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Review Article
Purpose: Tai chi is receiving increasing research attention with Results: Four studies met the inclusion criteria and were
its benefit of improving flexibility and balance. The objective included for data analysis. Results indicate positive effect
of this review was to examine the evidence concerning the of tai chi practice on dynamic postural stability in balance
impact of tai chi as a practical therapy for vestibular rehabilitation of its practitioners.
on individuals with balance and vestibular disorders. Conclusion: Tai chi may be a useful therapy as for vestibular
Method: A systematic review using 4 electronic databases rehabilitation as it improves dynamic balance control
was conducted. Randomized clinical trials and quasi- and flexibility of individuals with balance and vestibular
experimental studies were included. disorders.
P
eople with vestibular problems often experience Balance depends on proper function of vestibular, visual,
dizziness and trouble with balance, vision, or mo- and somatosensory systems, as well as other factors: muscle
bility. Vestibular disorders are associated with dys- strength, joint mobility, and cognition (Ganança, 2015).
function and deficit, unilateral or bilateral, in peripheral Balance impairment has a significant impact on health-
(outside the brain; part of the inner ear) and/or central system related quality of life of patients, especially on their emo-
(McDonnell & Hillier, 2015). Examples of these disorders tional and physical status (Gámiz & Lopez-Escamez, 2004;
include benign paroxysmal positional vertigo, vestibular Jacob, 1988; Lopez-Escamez, Gamiz, Fernandez-Perez,
neuritis, labyrinthitis, Ménière’s disease, and acoustic neuroma/ Gomez-Fiñana, & Sanchez-Canet, 2003).
vestibular schwannoma. Benign paroxysmal positional ver- Falls are reportedly the leading cause of physical and
tigo, for instance, a sudden vertigo induced by a change psychological trauma in population of age 65 years and
in head position (Hornibrook, 2011), is the most common older (Centers for Disease Control and Prevention [CDC],
disorder of the vestibular system in the inner ear that in- 2006). The risk of falls not only increases with age but is
creases in prevalence with age (Lawson, Johnson, Bamiou, also linked with balance and vestibular dysfunction, which
& Newton, 2005). Patients who undergo canalith reposi- has raised public health concerns (Scuffham, Chaplin, &
tioning maneuvers may show dizziness, insufficient postural Legood, 2003). A number of researchers proposed that
stability control, and increased risk of falls (Bressi et al., balance control ability and flexibility are associated with
2017; Di Girolamo et al., 1998). Moreover, vertiginous symp- falls, especially in the elderly population (Chiacchiero,
toms are often accompanied by elevated levels of anxiety and Dresely, Silva, DeLosReyes, & Vorik, 2010; Li et al., 2016;
emotional disturbance (Jacob, 1988). Dizziness is one of the Tse & Bailey, 1992). Participation in balance or muscle-
most common complaints among older adults (Furman, Raz, strengthening exercises can reduce the fall rate of this pop-
& Whitney, 2010; Hanley, O’Dowd, & Considine, 2001). ulation (CDC, 2006; Li et al., 2016; Tse & Bailey, 1992).
Tai chi, originally practiced as a martial art form by
the ancient Chinese (tai chi chuan), is an exercise derived
a
Department of Audiology and Speech Pathology, University of
from the martial art form consisting of slow, continuous,
Arkansas for Medical Sciences/University of Arkansas at Little Rock fluid movements for total self-development (Chang et al.,
b
Department of Audiology, Nova Southeastern University, 2011; Kuramoto, 2006). Physically, it is a gentle exercise
Fort Lauderdale, FL appropriate for older adults; mentally, it is a study of con-
c
Department of Library Education and Reference Services, University centration; spiritually, it is a practice of meditation (Galante,
of Arkansas for Medical Sciences, Little Rock 1981). Tai chi is also a preventive and curative branch in
Correspondence to Hsin-Wei Huang: hhuang2@uams.edu Chinese medicine (Kuramoto, 2006). Tai chi facilitates a
Editor-in-Chief: Sumitrajit Dhar number of health benefits, which include balance control,
Received July 13, 2018
Revision received December 3, 2018
Accepted December 10, 2018 Disclosure: The authors have declared that no competing interests existed at the time
https://doi.org/10.1044/2018_AJA-18-0115 of publication.
Participant (P) All patients of both sexes and all age groups with balance and vestibular disorders
Intervention (I) Use of tai chi as a practical therapy for vestibular rehabilitation on individuals with balance and vestibular
disorders
All styles of tai chi trainings were considered regardless of their forms, modifications (traditional or simplified),
and numbers of movements
Comparison (C) Following control groups were considered: patients who
(a) received no intervention
(b) conventional vestibular trainings
(c) rehabilitation including education, awareness, stress reduction, and exercises
Outcome (O) Clinical and/or behavioral measures to assess body and dynamic balance, dynamic gait function, neuromuscular
function, and trunk stability
Secondary outcome measures such as subjective evaluation of the symptom severity, relief of symptoms in
dizziness, level of confidence, and the impact of vestibular disorders in activities of daily living
PubMed, CINAHL, PsycINFO, and Web of Science on non–peer-reviewed publications, and uncontrolled studies
December 8, 2016, by an author with expertise in the devel- were also excluded.
opment of systematic search strategies (S. T.). Additional
publications were identified from the Google Scholar data- Types of Participants
base on January 31, 2017. Publication references were also Studies were not limited by age or gender of partici-
reviewed for potential study inclusion. Irrelevant publica- pants. Participants with balance and vestibular disorders
tions were excluded by scanning their titles and abstracts. were included.
