Preprint by Bob Levine and Dan Ogrydziak, 2001

T’ai Chi as a health maintenance practice and treatment modality in China

At sunrise in every park, garden or parking lot in China, hundreds of people, mostly elderly, meet to practice the graceful movements of T’ai Chi Chuan.  They begin as one large group, breathing, shifting weight and gently doing self-massage in unison.  After about fifteen or twenty minutes of this warm-up, the group breaks up and meets with their friends and teachers in reserved areas of the park.  There, they practice a wide variety of T’ai Chi forms, push hands routines (where practitioners work to sense the imbalances of partners while maintaining their own balance) and sword forms.  In the woods, standing alone, or seemingly in an intimate relationship with a tree or large rock, people are holding postures until their legs tremble, while they attempt to maintain their equilibrium by breathing in a deep and relaxed manner.  After an hour or two of using focusing and breathing to center scattered thoughts and emotions and exercising the body by relaxing all muscles except those needed for each movement of the T’ai Chi choreography, the T’ai Chi practitioners leave the park and begin their workday...

 Traditional Chinese Medicine (TCM) combines a variety of health practices to affect the healing process. The first stage of health maintenance involves a balanced diet and T’ai Chi exercises.  If the first stage fails and a person becomes ill or maintains an illness, herbs are used.  Acupuncture would then be used if the first and second stages fail to bring the person back to a balanced state (health).  In China, allopathic medicine is also utilized though it is quite separate from TCM.  Allopathic practitioners do, however, use T’ai Chi and dietary instructions in combination with Western style treatments. 

When asked in 1993, in an informal session of the First Symposium on Sexology: East and West,[i] about how T’ai Chi was utilized by allopathic doctors, Dr. Lei Bingjun[ii] of the West China University of Medical Sciences described a scenario of a patient with a liver inflammation who came to him.  After prescribing appropriate medication and suggesting foods that should be avoided, Dr. Lei referred the patient to a T’ai Chi practitioner at the hospital, who prescribed specific movements and standing positions with focused breathing patterns in order to “reduce the energy to the liver”, thus optimizing the effect of the medication.  This is not that different from a situation where a doctor in the US would prescribe the same medication and dietary advice, but would also suggest that the patient not overtax his or her system and get a lot of rest.  The difference is that in the Chinese example the referral to the T’ai Chi practitioner provides the patient with the tools to slow down in a manner that specifically relaxes the functioning of the liver.  Andrei Gagarin,[iii] formerly an internist at Leningrad Hospital, described the same protocol as the Chinese utilized in the former Soviet Union.

It is clear that in China, T’ai Chi is considered more than a physical exercise and relaxation routine.  The balance, muscular relaxation, movements that lubricate joints (hips, knees, ankles, etc.), and physical alignments provide the conditions for the concentration, flow and projection of vital energy (chi), allowing for health and the raising of spirits. Chi flows through and across the body via subtle pathways (commonly referred to as acupuncture meridians) that connect all of the organs of the body.   When there is a block in one of the pathways, less energy is delivered to a given organ, and consequently more is given to the others creating an imbalance that can manifest as either physical or psychological symptoms.  Left uncorrected, this condition may become a progressively more serious disease, and possibly threaten life.

The benefits of T’ai Chi are recognized by allopathic physicians in China, however, the understanding of chi energy is often ignored or met with embarrassment because it is not something that has yet met the test of scientific inquiry.  As a result, in China, even though both allopathic physicians and TCM practitioners are part of the Chinese Medical Association, there is as much competition between their worldviews as there is cooperation in practical ways.  For example, at the Sexology Symposium, representatives of both points of view presented, but following the presentation of the TCM theorist, the Chinese allopathic physicians apologized to the Western delegation for the “superstitious” beliefs of the speaker.  The allopathic doctor, like his western counterpart is committed to germ theory and the general approach that health can be achieved by treating the symptoms of the illness; the TCM practitioner is more interested in the underlying imbalance in the allocation of energy that is the cause of illness.  Whatever the belief structure, T’ai Chi and other arts, such as chi gung and calligraphy that balance the body, attitude and demeanor of human beings are widely utilized as treatment modalities in almost every therapeutic field.

Research Background: USA

In1992, Bill Moyers produced a PBS series entitled “Healing and the Mind”.[iv]  This production, seen nationwide, was the first serious exposure of T’ai Chi Chuan and other Eastern healing modalities as possible complements to established medical treatments.  It offered a view of health and illness from a completely different paradigm, one that utilizes effective alternative approaches to deal with ailments that Western medicine has been ineffective in treating.  Since that time, T’ai Chi has become a modality looked at in earnest by such institutions as the Multiple Sclerosis Association, The Brain Injury Association, The Blind Industries of America, The National Center for Institutions and Alternatives, and the University of Maryland’s Montebello Rehabilitation Hospital[v] to see if it could affect changes in the condition of people with psychiatric problems, neurotrauma, blindness and essentially untreatable conditions such as multiple sclerosis and Parkinson’s disease. 

