poor quality of life [82]Exercise showed some benefits in the treatment of patientswith fibromyalgia An important study of Tai Chi on fibromy-algia was reported by Wang and colleagues [83] In this trial66 patients with fibromyalgia were randomly assigned to aTai Chi group or a group that attended wellness educationand stretching program Each session lasted for 60minutestwice weekly for 12 weeks After training the Tai Chigroup displayed improvements in the Fibromyalgia ImpactQuestionnaire (FIQ) total score and SF-36 The SF-36 phys-ical component scores and mental component scores weresignificantly improved comparedwith the control groupThis

study proved that patients with fibromyalgia benefited fromTai Chi training with no adverse effects

Jones and colleagues [84] conducted a randomized con-trolled trial and assigned 101 patients with fibromyalgiato Tai Chi or education group The Tai Chi participantspracticed modified 8-form Yang-style Tai Chi 90 minutestwice weekly for over 12 weeks After training the Tai Chigroup demonstrated significant improvements in FIQ scorespain severity pain interference sleep and self-efficacy forpain control compared with the education group Functionalmobility variables including timed up-and-go static balanceand dynamic balance were also improved in the Tai Chigroup Tai Chi appears to be a safe and acceptable exercisemodality for patients with fibromyalgia

In a recent study Romero-Zurita and colleagues [85]reported the effects of Tai Chi training in women with fibro-myalgia Thirty-two women with fibromyalgia attended TaiChi intervention 3 sessions weekly for 28 weeks After train-ing patients improved in pain threshold total number oftender points and algometer score Patients also showedimprovement in the 6min walk back scratching handgripstrength chair stand chair sit amp reach 8-feet up-and-goand blind flamingo tests Additionally the Tai Chi groupimproved in the total score and six subscales of FIQ stiffnesspain fatigue morning tiredness anxiety and depressionFinally patients also showed improvement in six subscalesin SF-36 bodily pain vitality physical functioning physicalrole general health and mental health

7 Tai Chi for Orthopedic Disease

71 Osteoarthritis Patients with osteoarthritis (OA) showbenefits from 6ndash20 weeks of Tai Chi training The first ran-domized trial of Tai Chi and osteoarthritis was conducted byHartman and colleagues [86] In this study 33 older patientswith lower extremity OA were assigned to Tai Chi or controlgroup Tai Chi training included two 1-hour Tai Chi classesper week for 12 weeks After training Tai Chi participantsexperienced significant improvements in self-efficacy forarthritis symptoms total arthritis self-efficacy level of ten-sion and satisfaction with general health status

Song and colleagues [87] randomly assigned 72 patientswith OA to a Tai Chi group or a control group The TaiChi group practiced Sun-style Tai Chi for 12 weeks Aftertraining the Tai Chi group perceived significantly less jointpain and stiffness and reported fewer perceived difficultiesin physical functioning while the control group showed nochange or even deterioration in physical functioningThe TaiChi group also displayed significant improvement in balanceand abdominal muscle strength In a subsequent study Songand colleagues [88] reported that Tai Chi could improve kneeextensor endurance bone mineral density in the neck of theproximal femur Wardrsquos triangle and trochanter and reducefear of falling in women with OA

Brismee and colleagues [89] reported a randomizedcontrolled trial including 41 elderly patients withOA Patientswere assigned to a Tai Chi or an attention control groupThe Tai Chi group participated in six-week Tai Chi sessions40minsession three times a week followed by another six


weeks of home-based Tai Chi training and then a six-weekfollow up detraining period Subjects in the attention controlgroup attended six weeks of health lectures followed by 12weeks of no activity After six weeks of training the Tai Chigroup showed significant improvements in overall knee painmaximumknee pain and theWesternOntario andMcMasterUniversities Osteoarthritis Index (WOMAC) subscales ofphysical function and stiffness compared with the baselineThe Tai Chi group reported lower overall pain and betterWOMAC physical function than the attention control groupbut all improvements disappeared after detrainingThe resultimplies that a short-term Tai Chi program is beneficialfor patients with OA but long-term practice is needed tomaintain the therapeutic effect

Fransen and colleagues [90] randomly assigned 152 olderpersons with chronic hip or knee OA to hydrotherapy classesTai Chi classes or a wait-list control group After 12 weeks oftraining both the hydrotherapy group and the Tai Chi groupdemonstrated improvements for pain and physical functionscores and achieved improvements in the 12-Item Short FromHealth Survey (SF-12) physical component summary scoreThis study revealed that Tai Chi and hydrotherapy can pro-vide similar benefits to patients with chronic hip or knee OA

In a randomized controlled trial conducted by Wang andcolleagues [91] 40 patients with OA were assigned to TaiChi group or attention control group The Tai Chi grouppracticed 10 modified Yang Tai Chi postures twice weeklyfor 12 weeks After training the Tai Chi group significantlyimproved in WOMAC pain WOMAC physical functionpatient and physician global visual analog scale chair standtime Center for Epidemiologic Studies Depression Scaleself-efficacy score and SF-36 physical component summaryThe result showed that Tai Chi reduces pain and improvesphysical function self-efficacy depression and health-relatedquality of life for patients with knee OA

In a recent randomized controlled study [92] 58 commu-nity-dwelling elderly patients with knee OA and cognitiveimpairment were assigned to a Tai Chi (20-week program)or a control group After training the Tai Chi group showedsignificant improvement inWOMACpain physical functionand stiffness score than the control group The result showedthat practicing Tai Chi was effective in reducing pain andstiffness in patients with knee OA and cognitive impairment

Tai Chi is also beneficial to gait kinematics for the elderlywith knee OA Shen and colleagues [93] applied Tai Chi on40 patients with knee OA Patients participated in 6-week TaiChi training (1 hoursession 2 sessionsweek) After 6 weeksof Tai Chi exercise patientrsquos stride length stride frequencyand gait speedwere significantly increased and knee painwasdecreased

72 Osteoporosis Osteoporosis is the most common meta-bolic bone disorder and it is estimated that 44 millionindividuals in the United States over the age of 50 years haveosteoporosis or low bone mass [94] Exercise is an effectivetherapy to prevent or delay the development of osteoporosisQin and colleagues [95] reported that Tai Chi participantshad significantly higher bone mineral density (BMD) thanthe controls in the lumbar spine the proximal femur and

the ultradistal tibia The follow up measurements showedgeneralized bone loss in both groups but the quantitativecomputed tomography revealed significantly reduced rate ofbone loss in trabecular BMD of the ultradistal tibia and of thecortical BMD of the distal tibial diaphysis In a subsequentstudy Chan and colleagues [96] randomly assigned 132healthy postmenopausal women to Tai Chi or sedentary con-trol group The Tai Chi group practiced Tai Chi 45minutes aday 5 days a week for 12 months At 12 months of trainingBMDmeasurements revealed a general bone loss in both TaiChi and control subjects at lumbar spine proximal femur anddistal tibia but with a slower rate in the Tai Chi group Asignificant 26- to 36-fold retardation of bone loss was foundin both trabecular and cortical compartments of the distaltibia in the Tai Chi group as compared with the controls

In a recent trial Wayne and colleagues [97] reportedthe application of Tai Chi in 86 postmenopausal osteopenicwomen aging 45ndash70 years Women were assigned to either9 months of Tai Chi training plus usual care or usual carealone Protocol analyses of femoral neck BMD changes weresignificantly different between Tai Chi and usual care-groupChanges in bone formation markers and physical domains ofquality of life were more favorable in the Tai Chi group

73 Low-Back Pain Chronic low-back pain (LBP) is preva-lent in the general population and exercise therapy is amongthe effective interventions showing small-to-moderate effectsfor patients with LBP In a recent randomized trial [98] 160volunteers with chronic LBP were assigned either to a TaiChi group or to a wait-list control group The Tai Chi groupparticipated in 18 training sessions (40minutes per sessionover a 10-week period) and the wait-list control group con-tinuedwith usual healthcare After training theTaiChi groupreduced bothersomeness of back symptoms by 17 points on a0ndash10 scale reduced pain intensity by 13 points on a 0ndash10 scaleand improved self-report disability by 26 points on the 0ndash24 Roland-Morris Disability Questionnaire scaleThough theimprovements weremodest andmost of the patients were notldquocompletely recoveredrdquo the results showed that a 10-week TaiChi program provides benefits for pain reduction consideredclinically worthwhile for those experiencing chronic LBP