Two sets of search terms were used in each database. Terms
related to tai chi such as tai chi or taiji were searched and Types of Interventions
coupled with search terms related to balance and vestibular Studies investigating the use of tai chi as a practi-
disorders such as vertigo or dizziness or falls. Date limits cal therapy for vestibular rehabilitation on individuals
were not applied. The search terms and search strategy are with balance and vestibular disorders were included. In
shown in Appendix A. this review, all styles of tai chi trainings were considered
regardless of their forms, modifications (traditional or
simplified), and numbers of movements.
Inclusion/Exclusion Criteria
A priori inclusion criteria were extended from the Types of Controls
PICO question and organized by study design, type of Studies with the following control groups were con-
intervention, and outcome measures used. Inclusion was sidered: participants who received (a) no intervention,
limited to high-quality studies meeting strong methodologi- (b) conventional vestibular trainings, or (c) rehabilitation
cal rigor requirements. The studies included in this review including education, awareness, stress reduction, and
met the following criteria: (a) study design = randomized exercises.
controlled trials (RCTs) or quasi-experimental studies;
(b) intervention = tai chi; (c) outcome = clinical and/or be- Types of Outcome Measures
havioral measures of dynamic balance and stability. The All studies included in this review used clinical and/
following criteria were considered for exclusion: (a) studies or behavioral measures to assess body and dynamic bal-
not written in English; (b) reviews, letters, or comments ance, dynamic gait function, neuromuscular function, and
of original studies; and (c) incomplete data or data not trunk stability. Some of the studies also addressed second-
available. Duplicates were excluded. Inclusion was limited ary outcome measures such as subjective evaluation of
to studies published in English. the symptom severity, relief of symptoms in dizziness, level
of confidence, and the impact of vestibular disorders in
activities of daily living.
Study Selection
Types of Studies Data Extraction and Quality Assessment
Studies included in this review were either RCTs The reviewers (H. H. and N. N.) scanned the titles
or quasi-experimental studies. Trials in which tai chi and abstracts of all studies identified in the initial search
as an intervention was performed for impairments other to locate any relevant RCTs and quasi-experimental stud-
than balance and vestibular disorders were excluded. ies. Hardcopies of all studies meeting the inclusion criteria
Case studies, case series, qualitative studies, reviews, were obtained and read in full. Each study was read and
the six measures (except for Stand on Left Leg, p ≤ .1641) ANOVA(H) = 5.04, p ≤ .024; maximum sway area:
in Control Group 2b with the tai chi cross-over. The ANOVA(H) = 8.86, p ≤ .002) for subjects participating
electromyography results demonstrated significant reduc- in tai chi exercise over the control group.
tion of the following outcome measures after tai chi train- Parameters assessed in the McGibbon et al. (2005)
ing: (a) tabialis anterior onset time (Group 1 by 50.25 ms, study consisted of dynamic gait function (time–distance
p ≤ .004; Group 2b by 17.36 ms, p ≤ .028) and (b) co- function), lower extremity motor control (mechanical
contraction (Group 1 from 50% to 0%, p ≤ .016). energy expenditures [MEEs]), and trunk stability (kine-
In the Lee, Jung, Abraham, Lei-Rivera, and Kim matics). The results demonstrated that tai chi and vestib-
(2012) experiment, the Activities-Specific Balance Confidence ular rehabilitation can improve gait function (gait speed:
Scale (ABC; Powell & Myers, 1995) and the Dynamic Gait p ≤ .009 in tai chi but p ≤ .060 in vestibular rehabilitation;
Index (DGI; Shumway-Cook & Woollacott, 1995) were step length: p ≤ .010 in tai chi and p ≤ .045 in vestibular
used to evaluate the utility of tai chi as an effective form rehabilitation; stance duration: p ≤ .055 in tai chi but p ≤ .044
of vestibular rehabilitation. The results revealed significant in vestibular rehabilitation). Moreover, tai chi improved
improvement (2.617, p ≤ .047) on ABC in Group 1 (nor- lower extremity motor control more than vestibular rehabil-
mal vestibular testing) and significant improvement (3.87, itation (reduced relative hip concentric MEE: p ≤ .001,
p ≤ .003) on DGI on Group 2 (abnormal vestibular testing). adjusted α = .017; and increased relative ankle concentric
However, there was no significant difference in Group 3 MEE: p ≤ .019, adjusted α = .025) by selective redistribu-
(central) and Group 4 (indeterminate). tion of joint energetics. The correlation revealed a stronger
Body balance was studied by using the 8 Foot Up gait and better trunk control.
and Go Test (Rikli & Jones, 1999) and Computer Posturo-
graphy for the limits of stability in the Maciaszek and
Osinski (2012) study. The results showed significant Discussion
improvement in four parameters (8 Foot Up and Go: Falls are the leading cause of physical and psycho-
ANOVA(H) = 8.32, p ≤ .003; forward deflection: logical trauma in the elderly population, each year affecting
ANOVA(H) = 3.70, p ≤ .050; backward deflection: approximately 30% of people of age 65 years and above
Population
GRADE Sample size (sex, Mean age Intervention (regimen) Control (regimen) Outcome
Study Design scoring male/female) years) (n = male/female) (n = male/female) measures
Gatts & