Bottomley, J. (2000). The Use of T'ai Chi as a Movement Modality in Orthopaedics. Orthopaedic Physical Therapy Clinics of North America, September, pp. 361-373

ORTHOPAEDIC PHYSICAL THERAPY CLINICS OF NORTH AMERICA Complementary Medicine 9:3, September 2000 1059-1516/00 $15.00 +.00

The Use of Tai Chi as a Movement Modality in Orthopaedics

Jennifer M, Bottomley, PhD, MS, PT
From the Geriatric Rehabilitation Program. Wayland; and Harvard Division on Aging, Boston, Massachusetts

Note: This article has errors from the OCR transmission of this article from the printed page.

Many of the orthopaedic and musculoskeletal maladies that are encountered in physical therapy are the result of inactivity, trauma or injury, poor nutrition and hydration, a deficient or overly active immune system, or a pathologic process. Immobility leads to a loss of flexibility and strength, poor cardiopulmonary and cardiovascular endurance and compliance, bone loss, postural changes, balance deficits, an incompetent immune system, nutritional and metabolic changes related to a decrease in appetite and the loss of physiologic cellular efficiency:y, poor circulation, decreased oxygenation, depression, and an overall compromise in fitness and quality of life.

Trauma or injury to the musculoskeletal system is often the result of a fall, sprain, or strain. Many diseases and pathologic conditions are associated \'with balance deficits. Inactivity increases the risk of falling secondary to a loss in flexibility, strength, decreasing bone mass, poor posture, and endurance problems. Dehydration is a primary cause for dizziness and exacerbates further decrease in soft tissue mobility·. Poor nutrition affects the overall health of all tissues, including the bones, cartilage, ligaments, tendons, and muscles. The immune system is severely compromised "when nutrition and hydration at the cellular level is lacking, The immune system response can also cause the breakdown of the tissues that make up the musculoskeletal system through <1n inflammatory response or a suppression of the immune system, leading to sepsis and destrur:tion of the soft tissues of the body. Immobility owing to a number of acute, chronic, or progressive pathologies, such as cardiovascular (e.g., heart disease, peripheral vascular disease), pulmonary (e.g., chronic obstructive pulmonary disease, asthma), neurologic (e.g., cerebrovascular accident, Parkinson's disease, multiple sclerosis, peripheral neuropathies), metabolic (e.g., osteoporosis, diabetes), orthopaedic (e,g., fractures, osteoarthritis), immunologic (e.g. rheumatoid arthritis, scleroderma, AIDS), and psychologic (e.g., stress, depression) diseases and conditions, can limit functional capabilities and lead to the cascading sequelae of inactivity.

The enigmatic issues of health-related quality of life for patients with chronic illness may require some alternative efforts on the part of health care providers. Alternative therapies have emerged as additions to or replacements for traditional methods of health promotion and injury' prevention. Tai chi is a form of gentle exercise and meditation that has been recommended as a treatment for older adults with a variety of chronic illnesses. This article discusses the use of tai chi as an alternative exercise form and a promising movement modality in the treatment of orthopaedic conditions.

WHAT IS TAl CHI?

Tai chi is an ancient physical art form, originally a martial art, in which the defendant uses his or her attacker's own energy against himself or herself by drawing the attack, sidestepping the attacker, and throwing the opponent off balance. It is a technique that uses slow, purposeful physical movements of the body, accompanied by breathing and mental concentration (meditation) for the purpose of control and achieving a more balanced physiologic and psychologic state. The Chinese conceived the human mind to be an unlimited dimension and the body as limitless in its physical capacity.

There are numerous forms of tai chi involving 108 positions and transitions of controlled movement, each style with slightly different philosophic foundations. Family surnames came to be associated \with the different styles of tai chi that have been passed on from generation to generation (e.g., Wu style, Yang style, Ch'en style, Chuan style, Chih style). Each style is distinctive, but all follow the classic tai chi principles and the basic philosophies of Tao.4

TAl CHI IN ORTHOPAEDIC AND MUSCULOSKELETAL CONDITIONS

The use of tai chi in orthopaedic and musculoskeletal conditions is an alternative therapeutic approach that can greatly enhance the practice of orthopaedic physical therapy. It is a form of exercise that recognizes the mind/body COilnection.4. 7. 23 The movements are graceful and controlJed throughout the range of every joint. There is no impact on the joints. Stress is imposed on bones by \veight bearing and muscle pulL The tempo is slow and rhythmic, coordinated with breathing. The movements summon all postural responses and challenge kinesthetic and proprioceptive sensesY' 30. ~3 The ankle and hip strategies for maintenance of balance are continually being facilitated. Despite the fact that only a small radius is required for the tai chi exercise forms, it has been shown to have an aerobic training effect, lower blood pressure significantly, and improve metabolism on a cellular level, facilitating nutrient uptake and waste removal.

TAl CHI, MOVEMENT, AND THE IMMUNE SYSTEM

An overwhelming amount of evidence suggests that higher cognitive centers and limbic emotional centers are capable of regulating virtually all aspects of the immune system, and the mental calming effect induced by the meditative movements o(tai chi may enhance overall health and have an impact on illness. Because many of the musculoskeletal pathologies encountered in physical therapy are autoimmune diseases (3 hyperactive immune system), augmenting the balance of tlH~ immune system through active, gentle, meditative motion has the potential of improving functional status by affecting the rate of progressive destruction of the joints and fascia. Rheumatoid arthritis and the symptoms associated \vith various other inflammatory diseases (e.g., scleroderma, lupus) occur in large part because of prolonged activation of the immune system. This prolonged activation may go unchecked because of a deficiency in the chemical within the brain that normally triggers the production of the antiinflammatory hormones.

To understand this connection, one must understand the bodj"s immune system response to inflammatory triggers, something about the brain's stress response, and something about how the t\\70 systems communicate. VVhen there is a foreign invader, there is chemical warfare \vith toxic chemicals released from granules in different kinds of white blood cells, such as mast cells. Some white blood cells, for example, lymphocytes (B cells and T cells) can clone themselves, giving rise to a multitude of killer cells. Other cells (monocytes, macrophages, and ncutrophils) function as scavengers, engulfing and digesting the foreign invaders. Plasma cells make antibodies that attack the foreign cells. To prevent total chaos in this immune system response, interleukins provide the communication that coordinates cellular activity at the sites of inflammation. Interlcukins are proteins and pepticles, made by the cells of the immune system, that activate and signal specific cellular functions. The hypothalamus is the prim8ry strunure in the hrain that is activated ITy the presence of interleukins and responds to regulate the attack on the invading cells. This response activates the hypothalamic-pituitary-adrenal (HPA) axis in the following manner. The hypothillamus releases corticotropin-releasing factor (CRF). CRF stimulates the pituitary gland to release adrenocortocotropin hormone (ACTH), which stimulates the adrenal glands to release corticosteroids [glucocorticoids). The corticosteroids are among the most potent anti-inflammatory agents that the body makes.] The corticosteroids function to shut off the immune system inflammatory response as soon as the invading cells have been destroyed. A buildup of glucocorticoids in the blood triggers neurons in the brain to cease the process that gives rise to this steroid. CRF release is inhibited, and the release of ACTI-I: ,md glucocorticoids stops. It is called a negatil'R feedback loop and is a means by \vhich tbe system regulates itself.

The major impact of this axis on the immune system is its effect on T cells. T cells are acutely sensitive to glucocorticoids. Greatly elevated gJucocorticoid leveLs damage or destroy the T cells or prematurel.y induce their migration from the thymus to other immune tissues. The resultant shrinkage of the thYInlls is so pronounced that the gland's 'weight has been used as llll indirect ,way to assay the release of adrenal glucocorticoids. The effects of glucocorticoids are biphasic; in high concentrations, they mute the immune response, whereas in small amounts, they have been sho\'\."o to activate it. Normally the adrenal glands secrete glucocorticoids in a daily tidal rhythm, and the point at which lymphocytes respond most aggressively to antigens has been correlated \vith the interval during which the level of circulating glucocorticoids falls to its lowest point. Sometimes the glucocorticoid cortisol is referred to as the body's stress hormone because it is during stress that cortisol is most often released.
In autoimmune diseases, such as rheumatoid arthritis and scleroderma, the HPA axis is sluggish, and as a result the immune system goes on unchecked even after the foreign invader is vanquished.J·1s.16.42 Individuals \vith autoimmune diseases secrete inadequate amounts of ACTH and corticosterone in response to any inflammatory stimulus, and the hypothalamus secretes lO\~.r levels of CRF. This situation increases the susceptibility to prolonged, unsuppressed infection.

In a study done by Sun et al in 1989, it was found that there was a marked increase in blood T cells during and for a significant time after 45-minute sessions of tai chi. Jin1s, 16 showed a significant drop in cortisol levels during and after tai chi practice. Jin's studies also established a significant reduction in tension, anxiety, fatigue, depression, and confusion. Stress-related causes have been credited with greater than 80% of all illness. Although the evidence at this point is scant, these studies reflect a potential for altering the immune system response at the cellular level with the practice of tai chi.

TAl CHI AND THE MUSCULOSKELETAL SYSTEM

Tai chi exercise has been found to affect flexibilitJ-"', muscle strength, muscl-e tension, and postUff3 positively. y, 13.23.13,45-50 Theoretically, it also has the potential of increasing bone mass. 13. l~l, oL JZ Overall the beneficial effects of tai chi for musculoskeletal health appear to be remarkable.