74 Musculoskeletal Disorder Musculoskeletal disorder is aleading cause of work disability and productivity losses inindustrialized nations Tai Chi can be used as a simpleconvenient workplace intervention that may promote mus-culoskeletal health without special equipment A recent studyapplied Tai Chi to female computer users [99] and 52 subjectsparticipated in a 50-minute Tai Chi class per week for 12weeks The results showed significant improvement in heartrate waist circumference and hand-grip strength It impliedthat Tai Chi was effective in improving musculoskeletalfitness

In chronic muscular pain such as tension headache TaiChi also shows some benefits Abbott and colleagues [100]randomly assigned 47 patients with tension headache toeither a 15-week Tai Chi program or a wait-list control groupThe SF-36 and headache status were obtained at baseline andat 5 10 and 15 weeks during the intervention period After


training the results revealed significant improvements infavor of Tai Chi intervention for the headache status score andthe subsets of health-related quality of life including painenergyfatigue social functioning emotional well-being andmental health summary scores

8 Tai Chi for Cardiovascular Disease

In the United States the relative rate of death attributable tocardiovascular disease (CVD) declined by 327 from 1999 to2009 however CVD still accounted for 323 of all deaths in2009 [62] Exercise training is the core component of cardiacrehabilitation (CR) for patients with coronary heart disease(CHD) Tai Chi may be used in CR programs because itsexercise intensity is low to moderate and it can be easilyimplemented in communities In a recent study Taylor-Piliaeand colleagues [101] reported a study that included 51 cardiacpatients who participated in an outpatient CR programPatients were assigned to attend a group practicing Tai Chiplus CR or a group to attend CR only After rehabilitationsubjects attending Tai Chi plus CR had better balanceperceived physical health and Tai Chi self-efficacy comparedwith those attending CR only

81 Cardiovascular Risk Factors

811 Hypertension Hypertension is the most prevalent formof CVD affecting approximately 1 billion patients worldwideIn the United States about one in three adults has hyperten-sion [62] Hypertension is a major risk factor for coronaryartery disease heart failure stroke and peripheral vasculardisease Regular exercise and lifestyle change are the core ofcurrent recommendations for prevention and treatment ofhypertension Systemic review of randomized clinical trialsindicated that aerobic exercise significantly reduced BP andthe reduction appears to bemore pronounced in hypertensivesubjects [102 103]

Previous studies have shown that 6- to 12-week TaiChi training programs might decrease systolic and dias-tolic BP at rest or after exercise and hypertensive patientsexhibit the most favorable improvement [104ndash108] In arecent systemic review Yeh and colleagues [109] analyzed26 studies and found positive effect of Tai Chi on bloodpressure In patients with hypertension studies showed thatTai Chi training might decrease systolic BP (range minus7 tominus32mmHg) and diastolic BP (minus24 tominus18mmHg) In studiesfor noncardiovascular populations or healthy patients thedecreases ranged from minus4 to minus18mmHg in systolic BP andfrom minus23 to minus75mmHg in diastolic BP For patients withacute myocardial infarction (AMI) both Tai Chi and aerobicexercisewere associatedwith significant reductions in systolicBP but diastolic BP was decreased in the Tai Chi group only

812 Diabetes Mellitus Diabetes mellitus is a fast growingrisk factor for cardiovascular disease Estimated 197 millionAmerican adults have diabetes and the prevalence of pre-diabetes in the US adult population is 38 [62] Previousstudies have shown that exercise has benefits for those whohave diabetes or impaired glucose tolerance [110ndash112] In the

Da Qing Diabetes Prevention Study [113] for people withimpaired glucose tolerance lifestyle intervention groups (dietand exercise) displayed a 43 lower incidence of diabetesthan the control group over the 20-year follow up period

Several studies have shown the benefits of Tai Chi fordiabetic patients In a pilot study for 12 patients with diabetesWang [114] reported that an 8-week Tai Chi program coulddecrease blood glucose Additionally high- and low-affinityinsulin receptor numbers and low-affinity insulin receptor-binding capacity were increased For obese diabetic patientsChen and colleagues reported that 12 weeks of Chen TaiChi training induced significant improvement in body massindex triglyceride (TG) andhigh-density lipoprotein choles-terol (HDL-C) [115] In addition serum malondialdehyde(oxidative stress indicator) and C-reactive protein (inflam-mation indicator) decreased significantly

In diabetic patients complicatedwith peripheral neuropa-thy Ahn and Song reported that Tai Chi training one hourtwice per week for 12 weeks improved glucose control bal-ance neuropathic symptoms and somedimensions of qualityof life [116] A recent study reported that a 12-week Tai Chiprogram for diabetic patients obtained significant benefits inquality of life [117] After training the Tai Chi group revealedsignificant improvements in the SF-36 subscales of physicalfunctioning role physical bodily pain and vitality

813 Dyslipidemia Dyslipidemia or abnormalities in bloodlipid and lipoprotein is a major risk factor of cardiovasculardisease In theUnited States 260of adults hadhypercholes-terolemia during the period from 1999 to 2006 and approx-imately 27 of adults had a triglyceride level ge150mgdLduring 2007 to 2010 [62] The prevalence of dyslipidemiaincreases with age and westernized lifestyle but regularexercise may ameliorate the trend toward abnormal bloodlipid profile A meta-analysis of 31 randomized controlledtrials with exercise training reported a significant decreasein total cholesterol (TC) low-density lipoprotein cholesterol(LDL-C) and triglyceride and an increase in HDL-C [118]

Tsai and colleagues [107] randomly assigned 88 patients toTai Chi or sedentary control group After 12 weeks of classicalYang Tai Chi training TC TG and LDL-C decreased by 152238 and 197mgdL respectively and HDL-C increased by47mgdL By contrastThomas and colleagues [119] reportedno significant change in TC TG LDL-C and HDL-C after12 months of Tai Chi training This may be attributed todifferences in baseline lipid concentrations training amountand intensity changes in body composition or the adjunctiveinterventions such as diet or lipid-lowering agents

In a recent study Lan and colleagues [120] assigned 70dyslipidemic patients to a 12-month Yang Tai Chi traininggroup or the usual-care group After training the Tai Chigroup showed a significant decrease of 263 in TG (from2245 plusmn 2165 to 1659 plusmn 1478mgdL) 73 in TC (from2280 plusmn 410 to 2114 plusmn 465mgdL) and 119 in LDL-C(from 1343 plusmn 403 to 1183 plusmn 413mgdL) whereas the HDL-C did not increase significantly In addition the Tai Chigroup also showed a significant decrease in fasting insulinand a decrease in homeostasis model assessment of insulin


TG CHOL LDL HDL HOMA Insulin

Chan

ge (

)

Tai ChiUsual care

5

15

25

minus5

minus15

minus25

minus35

VO2peak

Figure 4 Changes of peak VO2and cardiovascular risk factors after

1 year of training in patients with dyslipidemia (Tai Chi group versususual-care group)

resistance (HOMA) index which is suggestive of improvedinsulin resistance (Figure 4)

82 Acute Myocardial Infarction Acute myocardial infarc-tion is the most common cause of mortality in patients withcardiovascular disease but exercise can significantly reducethe mortality rate in patients with AMI A recent Cochranereview [121] involved in 47 studies randomizing 10794patients with AMI to exercise-based cardiac rehabilitation orusual care Patients receiving exercise training reduced a 13of risk for total mortality a 26 of risk for cardiovascularmortality and a 31 of risk for hospital admissions Channerand colleagues [104] randomized 126 patients withAMI toTaiChi aerobic exercise or nonexercise support group The TaiChi and the aerobic exercise group participated in an 8-weektraining program attended twice weekly for three weeks andthen once weekly for five weeksThe results displayed that TaiChi was effective for reducing systolic and diastolic BP andthat it was safe for patients after AMI

83 Coronary Artery Bypass Grafting Lan and colleagues[122] assigned 20 patients after coronary artery bypass graft-ing surgery (CABG) to classical Yang Tai Chi program ormaintenance home exercise After 12 months of training theTai Chi group showed significant improvements of oxygenuptake at the peak exercise and the ventilatory threshold Atthe peak exercise the Tai Chi group showed 103 increase inVO2 while the control group did not show any improvement

Furthermore the Tai Chi group increased 176 in VO2at the

ventilatory threshold while the control group did not displaysignificant change The result showed that Tai Chi was safeand had benefits in improving functional capacity for patientsafter CABG