The results of these early programs have inspired serious scientific research to measure the effectiveness of T’ai Chi as a complementary healing modality.  Starting in 1996, results of these studies reached the health community as articles and editorials appeared in established journals such as the Journal of the American Medical Association and the Journal of the American Geriatric Society.  The positive results of these well designed, quantitative studies were consistent with the findings of anecdotal research done by the Institutes of Traditional Chinese Medicine (TCM) and the Chinese Medical Association.  As a result, the National Institute of Health has created a division to specifically study alternative medicine.  Other institutions have followed suit, such as the University of Maryland in Baltimore, Maryland.  In 1997 and 1998, many public health, psychiatric and social work seminars were presenting speakers who described methods of applying T’ai Chi and other therapies to the healing process.  Major medical institutions[vi] have begun to offer courses and continuing education seminars in complementary medicine to educate doctors on these various modalities.

The Research

The slow, focused and relaxed movements of the T’ai Chi form that seem to breathe the body are different from most other forms of exercise such as aerobics, resistance and weight training that accelerate breathing and tense muscles to build speed, strength and endurance.  A number of research projects have compared the benefits of T’ai Chi with normal exercise as possible preventative interventions for populations with limited capacities; the aged, people with compromised immune systems, people at risk for cardiac problems, people in rehabilitation etc.

The most sophisticated research has been done in relation to the prevention of injuries and maintenance of viability in the aged. “Each year, approximately 30% of persons over 65 years of age sustain a fall with about half of them having multiple events.  About 10% to 15% of falls result in serious injuries . . . Over 6% of all medical care dollars for persons aged 65 and older were spent on unintentional injury with the majority spent for fall injuries.  This was estimated to have reached $3.7 billion by 1984.”  The normally recommended fitness programs for the elderly have recently been shown to exacerbate the incidence of fall injuries.  In a 1998 news conference[vii] with Ann Brown, chairman of the Consumer Product Safety Commission and Dr. Nicholas DiNubile, spokesman for the American Academy of Orthopedic Surgeons, a warning was sent saying that improperly done exercise had resulted in a 54% increase in sports related injuries to older Americans.  “Paradoxically, the riskiest categories seemed to include those that should bring the greatest health benefits - aerobic activity and weight training.” Exercise injuries between 1990 to 1996 had risen 173%.

This situation prompted the initiation of the “Frailty and Injuries: Cooperative Studies of Intervention Techniques.”[viii]  FICSIT is the most extensive quantitative study involving T’ai Chi and other movement methods.  It was conducted by the National Institute on Aging and the National Center for Nursing Research.  The FICSIT trials ran from 1990 to 1994 at seven university sites, each with a unique intervention aimed at reducing frailty and maintaining postural integrity in persons aged 70 and older who were still living in the community (people with serious illness or dementia were excluded).  Emory University was the chief site for the T’ai Chi intervention.  Steve Wolf, Ph.D the director of the T’ai Chi study believed T’ai Chi to be a valuable intervention to examine because of it’s therapeutic elements.  According to Wolf,

Movements appear to be continuous and performed slowly.  Under these circumstances, progressively greater movement is seen, the knees are flexed, and body weight shifts.  For the most part, head and trunk are aligned in a straight and extended position.  Movements occur in a sequence of trunk, head, and extremity rotation.... There appear to be asymmetrical diagonal turns in leg movements about the waist and ultimately a progression toward unilateral weight bearing.  In other words, all the movement patterns usually associated with older individuals (a rounded posture, slightly flexed trunk, and limited base of support) appear to be counteracted within the components of T’ai Chi Quan.[ix]