The mechanism by which tai chi affects joint mobility; cartilage and bone health; and tendon, ligament, and muscle flexibility has not been studied, A hypothetical suggestion is presented here as to the underlying means by which flexibility of fibrO\1s r:onnedivp tissllp. is enhanced through the practice of tai chi. The health of the cartilage, tendons, ligaments, muscle, and bone depends on a balance between rest and stress of these tissues. Tai chi, because of its eccentric-concentric, \veight bearing and shifting, nonimpact flowing motions and its ultimate influence on reducing muscle tension,!' 15, 26 provides both. It also intuitively enhances circulation, improving nutrient availability to these structures. The author's hypothesis is as follows.

Collagen is the basic protein component in fibrous connective tissue inclusive of bone, muscle, tendon, ligament. and cartilage.lO.11 Procollagen, a protein material, is secreted by the ribosomes of connective tissue cells. Individual procollagen molecules bind together to form tropocollagen strands. These strands group together in a spiral fashion to form the mature collagen fiber.6 The diameter of the collagen fiber is increased by the surface aggregation of additional tropocollagen strands, with a resulting characteristic of a compressed and increasingly cross~liIlked central fiber.'" Further cross-linkages continue to be added even after the fiber has rcached maturity. It has been determined that the diameter of coJlagen fibers is greater in older subjects v,/hen compared with younger subjects,12 Generally the teIlsile strength of connet.live tissue in older persons is greater than that of younger indi\'iduals. The increased cross-linkage of collagen fibers is considered a normal change related to aging, but it may be the result of inactivity.
The clinical significance of this increased cross-linking is seen in resultant collagenous contractures. Bonds bet\veen adjacent collagen strands can produce shortening and distortion of the collagen fibers. This shortening may result jn contractures with a progressive restriction in tissue mobility.l1 Collagen fibers are tough and inelastic. Clinically, it has been determined that these chemical bonds are temperature sensitive.l~ By increasing circulation and the metabulic rate in the tissues, the temperature is increased, the bonds betv .. 'een collagen fibers become unstable, and the tissues can be mobilized. Continuous stretching 1.vhile performing tai chi has the potential of having this effect.

The glycoproteins form a group of relatively small molecules of soluble protein material. The presence of glycoproteins in the extracellular area produces the osmotic force that is important in maintaining the fluid content of the tissues and dra'lsing in nutrients.34 The higher the glycoprotein concentration, the greater amount of fluid and nutritional components that are retained in the tissues by osmotic attraction forces. The production and release of glycoproteins within the connectiye tissues is reduced with inactivity. As a result, it becomes increasingly difficult for the tissues to maintain i1 normal fluid balance and a steady nutritional status_ Dehydration and pood:)'" nourished tissues are the end result. The tissues become rigid and start to break down because of dehydration and poor nutrition. Glycoproteins are produced v,.'hen the cell is unstressed (at rest). The stress-unstressed c}'des encompassed in tai chi routines provide the needed unstressed phases. In addition to enhancing circulation of nutrients by the blood, osmotic forces attracting water and nun'ients into the cells would theoretically' also he int1uenced. The effect of tai chi in reducing muscle tension would allmv for a greatf~r quality of rest when the individual is actually resting.

Hyaluronic acid helps to regulate the viscosity of tissues and is produced by some of the ribosomes in the connective tissue cells, particularl:y those located in the cartilage. This substance helps to decrease the friction between cellular components during movement. There is a reduction in the amount of hyaluronic acid secreted associated with inactivity', reducing the ease of movement (viscosity) of the connective tissues and resulting in tissue degradation.s The production of h:yaluronic acid is enhanced hy activity, particularly stress at the cellular level. Exercise becomes particularly important for maintaining the viscosity of tissues. Lack of exercise and activity negatively affects the production of hyaluronic acid, producing tissue restrictions and decreasing mobility further. Tai chi. in contrast to other forms of exercise, stresses all musculoskeletal structures in the body uniformly. This consistency of stresses imposed on the entin~ system during tai chi routines may enhance the production of hyaluronic acid, improving lubrication and mobility in 8ll tissues of the body.
Contractile proteins provide motility \.vithin the connective tissues. Their presence provides removal of waste products or debris and enhances mobility "\vithin the tissue spaces as well as facilitating the capacity of cellular proteins to c:ross a capillary or lymphatic wa11.:l4 With inactivity, there is a reduction in the secretion and organization of contractile proteins l.vith a resultant decrease in moti.lity.:11 Contractile protein secretion is relatively small in normal fibroblasts. If ~n individual is active, waste products arc more likely to be removed by the circulatory s)rstem. Connective tissue cells that produce abnormally high amounts of contractile proteins have been fouod in chronically restricted tissues, such as the rotator cuff in shoulder-hand syndrome and in Dupu.ytren 's contracture.:!? The importance of activity to prevent the accumulation ofcontractile proteins (\vhich causes tissue adhesions) and prevent soft tissue restrictions and contractu res is evident. The uniformity.' ofinvoh'ement of all musculoskeletal tissues during tai chi would lend to the present theory that the system naturally removes its \\Taste products through the fluid movements ofthi5 alternati ve exercise form.