84 Congestive Heart Failure Congestive heart failure (CHF)is characterized by the inability of the heart to deliversufficient oxygenated blood to tissue CHF results in abnor-malities in skeletal muscle metabolism neurohormonalresponses vascular and pulmonary functions In 2009 heart

failure was the underlying cause in 56410 of those deaths inthe United States [62] Exercise training improves functionalcapacity and symptoms in patientswithCHF and the increasein exercise tolerance may be attributed to increased skeletalmuscle oxidative enzymes and mitochondrial density Previ-ous studies have shown that low-intensity Tai Chi trainingbenefited patients with CHF [123ndash128] In a study by Barrowand colleagues [123] 52 patients with CHF were randomizedto Tai Chi or standard medical care groupThe Tai Chi grouppracticedTai Chi twice aweek for 16weeks After training theTai Chi group did not show significant increase in exercisetolerance but they had improvement in symptom scores ofheart failure and depression scores comparedwith the controlgroup Yeh and colleagues [124 125] also reported that a12-week Tai Chi training in patients with CHF improvedquality of life sleep quality and 6-minute walking distanceand decreased serum B-type natriuretic peptide (BNP) BNPis produced by ventricular cardiomyocytes and is correlatedwith left ventricular dysfunction In a recent study Yeh andcolleagues [126] randomized 100 patients with systolic heartfailure into a Tai Chi group or a control group Tai Chi partic-ipants practiced 5 basic simplified Yang Tai Chi movementstwice weekly while the control group participated in an edu-cation program After 12 weeks of training the Tai Chi groupdisplayed greater improvements in quality of life exerciseself-efficacy and mood For patients with CHF low-intensityexercise such as simplified Tai Chi may increase the accep-tance Interval training protocol by using selected Tai Chimovements is suitable for patients with very low endurance

Tai Chi can combine endurance exercise to improvefunctional capacity Caminiti and colleagues [127] enrolled60 patients with CHF and randomized them into a combinedtraining group performing Tai Chi plus endurance trainingand an endurance training group After 12 weeks of training6-minute walking distance increased in both groups butthe combined training group showed more improvementthan the endurance training group Systolic BP and BNPdecreased in the combined training group compared withthe endurance training group Additionally the combinedtraining group had a greater improvement in physical per-ception and peak torque of knee extensor compared with theendurance training group

The left ventricle ejection fraction is found to be preservedin about half of all cases of heart failure Patients with heartfailure with preserved ejection fraction (HFPEF) appear tobe older and are more likely to be females have a historyof hypertension and have less coronary artery diseases[128] Yeh and colleagues [129] recently used Tai Chi inthe treatment of patients with HFPEF and 16 patients wererandomized into 12-week Tai Chi or aerobic exercise Changein VO

2peak was similar between groups but 6-minute walkingdistance increased more in the Tai Chi group Both groupshad improved Minnesota Living With Heart Failure scoresand self-efficacy but the Tai Chi group showed a decreasein depression scores in contrast to an increase in the aerobicexercise group In patients with HFPEF the Tai Chi groupdisplayed similar improvement as the aerobic exercise groupdespite a lower aerobic training workload


9 Tai Chi for Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is the fourthleading cause of mortality in the United States Patients withCOPD are at risk for low levels of physical activity leadingto increased morbidity and mortality [130] The effectivenessof exercise training in people with COPD is well establishedHowever alternativemethods of training such as Tai Chi havenot been widely evaluated

Chan and colleagues [131] have evaluated the effectivenessof a 3-month Tai Chi Qigong (TCQ) program in patients withCOPD 206 patients with COPD were randomly assignedto three groups (TCQ exercise and control) Patients inthe TCQ group participated in a TCQ program includingtwo 60-minute sessions each week for 3 months patientsin the exercise group practiced breathing exercise combinedwith walking After training the TCQ group showed greaterimprovements in the symptom and activity domains Inaddition the forced vital capacity forced expiratory volumein the first second walking distance and exacerbation ratewere improved in the TCQ group [132]

In a pilot study conducted by Yeh and colleagues [133] 10patients withmoderate-to-severe COPDwere randomized to12 weeks of Tai Chi plus usual care or usual care alone Aftertraining there was significant improvement in Chronic Res-piratory Questionnaire score in the Tai Chi group comparedwith the usual-care group There were nonsignificant trendstoward improvement in 6-minute walk distance depressionscale and shortness of breath score

In a recent study Leung and colleagues [134] examinedthe effect of short-form Sun-style Tai Chi training in peoplewith COPD Forty-two participants were randomly allocatedto Tai Chi or usual-care control group Participants in the TaiChi group trained twice weekly for 12 week and the exerciseintensity of Tai Chi was 53 plusmn 18 of oxygen uptake reserveCompared with the control Tai Chi significantly increasedendurance shuttle walk time reduced medial-lateral bodysway in semitandem stand and increased total score on theChronic Respiratory Disease Questionnaire

10 Tai Chi for Cancer

Cancer is a leading cause of death worldwide Exercisetherapy is a safe adjunct therapy that can mitigate commontreatment-related side effects among cancer patients [135]Additionally exercise has beneficial effects on certaindomains of health-related quality of life (QOL) includingphysical functioning role functioning social functioningand fatigue [136] Tai Chi has been reported to be beneficialfor physical emotional and neuropsychological functions inpatients with breast cancer [137ndash140] lung cancer [141] andgastric cancer [142]

In a recent randomized trial 21 breast cancer survivorswere assigned to Tai Chi or standard support therapy (con-trols) and patients in the exercise group practiced Tai Chithree times per week and 60 minutes per session for 12weeks [140] After training the Tai Chi group improved intotal QOL physical functioning physical role limitationssocial functioning and general mental health Tai Chi may

improve QOL by regulating inflammatory responses andother biomarkers associated with side effects from cancerand its treatments By contrast a recent meta-analysis didnot show convincing evidence that Tai Chi is effective forsupportive breast cancer care [143] Most Tai Chi studies arefocused onQOL of breast cancer survivors however the pos-itive resultsmust be interpreted cautiously becausemost trialssuffered from methodological flaws such as a small-samplesize and inadequate study design Further research involvinglarge number of participants is required to determine optimaleffects of Tai Chi exercise for cancer patients

11 Future Research of Tai Chi

The training effect of an exercise program depends on itsexercise mode intensity frequency and duration Althoughprevious studies have shown that Tai Chi has potential bene-fits most of the studies have limitations in study design suchas (1) a small-sample size (2) nonrandomized trials (3) lackof training intensity measurement and (4) significant differ-ences in training protocols In future research a randomizedcontrolled trial with standardized training protocol should beutilized according to the principles of exercise prescriptionTai Chi participants usually need 12 weeks of training tofamiliarize the movements During the familiarization phasethe exercise intensity and amount of training are inconsistentTherefore a suitable training program should take at least6 months of training Additionally heart rate monitoring inselected individuals is recommended to determine the exer-cise intensity of Tai Chi and the suitable duration of trainingis 40 to 60minutes including warm-up and cool-down

12 Conclusion

Tai Chi is a Chinese traditional conditioning exercise thatintegrated breathing exercise into body movements Thisliterature paper reveals that Tai Chi has benefits in healthpromotion and has potential role as an alternative therapyin neurological rheumatological orthopedic and cardiopul-monary diseasesThere are several reasons to recommendTaiChi as an exercise program for healthy people and patientswith chronic diseases First Tai Chi does not need specialfacility or expensive equipment and it can be practicedanytime and anywhere Second Tai Chi is effective in enhanc-ing aerobic capacity muscular strength and balance and inimproving cardiovascular risk factorsThird Tai Chi is a low-cost low- technology exercise and it can be easily imple-mented in the community It is concluded that Tai Chi iseffective in promoting health and it can be prescribed as analternative exercise program for patients with certain chronicdiseases

References

[1] China Sports Simplified ldquoTaijiquanrdquo ChinaPublicationsCenterBeijing China 2nd edition 1983

[2] C Lan S Y Chen J S Lai and M K Wong ldquoHeart rateresponses and oxygen consumption during Tai CM Chuan


practicerdquoAmerican Journal of ChineseMedicine vol 29 no 3-4pp 403ndash410 2001

[3] C E Garber B Blissmer M R Deschenes et al ldquoAmericanCollege of SportsMedicine position stand Quantity and qualityof exercise for developing and maintaining cardiorespiratorymusculoskeletal and neuromotor fitness in apparently healthyadults guidance for prescribing exerciserdquoMedicine and Sciencein Sports and Exercise vol 43 no 7 pp 1334ndash1359 2011