After adjusting for all risk factors, the FICSIT researchers examined frequency of falls, fear of falling, maintenance of upper body strength and blood pressure.  A comparison was done of a group practicing a distilled form of T’ai Chi with a group using computerized balance equipment and another group receiving an education program.  The T’ai Chi practitioners had 47.5% fewer falls.  After the T’ai Chi intervention only 8% of the participants still reported a fear of falling, as opposed to 23% prior to the intervention.  There was less loss of upper body strength in the T’ai Chi group during the course of the study, as measured by left hand grip strength.  The T’ai Chi group had lowered systolic blood pressure after a 12 minute walk.  The T’ai Chi group did not, however, walk as fast on average as the control group. “T’ai Chi emphasizes slow, rhythmic movements and awareness of the environment, behaviors that are consistent with the subject’s shorter ambulatory distance and lowered cardiovascular responses.”[x]  The researchers postulated that the slower walking of the T’ai Chi participants may be due to greater awareness.  Currently Steve Wolf and other members of the Emory FICSIT team are doing a 48 week follow up to test T’ai Chi as a long term intervention in fall prevention[xi].  At another FICSIT site, balance and weight training was used.  This was followed by six months of T’ai Chi instruction.  The strength and balance gained during the training were maintained successfully using only one session per week of T’ai Chi.[xii] 

The T’ai Chi groups did well enough in all of the clinical trials mentioned for the Journal of the American Geriatric Society to recommend it as a low technology approach to conditioning that can be implemented at relatively low cost in widely distributed facilities throughout the community.[xiii]  This suggestion was taken to heart by the Pennsylvania Commission on Aging’s, Fall and Injury Prevention Task Force.  The task force has published a program entitled, “Exercises to Improve Balance” in their FRIENDS (Fall Reduction Initiative: Establishing New Directions for Safety) manual[xiv] that relies extensively on T’ai Chi protocols approved by the T’ai Chi Foundation for working with the elderly.  This program is distributed free of charge and is implemented in Pennsylvania state-supported community centers.

Other research studies have indicated that T’ai Chi can significantly increase the immune system,[xv] suggesting that future research could benefit populations with AIDS and other immuno-deficient ailments.  Johns Hopkins University researcher Deborah Young in a 1998 speech reported the positive reduction of systolic blood pressure to an American Heart Association Conference.[xvi]  In Ms. Young’s study on the effect of aerobic exercise on hypertension, T’ai Chi was taught to the control group.  The study was not completed because the systolic blood pressure measurement of those in the T’ai Chi control group was reduced as much as that of the brisk walkers in the study group.  Another cardiovascular study comparing elderly T’ai Chi practitioners with a sedentary group found that “the T’ai Chi group showed 19% higher peak oxygen uptake in comparison with their sedentary counterparts.”[xvii] 

            Cheng Man-Ch’ing, in addition to being a master T’ai Chi practitioner was a well-respected physician holding a position in China that was the equivalent of the Surgeon General.  In his medical essays and T’ai Chi treatises, he recommended several directions for T’ai Chi research: first, the prevention of bone quality loss, especially in the case of post-menopausal women, second, as a tool in the prevention of cancer, third, in the treatment of tuberculosis and lastly, the prevention of heart disease.

It is known that weight-bearing exercise reduces loss of bone density.  T’ai Chi emphasizes single weightedness and slow movement with flexed knees.  A 1991 study evaluated people with rheumatoid arthritis who practiced T’ai Chi once or twice per week.  It was concluded that T’ai Chi was a safe form of exercise for people with rheumatoid arthritis “and may serve as an alternative for their exercise therapy and part of their rehabilitation program”.[xviii] Weight bearing exercises are known to stimulate bone growth and strengthen connective tissue, suggesting that future studies with people at risk for osteoporosis and osteo-arthritis might be valuable.  Other preliminary studies are in process at various research locations looking into the affect of T’ai Chi on Parkinson’s Disease, multiple sclerosis and neuro-trauma.  T’ai Chi emphasizes deep natural breathing and upper body relaxation combined with slow reflective movement.  Future studies of its affects on stress and other psychological factors such as depression and anxiety could prove beneficial.  T’ai Chi is a practice that the Chinese claim balances all of the organs of the body.  A long term study comparing the overall health of regular T’ai Chi practitioners over time, with the overall health of people who do other forms of exercise regularly and with people who don’t do any movement exercise at all would be enlightening.

Integrating Complementary Practice into the Established Health Care System - The Keswick Project

Both anecdotal and scientific research have demonstrated the medical and rehabilitation benefits of T’ai Chi.  T’ai Chi has been shown to dramatically improve many of the structural, metabolic, strength and problems of concentration normally associated with the aging process.  The evidence, however, also indicates that without regular practice the benefits gained progressively disappear.[xix]

In 1996, a national conference[xx] was held in Charlottesville, VA to discuss the role of complementary medicine in relationship to the established health care system in the US.  Many of those attending were executives working for HMO’s, insurance companies, drug companies and hospitals.  During the conference, a number of complementary practitioners provided evidence of the benefits of their modalities.  The audience, however, asked several questions.  What would be the vehicle for delivering these complementary therapies and who would determine the qualifications of practitioners to work with people who have imbalances or are at risk for falls?  These questions are obviously relevant.  There is currently little mechanism for utilizing complementary modalities in the health care system.   Many complementary therapies have not focused on the development of their practice in relationship to health care institutions.  For example, there are not enough qualified T’ai Chi practitioners[xxi] in enough locations to provide services with health care establishments.  There is also the question of whether someone trained in T’ai Chi has any place in a hospital environment, because they are not trained in the protocols of those institutions.  In addition, if an institution employs a T’ai Chi practitioner once or twice a week, there is frequently no compliance between visits, reducing the benefits to the patient. 

A form of T’ai Chi therapy called Psycho-Physical Balance Therapy approved by the T’ai Chi Foundation, a non-profit organization devoted to research, was developed by Robert Levine, a T’ai Chi practitioner for 25 years.  Psycho-Physical Balance Therapy™ has a curriculum intended to be taught to health care professionals.  Using the nursing school (nurses are the original practitioners of complementary medicine) format as its model, there is a balance of classroom learning and clinical evaluation.  Outcomes for certification have been established by the Foundation and each participant receives a manual to use as a guide and reminder.  This intervention does not rely on a non-medical staff of T’an ai Chi professional but, instead, trains the hospital staff to deliver the program and achieve the results.  It is believed that this method of delivery can assist the staff in maintaining continuity of treatment in a safe atmosphere; accelerate the pace of the recovery process for the patient; and give the staff an increased sense of effectiveness.  Using this therapy as a regular part of patient care increases the patient’s compliance and allows for continued benefits.

The staff of Keswick Multi-Care Center in Baltimore, MD[xxii] has been trained in Psycho-Physical Balance Therapy™ and throughout 1998 worked with the residents of the center.  Researchers from Sheppard and Enoch Pratt Hospital, The Johns Hopkins University, Levindale-Hebrew Geriatric Care Center and Hospital (the control group) as well as Keswick and the T’ai Chi Foundation are studying the effect of this project on the staff and residents.  Study parameters include the incidence of falls, changes in mobility, monitoring of blood pressure, depression and anxiety scales and scales to measure morale.  Because of the dementia level of many of the nursing home residents many of the results are inconclusive.

Many medical, nursing and physical therapy schools have courses in “complementary medicine”, but these are mostly informative and not intended to train the student to master any of these therapies.  The larger implication of the Keswick project is, that if it gets favorable results, it would make sense for these schools to add Psycho-Physical Balance Therapy™ to its curriculum, enriching the training and skill of our doctors, nurses and physical therapists.

CASE STUDY UTILIZING T'AI CHI THERAPY

                  MN was a 53 year old Caucasian male with neurological injuries resulting from an automobile accident.  He was a pediatrician prior to the accident, but he has since been unable to practice his profession because of the extent of the resulting disabilities.  His neurologist referred him for T'ai Chi therapies because his lack of balance had resulted in frequent falls with serious injuries (16 broken bones).

            On 10-2-96, MN presented for a T’ai Chi therapy evaluation.  At that time a history was taken, documenting the events leading up to and following the accident, including medical and rehabilitation interventions. MN was also asked to perform certain kinesthetic tasks to determine the extent to which the brain injury affected his gait, posture and reactions and his compensatory mechanisms.  In addition, MN was asked a series of questions to determine how he had emotionally coped with his condition. This evaluation was followed by seven one-hour treatment sessions scheduled about one week apart.

            His medical diagnoses included: cortical blindness (he could see but he didn’t know what he was seeing), cerebellar contusion, spastic right hemiplegia of the lower extremities, spastic left hemiplegia of the upper extremities, hyperclonus in the right leg and occasionally in the left.

            Physically, he reported limited use of his left and right hand.  His left leg felt normal, but his right leg was spastic.  Emotionally he reported being depressed and considering suicide.  He had gotten upset and emotional without provocation.  Intellectually he feels he is sharp, with a thirst for information.  He has figured out how to sign his name and was trying to solve the problem of his vision loss.  He had had extensive physical rehabilitation and his neurologist has prescribed Lorazepam q4h prn and Amiltriptyline bid 75mg. for anxiety and depression respectively.

            MN sat in a wheel chair.  His spine was curved as he slouched, shoulders pulling forward and elbows resting on his thighs.  His neck craned and his head hung down. His chest and abdomen showed little movement as he breathed.  The muscles in his thighs and calves were weak and undeveloped, but he could correctly identify where he was touched, tapped and squeezed.  His mind was focused and he had an ironic sense of humor, but he would occasionally refer to this practitioner as Bill instead of his proper name, Bob.  When the inconsistency was pointed out, he dismissed it as unimportant.