Fibrinous adhesions have great clinical implications in treatment of orthopaedic problems. Fibrinogen, a soluble plasma protein, is a normal molecular exudate within the capillary. \'Vhen this substance passes through the capillary wall into the surrounding tissues, it is converted to strands of insoluble fibrin.1 Fibrin strands can adhere to tissue structures and restrict movement of these structures. Normally, fibrin is removed as debris by reticuloendothelial cells. VI/ith increasing age and inactivity, the exudation of fibrinogen into the surrounding tissues is increased.J1 With reduced activity levels, complete breakdown of fibrin may not occur, leading to the accumulation of this substance, restricting movement, and possibly resulting in adhesions. After an injury (traumatic or surgically induced), fibrinogen also accumulates at the site of tissue damage. If activity is limited, these strands can consolidate and create an adhesion.J4 Activity enhances the removal of fibrinogen and should be resumed as quickly as possible after an injury to prevent irreversible tissue restriction and contractures. Because of the nonstressful, gentle, fluid nature of the tai chi exercise forms, it is relatively safe to begin tai chi immediately after an injury or surgical procedure. This author has also modified tai chi to be done in sitting or in a semireclined bed position. The use of a ball is also effective in providing support, while allowing for greater benefits to the lower extremities and to balance.

Kirsteins et al examined tai chi intervention l.vith rheumatoid arthritis patients and found there \vere no significant joint symptoms (e.g., joint tenderness, s\velling) with this weight-bearing form of exercise. It seems reasonable to assume that the cartilage, which is avascular and relies entirely on surrounding structures for its nourishment, would benefit from the increased availability of glycoproteins and hyaluronic acid for maintaining health and function. The nonimpact, gentle nature of the movement modality oftai chi \vould also prevent painful jarring of inflamed arthritic joints.

Ivlany researchers h,n-e found statistically signifir:ant strength gains in muscles tested as the result of tai chi intervention. One study examined the health effects of tai chi Chuan on older adults in a community setting and found great improvements in flexibility, ~lrel1gth, and muscle relaxation after 16 \veeks_;- Lan et al compared a group of sedentary older adults with dgroUP participating in a tai chi program ami found the tal chi group not onl:y had significant muscle strength gains, but also were c.haracterized by greater flexibility, improvement in posture measures, and a 10\ver percentage of body fat at the end of the study in comparison with their initial assessment and with their sedentary' cou~terparts. Lan et sF showed an average increase of 11 () in thoracic and lumbar flexibility and an increase of 18% to 20% and 15% to 169'0 in knee extensor and knee t1exor strength, respectively. This study also confirmed significant cardiovascular benefits as evidenced b~y \T02ma., and endurance measures, The results indicate that a tai chi program is effective for improving overall health and fitness of older adults.

Although the author could not find any studies that measured bone density specifically in relation to tai chi exercise, based on the muscle pull in multiple directions on the bone and the weight-bearing nature of this exercise form, it can be hypothesized that tai chi ,Nould have a beneficial effect on bone density based on the piezoelectric effect and the application of Wolff's law. Physical stress on bone stimulates increased bone deposition. The physical stress can be a result of any exercise that applies compressive and tensile stress, including tai chi. Simply overcoming the forces of gravity on the musculoskeletal system can stimulate bone depusition. Because of the large number of muscles (>600) that originate and insert on the nUmerous bones of the skeletal s)'stem (approximately 206), muscle contraction, especially against resistance (gravity or external loads), can place lctrge forces on the muscle tendon-bone junctions, and these forces are relayed to the bone matrix.

Bones are dynamic structures that undergo adaptive changes in direct response to the physical demands made of them. \Vhen regularly stressed, they respond by becoming mechanically stronger; if underused, the opposite occurs. This hypertrophic response to exercise is highly specillc and occurs only in the areas of the skeleton that are experiencing the extramechanical forces. Bassett and Becker" han'! hyputhesized that the mechanism for the localized control of bone growth is electric in nature. In their model, bone tissue functions as a piezoelectric crystal that converts the energy of mech,mical deformation into electrical energy. Through these charges, control over the level of cellular activity is exerted. Piezo is the Greek ·word for pressure or to squeeze. The piezoelectric effect is the electric current created ,\Then there are compression forces, pressure, or \veight bearing through a bone. An electric polarity or electricity is generated because of pressure, especially in a crystalline substance such as that found in the biochemical composition that makes up the minmal content of the bone. During mechanical stressing, the segment of bone experiencing compressive forces produces a negative electric charge stimulating osteoblast activit:,,.', whereas the segment under tension becomes positive, stimulating osteoclast activity. The negative polarity created bv compression forces Clttmcts positive ions such as Ca~ and other electrically p~sitive minerals. The mechanism for the localized control of bone growth is hypothesized to be electric in naturc.c
[I.·fatun:; bonn is strongest and stiffest during compression as a resuJt of the piezoelectric effect. Bone increases in strength and stiffnf)SS and stores more electric energy when there is an increasco. frequency of loading with repetitive weight-bearing forces. Tai chi is a movement modality that provides \v8ight bearing and prolonged loading on the hones, and the piezoelectric effect is hypothetically activated during a tai chi session.