[4] C Lan S Y Chen and J S Lai ldquoRelative exercise intensity ofTai Chi Chuan is similar in different ages and genderrdquoAmericanJournal of Chinese Medicine vol 32 no 1 pp 151ndash160 2004

[5] G Wu and J Hitt ldquoGround contact characteristics of Tai Chigaitrdquo Gait and Posture vol 22 no 1 pp 32ndash39 2005

[6] G Wu and X Ren ldquoSpeed effect of selected Tai Chi Chuanmovement on leg muscle activity in young and old practition-ersrdquo Clinical Biomechanics vol 24 no 5 pp 415ndash421 2009

[7] G Wu W Liu J Hitt and D Millon ldquoSpatial temporal andmuscle action patterns of Tai Chi gaitrdquo Journal of Electromyog-raphy and Kinesiology vol 14 no 3 pp 343ndash354 2004

[8] J J OrsquoConnor ldquoCan muscle co-contraction protect knee liga-ments after injury or repairrdquo Journal of Bone and Joint SurgeryB vol 75 no 1 pp 41ndash48 1993

[9] G Wu ldquoAge-related differences in Tai Chi gait kinematics andleg muscle electromyography a pilot studyrdquoArchives of PhysicalMedicine and Rehabilitation vol 89 no 2 pp 351ndash357 2008

[10] G Wu and D Millon ldquoJoint kinetics during Tai Chi gaitand normal walking gait in young and elderly Tai Chi Chuanpractitionersrdquo Clinical Biomechanics vol 23 no 6 pp 787ndash7952008

[11] F Li P Harmer E McAuley et al ldquoAn evaluation of the effectsof Tai Chi exercise on physical function among older personsa randomized controlled trialrdquo Annals of Behavioral Medicinevol 23 no 2 pp 139ndash146 2001

[12] J Church S Goodall R Norman and M Haas ldquoAn economicevaluation of community and residential aged care falls preven-tion strategies in NSWrdquoNew SouthWales Public Health Bulletinvol 22 no 3-4 pp 60ndash68 2011

[13] J Myers M Prakash V Froelicher D Do S Partington andJ Edwin Atwood ldquoExercise capacity and mortality among menreferred for exercise testingrdquo New England Journal of Medicinevol 346 no 11 pp 793ndash801 2002

[14] C Lan J S Lai M K Wong and M L Yu ldquoCardiorespiratoryfunction flexibility and body composition among geriatric TaiChi Chuan practitionersrdquo Archives of Physical Medicine andRehabilitation vol 77 no 6 pp 612ndash616 1996

[15] C Lan S Y Chen and J S Lai ldquoChanges of aerobic capacityfat ratio and flexibility in older TCC practitioners a five-yearfollow-uprdquoAmerican Journal of Chinese Medicine vol 36 no 6pp 1041ndash1050 2008

[16] C Lan J S Lai S Y Chen andM KWong ldquo12-month Tai Chitraining in the elderly its effect on health fitnessrdquoMedicine andScience in Sports and Exercise vol 30 no 3 pp 345ndash351 1998

[17] R Taylor-Piliae ldquoThe effectiveness of Tai Chi exercise inimproving aerobic capacity an updated meta-analysisrdquo Medi-cine and Sport Science vol 52 pp 40ndash53 2008

[18] L Wolfson R Whipple C Derby et al ldquoBalance and strengthtraining in older adults intervention gains and Tai Chi mainte-nancerdquo Journal of the American Geriatrics Society vol 44 no 5pp 498ndash506 1996

[19] B H Jacobson H C Chen C Cashel and L Guerrero ldquoTheeffect of Trsquoai Chi Chuan training on balance kinesthetic sense

and strengthrdquo Perceptual and Motor Skills vol 84 no 1 pp 27ndash33 1997

[20] C Lan J S Lai S Y Chen andM KWong ldquoTai Chi Chuan toimprove muscular strength and endurance in elderly individu-als a pilot studyrdquo Archives of Physical Medicine and Rehabilita-tion vol 81 no 5 pp 604ndash607 2000

[21] GWu F ZhaoX Zhou andLWei ldquoImprovement of isokineticknee extensor strength and reduction of postural sway in theelderly from long-term Tai Chi exerciserdquo Archives of PhysicalMedicine and Rehabilitation vol 83 no 10 pp 1364ndash1369 2002

[22] G Wu ldquoMuscle action pattern and knee extensor strength ofolder Tai Chi exercisersrdquoMedicine and Sport Science vol 52 pp30ndash39 2008

[23] X Lu C W Hui-Chan and W W Tsang ldquoTai Chi arterialcompliance and muscle strength in older adultsrdquo EuropeanJournal of Preventive Cardiology vol 20 no 4 pp 613ndash619 2012

[24] J X Li D Q Xu and Y Hong ldquoChanges in muscle strengthendurance and reaction of the lower extremities with Tai Chiinterventionrdquo Journal of Biomechanics vol 42 no 8 pp 967ndash971 2009

[25] X Lu C W Hui-Chan and W W Tsang ldquoEffects of TaiChi training on arterial compliance and muscle strength infemale seniors a randomized clinical trialrdquo European Journalof Preventive Cardiolog vol 20 no 2 pp 238ndash245 2013

[26] L M Nashner ldquoEvaluation of postural stability movement andcontrolrdquo in Clinical Exercise Physiology S M Hasson Ed pp199ndash234 Mosby St Louis Mo USA 1994

[27] S M Fong and G Y Ng ldquoThe effects on sensorimotor perform-ance and balance with Tai Chi trainingrdquo Archives of PhysicalMedicine and Rehabilitation vol 87 no 1 pp 82ndash87 2006

[28] D W Mao J X Li and Y Hong ldquoThe duration and plantarpressure distribution during one-leg stance in Tai Chi exerciserdquoClinical Biomechanics vol 21 no 6 pp 640ndash645 2006

[29] Y C Lin A M Wong S W Chou F T Tang and P Y WongldquoThe effects of Tai Chi Chuan on postural stability in the elderlypreliminary reportrdquo Chang GungMedical Journal vol 23 no 4pp 197ndash204 2000

[30] W W Tsang V S Wong S N Fu and C W Hui-Chan ldquoTaiChi improves standing balance control under reduced or con-flicting sensory conditionsrdquo Archives of Physical Medicine andRehabilitation vol 85 no 1 pp 129ndash137 2004

[31] E W Chen A S N Fu K M Chan and W W N Tsang ldquoTheeffects of Tai Chi on the balance control of elderly persons withvisual impairment a randomised clinical trialrdquoAge and Ageingvol 41 no 2 pp 254ndash259 2012

[32] A M Wong Y C Lin S W Chou F T Tang and P Y WongldquoCoordination exercise and postural stability in elderly peopleeffect of Tai Chi Chuanrdquo Archives of Physical Medicine andRehabilitation vol 82 no 5 pp 608ndash612 2001

[33] W W N Tsang and C W Y Hui-Chan ldquoEffects of Tai Chion joint proprioception and stability limits in elderly subjectsrdquoMedicine and Science in Sports and Exercise vol 35 no 12 pp1962ndash1971 2003

[34] W W N Tsang and C W Y Hui-Chan ldquoEffects of exercise onjoint sense and balance in elderly men Tai Chi versus golfrdquoMedicine and Science in Sports and Exercise vol 36 no 4 pp658ndash667 2004

[35] D Xu Y Hong J Li and K Chan ldquoEffect of tai chi exercise onproprioception of ankle and knee joints in old peoplerdquo BritishJournal of Sports Medicine vol 38 no 1 pp 50ndash54 2004


[36] J C Kwok C W Hui-Chan andW W Tsang ldquoEffects of agingand Tai Chi on finger-pointing toward stationary and movingvisual targetsrdquo Archives of Physical Medicine and Rehabilitationvol 91 no 1 pp 149ndash155 2010

[37] W W Tsang and C W Hui-Chan ldquoStanding balance aftervestibular stimulation inTai Chimdashpracticing and nonpracticinghealthy older adultsrdquoArchives of Physical Medicine and Rehabil-itation vol 87 no 4 pp 546ndash553 2006

[38] T C Hain L Fuller L Weil and J Kotsias ldquoEffects of Trsquoai Chion balancerdquoArchives of Otolaryngology vol 125 no 11 pp 1191ndash1195 1999

[39] C A McGibbon D E Krebs S L Wolf P M Wayne DM Scarborough and S W Parker ldquoTai Chi and vestibularrehabilitation effects on gaze and whole-body stabilityrdquo Journalof Vestibular Research vol 14 no 6 pp 467ndash478 2004