            He said he could see a human figure only as an unrecognizable shape when it was within three feet of him.  He indicated that he could see the rug and its patterns but could only recognize it as such because he trained himself to do so by its location.  He was observed walking behind his wheel chair.  While doing so, he leaned forward, moving his legs without bending his knees.  He legs moved in rapid small spastic steps.  There was a great deal of back-and-forth movement in the torso and arms as well.

             MN's anxiety and depression appeared to be the result of his difficulty adapting to his disabled situation.  His posture, upper body tension, shallow breathing and his frantic walking may have been related to the embodiment of that fear and despondency.  He appeared fixated on the injustice done to him.  He used this injustice as a rationalization for his resistance to take responsibility for his outbursts.  His upper body tension, the lack of strength in his legs and his leaning posture accentuated the lack of balance and his tendency to fall.  Additionally, there was profound impact of his visual distortion and spasticity.

            A treatment plan was designed and implemented.  MN was taught to use methods of T’ai Chi practice and related tools of self-recognition to address all of his physical, emotional and intellectual disabilities within the limits of his brain injury.  Recognizing his inability to control his spasticity or prevent falls by stepping back in time to catch himself, the first step was to teach him to fall in a way that he could protect himself from injury.  MN reported falling every day for the duration of the treatment, but suffered no serious injury.  This apparently gave him the confidence to try other methods aimed at increasing his ambulation. 

            T'ai Chi breathing techniques were taught to assist him in getting more oxygen to his brain and to relax his chest and abdomen.  He began breathing in a prone position, allowing his upper body to stay straight and maximizing expansion of the chest.  This affected MN in three ways; he learned how to change his posture for optimal breathing, his moods were improved when he breathed deeply and his intellectual focus improved.

            MN was taught the T’ai Chi method of pouring weight from one leg to the other slowly, focusing on emptying the weight from one leg as it is shifted to the other.  The therapist molded MN’s body to straighten his posture and head while he shifted his weight and while he sat in his wheel chair.  He was also taught T'ai Chi exercises that helped coordinate the upper and lower body.  These “exercises”, provided a means of strengthening his legs allowing him to move with his knees bent and his upper body relaxed.  They also served to focus his thoughts on his points of balance, giving him some power over his tendency to fall. His new body awareness resulted in a postural straightness.  All of his friends commented about how good he looked.  He practiced diligently and his legs strengthened to the point where he could walk slowly but confidently when his girl friend held both hands.  He commented that this was the first time in three years that he was able to dance.  He was able to get out of his wheel chair and come gracefully to a standing position (previously he had to go down to the ground on his knees and pull himself up, using the side of his wheel chair).

            A method of emotional self-recognition was taught to MN to help him deal with his emotionality.  This was a gradual process.  In the first week he was asked to notice, and keep a diary of every time he had an emotional charge, and to identify the charge, e.g. anger, grief joy, etc.  The next week, he was asked to notice the muscular tension accompanying the charge, e.g. tightness in a particular location, posturing or facial tension.  In the third week he was taught to use the breathing and other T'ai Chi techniques he had learned, to relax any tension; muscular, postural or facial and observe how it affected the charge.  After the fourth session, he said the outbursts stopped.  His girl friend/caretaker felt she could take a break and go shopping, but his anxiety returned as he imagined being abandoned.  Each week he reported  "good days and bad" not just bad days.  This represented progress; he was problem solving, not just expressing the monotone of depression.

Conclusion

            Originating in China, but restricted in it’s spread until this century, the benefits of T’ai Chi practice are now available both East and West. The uniqueness of T’ai Chi emerges from it’s conscious focus on the fundamental principles of movement, while minimizing the expenditure of energy needed to accomplish any task. This approach has given rise to a martial art based on relaxation and yielding, which can be adapted as a health exercise that is both a method of conditioning and rehabilitation.

            Modern research has shown that when T’ai Chi is practiced on a regular basis, the immune, cardio-vascular, and musculo-structural systems receive significant benefit. Because of it’s gentle nature, T’ai Chi is an excellent choice as a life long health activity. Additionally, T’ai Chi is an appropriate choice for people whose health is challenged, and even for those in a rehabilitative situation such as a hospital or nursing home. By distilling the elements of the T’ai Chi form, while maintaining the essential principles, nursing and physical rehabilitative staff can be trained to deliver T’ai Chi as a therapeutic modality.

            Research studies to date have provided a small insight into the possibilities of T’ai Chi as a complementary therapy. Hopefully, future studies will be expanded to more fully explore the rich health generating potential of T’ai Chi Chuan.