Wolffs law states that bone formation occurs in response to mechanical loading of bone, whereby bone trabeculi are laid dQl.vn in the direction of muscle pull or weight-bearing forces. Bone is laid down in areas of stress and reabsorbed in areas that are unstressed. The mechanism hy which this occurs is that mechanical strain activates the cell-remodeling process in such a way as to ensure structural competence. The cellular response is to provide sufficient bone tissue to \vithstand the functional loads placed on the bone. Bone is considered to be an anisotropic material, exhibiting different mechanical properties vvhen loaded in different directions. I\'fuscle activity alters the stress pattern in bone, as do compressive forces. Tai chi is an exercise modality that loads all of the bones of the body through weight bearing and through muscle pull for prolonged periods. Future research would be helpful in verifying the hypothesis that the piezoelectric effect and \Nolffs la\\' are influential during a tai chi routine.

TAl CHI AND CARDIOVASCULAR AND CARDIORESPIRATORY HEALTH

If an orthopaedic client is in poor shape from a cardiovascular perspective, the likelihood of impro\'ing orthopaedic status is compromised greatly. Tai chi has the potential of improving cardiovascular and musculoskeletal parameters. Young et aPl measured blood pressure during three screening visits and every 2 weeks during a comparison study of a moderate-intcnsity aerobic exercise program v·.'ith a light-intensity' tai chi program in previously sedentary adults. Estimated maximal oxygen uptake and measures of physical activity level vI.'ere determined at baseline and at the end of the intervention period. Comparing the two exercise groups, the moderate-intensity aerobir: group had similar effects on blood pressure when compared with the tai chi group. \T02max and all other measures of physical activity in the tai chi group showed remarkably greater improvements, hOW8\'Cr, when compared with the aerobic exercise group. In a study by Lai et aFu it \vas determined that the elderly tai chi exercisers shovlI'ed a significant improvement in \702 uptake compared with an age-matched control group of sedentary; elders, Lai et aFu concluded that the data substantiated the practice of tai chi as a means of delaying the decline in cardiorespirator~y function commonly considered normal for aging individuals. Tai chi \/llaS shown to be a suitable aerobic exercise for older adults.25 A subsequent study by Lai et aF5 substantiated further that tai chi exercise is aerobic exercise of moderate intensity.

In the past, it was believed, although never studied, that tai chi exercise forms did not ha\'8 a significant cardiorespiratory component, and they \\'er8 deemed nonaerobic. Zhuo et aP~ designed a stud:y to determine the physiologic demands of tai chi. The results indicate that tai chi may he classed as moderate exercise, and its intensity docs Ilot c:\cced 50[;0 of the individual's V02n",X uptake. Schneider and Leungi") sho\yed that ventilatory capacity measures showed signifir;ant improvement in tai chi practitioners. in addition to producing a slightly higher heart rate relative to metabolic load \vhen compared with traditional aerobic activities. In a study of post-m).'Ocardial in farction patients, Channer et aP compared a tai chi group with an aerobic exercise group and found not only significant improvements in blood pressure, heart rate, and respiratory response to exercise (in both groups), but also found compliance was greater for the patients in the tai chi group. This movement modality not only has the benefits of improving cardiovascular and cardiorespiratory health, but also it appears that individuals practicing tai chi enja,y it. It has been shown in these studies that despite the slo ..... v, steady. smooth pace of tai chi exercise routines, there is a significant positi\'c effect on the cardiovascular and cardiorespiratory systemY' 33