[40] C A McGibbon D E Krebs S W Parker D M ScarboroughP M Wayne and S L Wolf ldquoTai Chi and vestibular rehabili-tation improve vestibulopathic gait via different neuromuscularmechanisms preliminary reportrdquoBMCNeurology vol 5 article3 2005

[41] J MacIaszek andWOsinski ldquoEffect of Tai Chi on body balancerandomized controlled trial in elderly men with dizzinessrdquoAmerican Journal of Chinese Medicine vol 40 no 2 pp 245ndash253 2012

[42] S LWolf H X Barnhart N G Kutner EMcNeely C Cooglerand T Xu ldquoReducing frailty and falls in older persons aninvestigation of Tai Chi and computerized balance trainingAtlanta FICSITGroup Frailty and Injuries Cooperative Studiesof Intervention Techniquesrdquo Journal of the American GeriatricsSociety vol 44 no 5 pp 489ndash497 1996

[43] F Li P Harmer K J Fisher et al ldquoTai Chi and fall reductionsin older adults a randomized controlled trialrdquo Journals ofGerontology A vol 60 no 2 pp 187ndash194 2005

[44] A Voukelatos R G Cumming S R Lord andC Rissel ldquoA ran-domized controlled trial of tai chi for the prevention of falls thecentral sydney tai chi trialrdquo Journal of the American GeriatricsSociety vol 55 no 8 pp 1185ndash1191 2007

[45] HCHuang C Y Liu Y THuang andWGKernohan ldquoCom-munity-based interventions to reduce falls among older adultsin Taiwanmdashlong time follow-up randomised controlled studyrdquoJournal of Clinical Nursing vol 19 no 7-8 pp 959ndash968 2010

[46] M TousignantH Corriveau PM Roy J Desrosiers NDubucand R Hebert ldquoEfficacy of supervised Tai Chi exercises versusconventional physical therapy exercises in fall prevention forfrail older adults a randomized controlled trialrdquo Disability andRehabilitation vol 35 no 17 pp 1429ndash1435 2013

[47] D Taylor L Hale P Schluter et al ldquoEffectiveness of Tai Chi as acommunity-based falls prevention intervention a randomizedcontrolled trialrdquo Journal of American Geriatric Society vol 60no 5 pp 841ndash848 2012

[48] JWoo AHong E Lau andH Lynn ldquoA randomised controlledtrial of Tai Chi and resistance exercise on bone health musclestrength and balance in community-living elderly peoplerdquo Ageand Ageing vol 36 no 3 pp 262ndash268 2007

[49] I H J Logghe P E M Zeeuwe A P Verhagen et al ldquoLack ofeffect of tai chi chuan in preventing falls in elderly people livingat home a randomized clinical trialrdquo Journal of the AmericanGeriatrics Society vol 57 no 1 pp 70ndash75 2009

[50] I H J Logghe A P Verhagen A C H J Rademaker et al ldquoTheeffects of Tai Chi on fall prevention fear of falling and balancein older people a meta-analysisrdquo Preventive Medicine vol 51no 3-4 pp 222ndash227 2010

[51] D P K Leung C K L Chan H W H Tsang W W N Tsangand A Y M Jones ldquoTai chi as an intervention to improvebalance and reduce falls in older adults a systematic and meta-analytical reviewrdquoAlternativeTherapies in Health andMedicinevol 17 no 1 pp 40ndash48 2011

[52] N G Kutner H Barnhart S L Wolf E McNeely and T XuldquoSelf-report benefits of TaiChi practice by older adultsrdquo Journalsof Gerontology B vol 52 no 5 pp P242ndashP246 1997

[53] A Dechamps P Diolez E Thiaudiere et al ldquoEffects of exerciseprograms to prevent decline in health-related quality of lifein highly deconditioned institutionalized elderly persons arandomized controlled trialrdquo Archives of Internal Medicine vol170 no 2 pp 162ndash169 2010

[54] P Jin ldquoChanges in heart rate noradrenaline cortisol and moodduring Tai Chirdquo Journal of Psychosomatic Research vol 33 no2 pp 197ndash206 1989

[55] P Jin ldquoEfficacy of Tai Chi brisk walking meditation andreading in reducing mental and emotional stressrdquo Journal ofPsychosomatic Research vol 36 no 4 pp 361ndash370 1992

[56] D R Brown Y Wang A Ward et al ldquoChronic psychologicaleffects of exercise and exercise plus cognitive strategiesrdquoMedi-cine and Science in Sports and Exercise vol 27 no 5 pp 765ndash775 1995

[57] R E Taylor-Piliae W L Haskell C M Waters and E S Froe-licher ldquoChange in perceived psychosocial status following a12-week Tai Chi exercise programmerdquo Journal of AdvancedNursing vol 54 no 3 pp 313ndash329 2006

[58] C Wang R Bannuru J Ramel B Kupelnick T Scott and CH Schmid ldquoTai Chi on psychological well-being systematicreview and meta-analysisrdquo BMC Complementary and Alterna-tive Medicine vol 10 article 23 2010

[59] P J Jimenez A Melendez and U Albers ldquoPsychological effectsof Tai Chi Chuanrdquo Archives of Gerontology and Geriatrics vol55 no 2 pp 460ndash467 2012

[60] A Yeung V Lepoutre P Wayne et al ldquoTai Chi treatmentfor depression in Chinese Americans a pilot studyrdquo AmericanJournal of Physical Medicine and Rehabilitation vol 91 no 10pp 863ndash870 2012

[61] American College of Sports Medicine Guidelines for ExerciseTesting and Prescription Lippincott Williams ampWilkins Balti-more Md USA 9th edition 2014

[62] A S Go D Mozaffarian and V L Roger ldquoHeart disease andstroke statisticsmdash2013 update a report from the AmericanHeart AssociationrdquoCirculation vol 127 no 1 pp e6ndashe245 2013

[63] O Stoller E D de Bruin R H Knols and K J Hunt ldquoEffects ofcardiovascular exercise early after stroke systematic review andmeta-analysisrdquo BMC Neurology vol 12 article 45 2012

[64] J Hart H Kanner R Gilboa-Mayo O Haroeh-Peer NRozenthul-Sorokin and R Eldar ldquoTai Chi Chuan practice incommunity-dwelling persons after strokerdquo International Jour-nal of Rehabilitation Research vol 27 no 4 pp 303ndash304 2004

[65] S S Y Au-Yeung C W Y Hui-Chan and J C S Tang ldquoShort-form tai chi improves standing balance of people with chronicstrokerdquoNeurorehabilitation and Neural Repair vol 23 no 5 pp515ndash522 2009

[66] W Wang M Sawada Y Noriyama et al ldquoTai Chi exercise ver-sus rehabilitation for the elderly with cerebral vascular disordera single-blinded randomized controlled trialrdquo Psychogeriatricsvol 10 no 3 pp 160ndash166 2010

[67] R E Taylor-Piliae and B M Coull ldquoCommunity-based Yang-style Tai Chi is safe and feasible in chronic stroke a pilot studyrdquoClinical Rehabilitation vol 26 no 2 pp 121ndash131 2012


[68] M E Morris ldquoLocomotor training in people with Parkinsondiseaserdquo Physical Therapy vol 86 no 10 pp 1426ndash1435 2006

[69] F Li P Harmer K J Fisher J Xu K Fitzgerald and N Vong-jaturapat ldquoTai Chi-based exercise for older adults with Parkin-sonrsquos disease a pilot-program evaluationrdquo Journal of Aging andPhysical Activity vol 15 no 2 pp 139ndash151 2007

[70] M E Hackney and G M Earhart ldquoTai Chi improves balanceand mobility in people with Parkinson diseaserdquo Gait and Pos-ture vol 28 no 3 pp 456ndash460 2008

[71] F Li P Harmer K Fitzgerald et al ldquoTai chi and postural stabili-ty in patients with Parkinsonrsquos diseaserdquo New England Journal ofMedicine vol 366 no 6 pp 511ndash519 2012

[72] M Y Shapira M Chelouche R Yanai C Kaner and A SzoldldquoTai Chi Chuan practice as a tool for rehabilitation of severehead trauma 3 Case reportsrdquo Archives of Physical Medicine andRehabilitation vol 82 no 9 pp 1283ndash1285 2001

[73] C Gemmell and J M Leathem ldquoA study investigating theeffects of Tai ChiChuan individuals with traumatic brain injurycompared to controlsrdquo Brain Injury vol 20 no 2 pp 151ndash1562006

[74] H Blake and M Batson ldquoExercise intervention in brain injurya pilot randomized study of Tai Chi Qigongrdquo Clinical Rehabili-tation vol 23 no 7 pp 589ndash598 2009

[75] C Husted L Pham A Hekking and R Niederman ldquoImprov-ing quality of life for people with chronic conditions theexample of Trsquoai chi andmultiple sclerosisrdquoAlternativeTherapiesin Health and Medicine vol 5 no 5 pp 70ndash74 1999

[76] R C Lawrence D T Felson C G Helmick et al ldquoEstimatesof the prevalence of arthritis and other rheumatic conditions intheUnited States Part IIrdquoArthritis and Rheumatism vol 58 no1 pp 26ndash35 2008

[77] C Wang ldquoRole of Tai Chi in the treatment of rheumatologicdiseasesrdquo Current Rheumatology Report vol 14 no 6 pp 598ndash603 2012

[78] A Han V Robinson M Judd W Taixiang G Wells and PTugwell ldquoTai chi for treating rheumatoid arthritisrdquo CochraneDatabase of Systematic Reviews no 3 Article ID CD0048492004

[79] C Wang ldquoTai Chi improves pain and functional status inadults with rheumatoid arthritis results of a pilot single-blindedrandomized controlled trialrdquo Medicine and Sport Science vol52 pp 218ndash229 2008

[80] T Uhlig C Fongen E Steen A Christie and S OslashdegardldquoExploring Tai Chi in rheumatoid arthritis a quantitative andqualitative studyrdquoBMCMusculoskeletal Disorders vol 11 article43 2010

[81] E N Lee Y H Kim W T Chung and M S Lee ldquoTai Chifor disease activity and flexibility in patients with ankylosingspondylitismdasha controlled clinical trialrdquo Evidence-Based Com-plementary and Alternative Medicine vol 5 no 4 pp 457ndash4622008

[82] A J Busch S CWebberM Brachaniec et al ldquoExercise therapyfor fibromyalgiardquo Current Pain and Headache Reports vol 15no 5 pp 358ndash367 2011

[83] C Wang C H Schmid R Rones et al ldquoA randomized trial oftai chi for fibromyalgiardquo New England Journal of Medicine vol363 no 8 pp 743ndash754 2010

[84] K D Jones C A Sherman S D Mist J W Carson R MBennett and F Li ldquoA randomized controlled trial of 8-form TaiChi improves symptoms and functional mobility in fibromy-algia patientsrdquo Clinical Rheumatology vol 31 no 8 pp 1205ndash1214 2012

[85] A Romero-Zurita A Carbonell-Baeza V A Aparicio J RRuiz P Tercedor and M Delgado-Fern119897ndez ldquoEffectiveness ofa tai-chi training and detraining on functional capacity symp-tomatology and psychological outcomes in women with fibro-myalgiardquo Evidence-Based Complementary and Alternative Med-icine vol 2012 Article ID 614196 9 pages 2012

[86] C A Hartman T M Manos C Winter D M Hartman BLi and J C Smith ldquoEffects of Trsquoai Chi training on functionand quality of life indicators in older adults with osteoarthritisrdquoJournal of the American Geriatrics Society vol 48 no 12 pp1553ndash1559 2000

[87] R Song E O Lee P Lam and S C Bae ldquoEffects of tai chi exer-cise on pain balancemuscle strength and perceived difficultiesin physical functioning in older women with osteoarthritis arandomized clinical trialrdquo Journal of Rheumatology vol 30 no9 pp 2039ndash2044 2003

[88] R Song B L Roberts E O Lee P Lam and S C Bae ldquoA ran-domized study of the effects of trsquoai chi on muscle strength bonemineral density and fear of falling in women with osteoarthri-tisrdquo Journal of Alternative and ComplementaryMedicine vol 16no 3 pp 227ndash233 2010

[89] J M Brismee R L Paige M C Chyu et al ldquoGroup andhome-based tai chi in elderly subjects with knee osteoarthritis arandomized controlled trialrdquo Clinical Rehabilitation vol 21 no2 pp 99ndash111 2007

[90] M Fransen L Nairn J Winstanley P Lam and J EdmondsldquoPhysical activity for osteoarthritis management a randomizedcontrolled clinical trial evaluating hydrotherapy or Tai Chiclassesrdquo Arthritis Care and Research vol 57 no 3 pp 407ndash4142007

[91] C Wang C H Schmid P L Hibberd et al ldquoTai Chi is effectivein treating knee osteoarthritis a randomized controlled trialrdquoArthritis Care and Research vol 61 no 11 pp 1545ndash1553 2009

[92] P F Tsai J Y Chang C Beck Y F Kuo and F J Keefe ldquoApilot cluster-randomized trial of a 20-Week Tai Chi programin elders with cognitive impairment and osteoarthritic kneeeffects on pain and other health outcomesrdquo Journal of PainSymptom Management vol 45 no 4 pp 660ndash669 2013

[93] C L Shen C R James M C Chyu et al ldquoEffects of tai chion gait kinematics physical function and pain in elderly withknee osteoarthritismdasha pilot studyrdquo American Journal of ChineseMedicine vol 36 no 2 pp 219ndash232 2008

[94] National Osteoporosis Foundation (NOF) Americarsquos BoneHealth The State of Osteoporosis and Low Bone Mass in OurNation National Osteoporosis Foundation Washington DCUSA 2002

[95] L Qin S Au W Choy et al ldquoRegular Tai Chi Chuan exercisemay retard bone loss in postmenopausal women a case-controlstudyrdquo Archives of Physical Medicine and Rehabilitation vol 83no 10 pp 1355ndash1359 2002

[96] K Chan L QinM Lau et al ldquoA randomized prospective studyof the effects of Tai Chi Chun exercise on bone mineral densityin postmenopausal womenrdquo Archives of Physical Medicine andRehabilitation vol 85 no 5 pp 717ndash722 2004

[97] P M Wayne D P Kiel J E Buring et al ldquoImpact of TaiChi exercise on multiple fracture-related risk factors in post-menopausal osteopenic women a pilot pragmatic randomizedtrialrdquo BMC Complementary and Alternative Medicine vol 12article 7 2012

[98] A M Hall C G Maher P Lam M Ferreira and J LatimerldquoTai chi exercise for treatment of pain and disability in people


with persistent low back pain a randomized controlled trialrdquoArthritis Care and Research vol 63 no 11 pp 1576ndash1583 2011

[99] H Tamim E S Castel V Jamnik et al ldquoTai Chi workplaceprogram for improving musculoskeletal fitness among femalecomputer usersrdquoWork vol 34 no 3 pp 331ndash338 2009

[100] R B Abbott K K Hui R D Hays M D Li and T Pan ldquoArandomized controlled trial of Tai Chi for tension headachesrdquoEvidence-Based Complementary and Alternative Medicine vol4 no 1 pp 107ndash113 2007

[101] R E Taylor-Piliae E Silva and S P Sheremeta ldquoTai Chi asan adjunct physical activity for adults aged 45 years and olderenrolled in phase III cardiac rehabilitationrdquo European Journalof Cardiovascular Nursing vol 11 no 1 pp 34ndash43 2010

[102] S P Whelton A Chin X Xin and J He ldquoEffect of aerobicexercise on blood pressure a meta-analysis of randomizedcontrolled trialsrdquoAnnals of Internal Medicine vol 136 no 7 pp493ndash503 2002

[103] R H Fagard ldquoExercise characteristics and the blood pressureresponse to dynamic physical trainingrdquoMedicine and Science inSports and Exercise vol 33 supplement 6 pp S484ndashS492 2001

[104] K S Channer D Barrow R Barrow M Osborne and GIves ldquoChanges in haemodynamic parameters following Tai ChiChuan and aerobic exercise in patients recovering from acutemyocardial infarctionrdquo Postgraduate Medical Journal vol 72no 848 pp 349ndash351 1996

[105] R E Taylor-Piliae W L Haskell and E Sivarajan FroelicherldquoHemodynamic responses to a community-based Tai Chi exer-cise intervention in ethnic Chinese adults with cardiovasculardisease risk factorsrdquo European Journal of Cardiovascular Nurs-ing vol 5 no 2 pp 165ndash174 2006

[106] E W Thornton K S Sykes and W K Tang ldquoHealth benefitsof Tai Chi exercise improved balance and blood pressure inmiddle-aged womenrdquo Health Promotion International vol 19no 1 pp 33ndash38 2004