TAl CHI AND FALLS

Falls often lead to the fracture of bones or injuries to the joints and soft tissues, especially in an elderly population. The potential value of tai chi exercise in promoting postural control, improving balance, and preventing falls has been substantiated by several researchers.17, h 43. 4:;-50 Tse and Bailey43 found that tai chi practitione;s had significantly better postural control than the sedcntarynon practitioner. Pro-vince et ap5 found that treatments directed to\,vard flexibilitv, balance, d:Jmamic balance, and resistance, a111.0mponents oftai chi exercise, r~duccd the risk of falls for elderly adults. \Volfson et aF3, 50 showed that shortterm exposure to "altered sensor)' input or destabilizing platform movement" during treatment sessions, in addition to home-based tai chi exercises, elicited significant improvements in s\\/ay control and inhibited inappropriate motor responses. The outcome measure of functional balance improved more substantially in the exercise group that combined the treatment sessions with the home program of tai chi. \Volf et aI's compared a balance training group, in \vhich balance was stressed on a static-to-moving platform using biofeedback, with a group of tai chi Quan exercisers. A third group sef\'ed as a control for exercise inten'ention. This study sho\ved that a moderate t<ii chi program can affect favorably the defined biomedical and psychosocial indices of frailty in an oldcr adult population and has favorable effects on the occurrence of falls.4b, 4R The benefits of tai chi in fall prevention have been also supported in a study by Judge et aV' in 'which these researchers showed improvements in single-stance postural s\vay in older \vomen vlrith tai chi exercises. Shih')O examined the effect of tal chi on postural sway and noted substantial positive changes in anterior and posterior directions in s'i.vay velocities and efficiency of postural corrections to balance perturbations.

Of great importance is the ability to tell where one is in space. Jacobson et al13 assessGd the effect of tai chi training on lateral stability, kinesthetic sense. and strength Df voluntary knee extension and found improvement in all three of these areas of measurement \vhen compared with a nonexercise group. One contributing factor in falls is that individuals fall when they arc unfamiliar ·with the task they are doing. By pracUcing movement, tai chi participants gained a sense of how to manage their balance in a variety of positions. Forrest9 established that practicing tai chi leads to <i greater use of the elasticity of the peripheral structures involving muscles, ligaments. and tendons and that a greater awareness of postural equilibrium (i.e., \vhere one is in space) was based on antidpatory postural adjustments. This finding makes sense because each movement transition in tai chi is a planned movement, and concentration (meddation) is a key' element in the practice of this choreographed movement modality.

CONCLUSION

The benefits of tai chi are immense. It can positively augment physical therapy programs aimed at improving balance and posture, coordination and integration of movement, endurance, strength, flexibility, and relaxation.5. 7. q, 13-]&. H. 28 -f9.50 Tai chi exercise has cardiovascular,5. 7, 26, 27, 39.51. 52 neuromuscular,9. 13. llL 19, 30.·;3, 4&.49 psychologic,4. 15. 1&.38.41 and musculoskeletaF·13, 18, 19,21.32, 3e benefits that are observable clinically. It can be used in patients who normally avoid activity because of pain, lack of motivation, or fear. The author has had great success in the use of tai chi \I\rith patients with chronic pain, chronic low back conditions, fibromyalgia, depression, fractures of all kinds, rheumatoid arthritis and osteoarthritis, osteoporosis, Paget's disease, scleroderma, lupus, and most orthopaedic conditions.
Tai chi is a form of exercise that allows the individual to assume an active role in obtaining maximal health and focusing on the prevention of disease, rather than the passive acceptance of illness as a consequence of life, aging, fate, or genetics.4.7 It is an exercise form that is particularly helpful in an older adult population because of its measured, controlled, non-impact~t:ype, eccentric and concentric movements, 'Nhich challenge the center of gravity and require and increase kinesthetic and proprioceptive 8\,vareness. This exercise form incorporates all of the motions that often become restricted with inactivity and aging. It improves respiratory status, stresses trunk control, stimulates greater ay o. '-areness of the base of support, improves rotation of the trunk and coordination of isolated extremity motions, and helps to facilitate consciousness of movement and position,4. 9.13.24. 4U

Health and disease do not depend on sharply compartmentalized anatomic or self-limiting physiologic systems. The body functions as a unit, and this unity cannot be understood without the musculoskeletal system, which constitutes 60% of the body mass. Although joint sprains and strains, fractures, and other orthopaedic conditions resulting in pathologic limitations of normal motion manifest their more obvious effects in the local area of the lesion, they are likely to affect the function of other remote body systems. Tai chi offers a form of exercise that incorporates the rnm'ement of the body as a v",hole and stresses every body s)Tstem. It is a "\vonderful adjunct to traditional physical therapy for all orthopaedic problems. Tai chi holds great promise toward health promotion, mental and physical fitness, wcllness, attaining maximal functional capabilities, and improving the quality of life.

RESOURCES

For an in-depth review of the philosophy and histor)' of tai chi as "veIl as a description with pictures of a modified tai chi routine for older adults with functional limitations, refer to Complementary

Therapies in Rehabilitation:

Holistic ,Approuches for Prevention and 1Vellness.4 Although the author has dozens of manuals and instructional \'ideotapes, only one is recommended for the health care professional: 7"oi Chi Fundamentals for Health Care ProfessionoIs ulld Instructors: A. Simplified /\pproach for AIastering T'ai Chi Basjc~'s, by Tricia Yu, !'vIA, and Jill Johnson, MS, PT, GCS, published by Uncharted Country Publishing. Published in 1999, this is the clearest, most concise, and most comprehensive video and manual available.