[107] J C Tsai W H Wang P Chan et al ldquoThe beneficial effects ofTai Chi Chuan on blood pressure and lipid profile and anxietystatus in a randomized controlled trialrdquo Journal of Alternativeand Complementary Medicine vol 9 no 5 pp 747ndash754 2003

[108] D R Young L J Appel S Jee andE RMiller III ldquoThe effects ofaerobic exercise and Trsquoai Chi on blood pressure in older peopleresults of a randomized trialrdquo Journal of the American GeriatricsSociety vol 47 no 3 pp 277ndash284 1999

[109] G Y Yeh C Wang P M Wayne and R S Phillips ldquoThe effectof Tai Chi exercise on blood pressure a systematic reviewrdquoPreventive Cardiology vol 11 no 2 pp 82ndash89 2008

[110] J Tuomilehto J Lindstrom J G Eriksson et al ldquoPreventionof type 2 diabetes mellitus by changes in lifestyle among sub-jects with impaired glucose tolerancerdquo New England Journal ofMedicine vol 344 no 18 pp 1343ndash1350 2001

[111] WCKnowler E Barrett-Connor S E Fowler et al ldquoReductionin the incidence of type 2 diabetes with lifestyle intervention ormetforminrdquo New England Journal of Medicine vol 346 no 6pp 393ndash403 2002

[112] J Lindstrom P Ilanne-Parikka M Peltonen et al ldquoSustainedreduction in the incidence of type 2 diabetes by lifestyle inter-vention follow-up of the Finnish Diabetes Prevention StudyrdquoLancet vol 368 no 9548 pp 1673ndash1679 2006

[113] G Li P Zhang J Wang et al ldquoThe long-term effect of lifestyleinterventions to prevent diabetes in theChinaDaQingDiabetesPrevention Study a 20-year follow-up studyrdquo The Lancet vol371 no 9626 pp 1783ndash1789 2008

[114] J Wang ldquoEffects of Tai Chi exercise on patients with type 2diabetesrdquoMedicine and Sport Science vol 52 pp 230ndash238 2008

[115] S C Chen K C Ueng S H Lee K T Sun and M C LeeldquoEffect of Trsquoai Chi exercise on biochemical profiles and oxidativestress indicators in obese patients with type 2 diabetesrdquo Journalof Alternative and Complementary Medicine vol 16 no 11 pp1153ndash1159 2010

[116] S Ahn and R Song ldquoEffects of tai chi exercise on glucose con-trol neuropathy scores balance and quality of life in patientswith type 2 diabetes and neuropathyrdquo Journal of Alternative andComplementary Medicine vol 18 no 12 pp 1172ndash1178 2012

[117] X Liu Y D Miller N W Burton J H Chang and W JBrown ldquoThe effect of Tai Chi on health-related quality of life inpeople with elevated blood glucose or diabetes a randomizedcontrolled trialrdquo Quality of Life Research 2012

[118] J A Halbert C A Silagy P Finucane R T Withers and P AHamdorf ldquoExercise training and blood lipids in hyperlipidemicand normolipidemic adults a meta-analysis of randomizedcontrolled trialsrdquo European Journal of Clinical Nutrition vol 53no 7 pp 514ndash522 1999

[119] G N Thomas A W L Hong B Tomlinson et al ldquoEffects ofTai Chi and resistance training on cardiovascular risk factors inelderly Chinese subjects a 12-month longitudinal randomizedcontrolled intervention studyrdquo Clinical Endocrinology vol 63no 6 pp 663ndash669 2005

[120] C Lan T C Su S Y Chen and J S Lai ldquoEffect of Trsquoai ChiChuan training on cardiovascular risk factors in dyslipidemicpatientsrdquo Journal of Alternative and Complementary Medicinevol 14 no 7 pp 813ndash819 2008

[121] B S Heran JM Chen S Ebrahim et al ldquoExercise-based cardi-ac rehabilitation for coronary heart diseaserdquoCochrane Databaseof Systematic Reviews no 7 Article ID CD001800 2011

[122] C Lan S Y Chen J S Lai and M K Wong ldquoThe effect ofTai Chi on cardiorespiratory function in patients with coronaryartery bypass surgeryrdquo Medicine and Science in Sports andExercise vol 31 no 5 pp 634ndash638 1999

[123] D E Barrow A Bedford G Ives L OrsquoToole and K S ChannerldquoAn evaluation of the effects of Tai Chi Chuan and Chi Kungtraining in patients with symptomatic heart failure a ran-domised controlled pilot studyrdquo Postgraduate Medical Journalvol 83 no 985 pp 717ndash721 2007

[124] G Y Yeh M J Wood B H Lorell et al ldquoEffects of Tai Chimind-bodymovement therapy on functional status and exercisecapacity in patients with chronic heart failure a randomizedcontrolled trialrdquo American Journal of Medicine vol 117 no 8pp 541ndash548 2004

[125] G Y Yeh J E Mietus C K Peng et al ldquoEnhancement of sleepstability with Tai Chi exercise in chronic heart failure prelimi-nary findings using an ECG-based spectrogram methodrdquo SleepMedicine vol 9 no 5 pp 527ndash536 2008

[126] G Y Yeh E P McCarthy P MWayne et al ldquoTai chi exercise inpatients with chronic heart failure a randomized clinical trialrdquoArchives of Internal Medicine vol 171 no 8 pp 750ndash757 2011

[127] G Caminiti M Volterrani G Marazzi et al ldquoTai Chi enhancesthe effects of endurance training in the rehabilitation of elderlypatients with chronic heart failurerdquo Rehabilitation Research andPractice vol 2011 Article ID 761958 6 pages 2011

[128] T E Owan D O Hodge R M Herges S J Jacobsen V LRoger and M M Redfield ldquoTrends in prevalence and outcomeof heart failure with preserved ejection fractionrdquo New EnglandJournal of Medicine vol 355 no 3 pp 251ndash259 2006


[129] G Y Yeh M J Wood P M Wayne et al ldquoTai Chi in patientswith heart failure with preserved ejection fractionrdquo CongestiveHeart Failure vol 19 no 2 pp 77ndash84 2013

[130] C G Foy K L Wickley N Adair et al ldquoThe ReconditioningExercise and Chronic Obstructive Pulmonary Disease Trial II(REACT II) rationale and study design for a clinical trial ofphysical activity among individuals with chronic obstructivepulmonary diseaserdquo Contemporary Clinical Trials vol 27 no2 pp 135ndash146 2006

[131] A W K Chan A Lee L K P Suen and W W S TamldquoEffectiveness of a Tai chiQigong program in promoting health-related quality of life and perceived social support in chronicobstructive pulmonary disease clientsrdquoQuality of Life Researchvol 19 no 8 pp 653ndash664 2010

[132] A W K Chan A Lee L K P Suen and W W S TamldquoTai chi Qigong improves lung functions and activity tolerancein COPD clients a single blind randomized controlled trialrdquoComplementary Therapies in Medicine vol 19 no 1 pp 3ndash112011

[133] G Y Yeh D H Roberts P MWayne R B Davis M T Quiltyand R S Phillips ldquoTai chi exercise for patients with chronicobstructive pulmonary disease a pilot studyrdquo Respiratory Carevol 55 no 11 pp 1475ndash1482 2010

[134] R W Leung Z J McKeough M J Peters and J A AlisonldquoShort-form Sun-style Tai Chi as an exercise training modalityin people with COPDrdquoEuropean Respiratory Journal vol 41 no5 pp 1051ndash1057 2013

[135] LW Jones andCMAlfano ldquoExercise-oncology research pastpresent and futurerdquo Acta Oncology vol 52 no 2 pp 195ndash2152013

[136] S I Mishra R W Scherer C Snyder P M Geigle D RBerlanstein and O Topaloglu ldquoExercise interventions onhealth-related quality of life for peoplewith cancer during activetreatmentrdquo Cochrane Database Systemic Review no 8 ArticleID CD008465 2012

[137] KMMustian J A Katula D L Gill J A Roscoe D Lang andK Murphy ldquoTai Chi Chuan health-related quality of life andself-esteem a randomized trial with breast cancer survivorsrdquoSupportive Care in Cancer vol 12 no 12 pp 871ndash876 2004

[138] KMMustian J A Katula andH Zhao ldquoA pilot study to assessthe influence of Tai Chi Chuan on functional capacity amongbreast cancer survivorsrdquo Journal of Supportive Oncology vol 4no 3 pp 139ndash145 2006