References

1 /\strand PO, Rodahl K' Textbook of Work Physiology. San Francisco, fvfcGr8'\N-
Hill, 1970

Z Bassett CA, Becker RO: Generatton of electric potentials by bone in response to
mechanical stress. Science 137:1063-1064, 1992

3 Blalock JE: The immune system: Our sixth sense. Immunology 2:8-15, 1994

4 Bottomley' jivI: T'ai Chi: Choreography of body and mind. In DavisC:tv{ (ed): Comple-
mentary Therapies in Rehabilitation: Holistic Approaches for Prevention and Wellness. Thorofare, NJ, Stack, 1997, pp 133-156

5 Charmer KS, Barro\\' D, Barrow R, et a1: Changes in haemodynamic parameters
following Tai Chi Chuan and aerobic exercise in patients reco"ering from acute myocardial infarction. Postgrad ivied J 72:349-351, 1996

6 Chapman EA, DeVries HA, Swezey R: Joint stiffness: Effects of exercise on young
and old men. J Gerontal 27:218-221, 1972

7 Chen \'V, Sun \\': Tai Chi Chuan, an alternative form of exercise for health prumotion
and disease pW\'ention for older adults in the community. International Quarterly of Community Health Education 16:333-339, 1997

8 Donatelli R. Owens-Burkart H: Effects of immobilization on the extensibility of
perii'nticuli1r connective tissue. J Orthop Sports Phys Ther 3:67-71,1981

9 forrest \VR: Anticipatory postural adjustment and Tai Chi Ch'uan. Biomed Sci
In strum 13:65-70, 1997

10 Goldberg AL. Goodman H}.1: Effects of disuse and denervation on amino acid
tri1llsjJur\ h}' skeletal Illusde. Am J Physiol 216:1115-1119, 1975

11 Hamlin CR. Lusr:hin JH, Kahn RR: Aging of collagen: Cornparali'\/8 rates in four
mammalian species. Exp Geronto115:393-398, 1980

12 llunter noV, Kearney RE: Respiratory components of human postural sway. Neurosci
LeU 25:155-159, 1981

13 Jacobson RH, Chen HC, Cashel C, et a1: The effect of T'ai Chi Chuan training on
balance, kinesthetic sense, and strength. Perr:ept Mot Skills 84:27-33, 1997

14 Jt~ong BI': Respiration effect on standing balance. Arch Phys !\fed Rehabil 72:642-
645,1991

15 Jin P: Chang($ in heart rate, noradrenaline, cortisol and mood during T'ai Chi.
J Psvchosom Res 33:197-206, 1989

16 Jin P: Efficacy uf T'ai Chi, brisk walking, meditation, and reading in reducing
IIlL:otal and emotional stress. J Psychos-om Res 36:765-77.'), 1992

17 Judge jO. Lindsey C, Under\vood t\'f, et a1: 8al'm.ce improyements in older women:
Effects of exercise training. Phys Ther 73:254-265, 1993

18 Kessenich CR: THi Chi as a melhod of fall pre\'ention in the elderly. Orthop Nms
17:27-·29.1 ~mn

19 Kessenich CE· Health-related quality of life in osteoporosis. J Clin DeIlsitometry
1.2i-:n. Fi'm

20 Kirsta A: The Book of Stress Survival: Identifying and Reducing Stress. New York,
Simon & Schuster, 1986

21 Kirsteins AE, Dietz F, H\vang SM: E\'aluating the safety and potential use of a
weight-bearing exercise, Tai-Chi Chuan, for rheumatoid arthritis patients. Am J Phys r,'1ed Rehabil 70:136-141, 1991

22 Klein FA, Rajan RK: Normal aging: Effects on connective tissue metabolism and
structure. J Gerontol 40:579-585, 1985

23 Koh TC: Tai Chi Chuan. Am J Chin Mod 9:15-22, 1981

24 Kutner NG, Bamhart H. 'Wolf 5L, et a1: Self-report benefits of Tai Chi practice by
older adults. J Gerontal B Psychul Sac Sci 52:P242-246, 1997

25 Lai ]S, Lan C, Wong J\lK. et aI: Two-year trends in cardiorespiratory function
among older Tai Chi Chuan practitiol1ms and sedentary subjects. J Am Geriatr Sac 43:1222-1227,1995

26 Lai is, Wong i\1K. Lan C, P-t al: Cardiorespiratory responses of Tai Chi Chuan
practitioners and sedentary subjects during cycle ergometer. J Formos Med Assoc 92:894-899,1993