[139] M C Janelsins P G Davis L Wideman et al ldquoEffects of TaiChi Chuan on insulin and cytokine levels in a randomizedcontrolled pilot study on breast cancer survivorsrdquo ClinicalBreast Cancer vol 11 no 3 pp 161ndash170 2011

[140] L K Sprod M C Janelsins O G Palesh et al ldquoHealth-relat-ed quality of life and biomarkers in breast cancer survivorsparticipating in tai chi chuanrdquo Journal of Cancer Survivorshipvol 6 no 2 pp 146ndash154 2012

[141] R Wang J Liu P Chen and D Yu ldquoRegular tai chi exercisedecreases the percentage of type 2 cytokine-producing cellsin postsurgical non-small cell lung cancer survivorsrdquo CancerNursing vol 36 no 4 pp E27ndashE34 2013

[142] E O Lee Y R Chae R Song A Eom P Lam andMHeitkem-per ldquoFeasibility and effects of a tai chi self-help educationprogram for Korean gastric cancer survivorsrdquoOncology NursingForum vol 37 no 1 pp E1ndashE6 2010

[143] M S Lee T Y Choi and E Ernst ldquoTai chi for breast cancerpatients a systematic reviewrdquo Breast Cancer Research and Treat-ment vol 120 no 2 pp 309ndash316 2010

Submit your manuscripts athttpwwwhindawicom

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2013

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawi Publishing Corporation httpwwwhindawicom Volume 2013

The Scientific World Journal

International Journal of

EndocrinologyHindawi Publishing Corporationhttpwwwhindawicom

Volume 2013

ISRN Anesthesiology


Hindawi Publishing Corporationhttpwwwhindawicom

OncologyJournal of

Volume 2013

PPARRe sea rch


OphthalmologyJournal of


ISRN Allergy


BioMed Research International



ObesityJournal of

ISRN Addiction



Computational and Mathematical Methods in Medicine

ISRN AIDS


Clinical ampDevelopmentalImmunology


Volume 2013

Diabetes ResearchJournal of


Evidence-Based Complementary and Alternative Medicine

Volume 2013Hindawi Publishing Corporationhttpwwwhindawicom


Gastroenterology Research and Practice


ISRN Biomarkers


MEDIATORSINFLAMMATION

of


1 2 3 4

5 6 7

Figure 1 An example of a typical form of Tai Chi (push down and stand on one leg) The sequential motions are performed in a semi-squatposture (From [1] with permission)

popular exercise worldwide and researches are flourishingThe objective of this paper is to review the existing literatureon Tai Chi and to introduce the characteristics of training(exercise intensity and biomechanical aspects) the effecton health promotion (aerobic capacity muscular strengthbalance health-related quality of life and psychological well-being) and potential applications in medicine (eg neuro-logical diseases rheumatological diseases orthopedic dis-eases cardiopumonary diseases and cancers)

2 Training Characteristics of Tai Chi

21 Exercise Intensity The exercise intensity of Tai Chidepends on its training style posture and duration Varia-tions in training approaches result in substantial differencesin exercise intensity Lan and colleagues [2] have measuredheart rate (HR) responses and oxygen uptake while perform-ing classical Yang Tai Chi in middle-aged subjects Figure 2illustrates the heart rate response and oxygen uptake ( VO

2)

during the practice of Tai Chi In the 24 minutes of practicesubjectsrsquo HR increased rapidly in the first 12minutes and thenincreased slowly towards the end of the exercise By contrastsubjectsrsquo VO

2showed a sharp increase in the first three

minutes and then it achieved a steady state towards the end ofthe exercise In the steady state of Tai Chi practice the averageHR was 58 of the heart rate reserve (HRR) and the oxygenuptake was 55 of the peak oxygen uptake ( VO

2peak) HRR isthe difference betweenmaximum heart rate and resting heartrate HRR is typically utilized to establish HR-based trainingzones according to the heart rate reserve method The HRRmethod is demonstrated as follows Target HR = [(HRmaxminusHRrest) times intensity desired] + HRrest According to the

recommendations of American College of Sports Medicinemoderate-intensity (40ndash59 of HRR) aerobic exercise isrecommended for most of the adults [3] The HR during TaiChi practice is 50ndash58 of HRR in subjects aging from 25 to80 years (Figure 3) which indicates that the exercise intensityis similar across different ages [4] Previous studies reportedthat the energy cost during Tai Chi practice was between 3and 6 metabolic equivalents (METs) depending on differentstyles and training requirements Therefore a suitable styleof Tai Chi and selected movements can be chosen to fitparticipantsrsquo needs

22 Biomechanical Aspects Wu and Hitt [5] have examinedthe kinematics of Tai Chi gait (TCG) and normal gait byusing a motion analysis system and biomechanical forceplates TCG had a low-impact force an evenly distributedbody weight between the fore-foot and the rear-foot anda large medial-lateral displacement of the foot center ofpressure (COP) The low-impact force may be attributed tothe slow speed of Tai Chi and the coordinated muscularactivities of the lower extremities The activation duration ofleg muscles especially the knee extensors is significantlyaffected by the speed of Tai Chimovement Practicing Tai Chiat a different speed may alter the role of muscular functionin movement control [6] Additionally the spatial temporaland neuromuscular activation patterns of TCGwere differentwith normal gait Compared with normal gait Tai Chi gaithad (1) a longer cycle duration and duration of single-legstance (2) a larger jointmotion in ankle dorsiplantar flexionknee flexion hip flexion and hip abduction (3) a largerlateral body shift and (4) a significant involvement of ankle


180

156

132

108

84

60

28

24

20

16

12

8

4

010

0Rest Rest

StartTCC Stop

StartTCC Stop

0 4 8 12 16 20 24Time (min)


HR

(bpm

)

VO2

(mL

kgm

in)


160

140

120

100

80

60

100

HR

(bpm

)

160

140

120

100

80

60

100

HR

(bpm

)

Men Women

0 4 8 12 16 20 24(min)


0 4 8 12 16 20 24(min)


Rest Rest

StartTCC Start

TCC

Stop Stop





































































































Chan

ge (

)

Tai ChiUsual care

5

15

25

minus5

minus15

minus25

minus35

VO2peak

























12 Conclusion


References































































































































































Volume 2013

ISRN Anesthesiology



OncologyJournal of

Volume 2013

PPARRe sea rch




ISRN Allergy





ObesityJournal of

ISRN Addiction




ISRN AIDS




Volume 2013








ISRN Biomarkers



of


180

156

132

108

84

60

28

24

20

16

12

8

4

010

0Rest Rest

StartTCC Stop

StartTCC Stop

0 4 8 12 16 20 24Time (min)


HR

(bpm

)

VO2

(mL

kgm

in)


160

140

120

100

80

60

100

HR

(bpm

)

160

140

120

100

80

60

100

HR

(bpm

)

Men Women

0 4 8 12 16 20 24(min)


0 4 8 12 16 20 24(min)


Rest Rest

StartTCC Start

TCC

Stop Stop





































































































Chan

ge (

)

Tai ChiUsual care

5

15

25

minus5

minus15

minus25

minus35

VO2peak

























12 Conclusion


References































































































































































Volume 2013

ISRN Anesthesiology



OncologyJournal of

Volume 2013

PPARRe sea rch




ISRN Allergy





ObesityJournal of

ISRN Addiction




ISRN AIDS




Volume 2013








ISRN Biomarkers



of





























































































Chan

ge (

)

Tai ChiUsual care

5

15

25

minus5

minus15

minus25

minus35

VO2peak

























12 Conclusion


References































































































































































Volume 2013

ISRN Anesthesiology



OncologyJournal of

Volume 2013

PPARRe sea rch




ISRN Allergy





ObesityJournal of

ISRN Addiction




ISRN AIDS




Volume 2013








ISRN Biomarkers



of













12 Conclusion


References































































































































































Volume 2013

ISRN Anesthesiology



OncologyJournal of

Volume 2013

PPARRe sea rch




ISRN Allergy





ObesityJournal of

ISRN Addiction




ISRN AIDS




Volume 2013








ISRN Biomarkers



of





























































































































































Volume 2013

ISRN Anesthesiology



OncologyJournal of

Volume 2013

PPARRe sea rch




ISRN Allergy





ObesityJournal of

ISRN Addiction




ISRN AIDS




Volume 2013








ISRN Biomarkers



of

reviewarticle tai chi chuan in medicine and health...

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