27 Lan C, Lai IS, Chen SY, et a1: 12-01onth Tai chi training in the elderly: Its effect
on health fitness_ :'vled $ci Sports Exerc 30:345-351, 1998

28 Lan C, Lai JS, Wong I'vTK, et al: Cardiorespiratory function, flexibility, and body
composition among geriatric Tai Chi Chuan practitioners. Arch Phys Med Rehabil 77:612-616,1996

29 Lehman, J, \-Varren C. Scham S: Therapeutic heat and cold. Clin Drthop 9B:207-
209, 1974

30 Lichtenstein 1\[J, Shields SL, Shiavi RG, et a1: Exercise and balance in aged \vomen:
A pilot controlled clinical trial. Arch Phys Med l{chabil 70:138-143, 1989

31 Meyer K, et a1: IVlucopolysacchrides of costal cartilage, Science 128:896, 1958

32 Myers ER, WeinerGI: Injury' Prevention: Keeping Old Bones Whole. Harvard Health
Letter 21:11, 1996

33 Ng RK: Cardiopulmonary exercise:.A. recently discoFered secret ofT'ai chi. Ha\vaii
Med J 51:216<~17, 1992

34 Pickles LH': Erf(-~cts of aging on connective tissues_ C;E:~riatrics 38:71-78, 1983

35 Province \l.L\, HCldJey ED, Hornbrook !\1C, et a1: The effects of exercise on falls in
elderly patients: ;\ pre planned meta-analysis of the FICSIT Trials, Frailty and Injuries: Couperative Studic~s of Intervention Techniques. JAMA 273:13411347, 1995

36 Reichlin S: Neuroendocrine-immune interactions. N Engl J Ivied 38:1246-1253,
1993

37 Ryan AJ: The role of tissur: viscosity in injury prevention. In Ryan AJ, Allman FL
(eds): Sports I'vledicine. Ne\v York, Academic Press, 1974

38 Schaller K]: Tai Chi Chih: t\n exercise option for older adults. J Gerontal Nurs
22:12-17,1996

39 Schneider D, Leung R: IVlctabolic and cardiorespiratory responses to the perfor-
mance of \Ving C:hun and Tai Chi Cbuc!!l exercise. Int J Sports Med 12:319323.1991

40 Shih J: Basic Beijing lwenty·four forms of Tai Chi exercise and average velocity
of s\vay. Percept ]\·10t Skills 84:287-290, lSJ97

41 Sun WY: lrnpact of a Tai Chi Chuan program 011 the health among older adults.
Student 1\'1onograph 12:73-8(), 1~HJ4

42 Sun XS, Xu 't', Xia YJ: Determination of E-rosette-formirrg lymphocytes in aged
subjects with Taichiquan exercise. Int J Sports !\fed 10:217-219, 1989

43 Tse SK, B<tiley 01\1: T'ai chi LInd postural control in the well elderly. Am f Occup
Ther 4G:29;,-JOU, lWJ2

44 Viidik A: Function properties of collagenolls tissue. lnt Rev Connect Tissue Res
6:127-215. 1~j82

45 Wolf SL Barnhart HX. Ellison GL, pt al: The effect ofTai Chi Quail and computer-
ized balance training on postural Sb1hility in older subjec.ts. Phys Ther 77:371384,1997

46 \Volf SL, Barnhart HX, Kutner NG, et aL Reducing fmilty and falls in older persons:
An investigation of T'ai Chi <,me! computerized balance training. J Am Geriatr Sac 44:S9g-600, 1996

47 VVoif SL, Coogler C, Xu T: Exploring the basis for Tai Chi Cbuan as a therapeutic
exercise approach. Arch Phys Mcd Kehab!l 79:886-892, 1997

48 \Vol£ SL, Kutner NG, Green RC. et al: The Atlanta FICSIT study: Two exercise
interventions to reduce frailty in elders, J Am Geriatr Sac 41:329-332,1993

49 Wolfson L, \.'Vhipple R, Derby C, et al: Balance and strength training in older adults:
Intervention gains and Tai Chi maintenance. J .Am Geriatr Sac 44:498-506, 1996

50 Wolfson L, Whipple R, Judge J, et aL Training balance and strength in the elderly
Lo improve function. J A.m Geriatr Sac 41:341-343, 1993

51 Young DR, Appel LJ, fee S, et a1: The effects of aerobic exercise and Tai Chi on
blood pressure in older people: Results of a randomized trial. J Am Geriatr Sac 47:277-284,1999

52 Zhuo D, Shephard RJ, Plyley tvfJ, et al: Cardiorespiratory and metabolic responses
during Tai Chi Chu,m exercise. Can J Appl Sport Sci ~j:7-10. 1,g84
ADDRESS REPRJ"T REQUESTS TO:
Jennifer M. Bottomley, PhD
e-mail: [email protected]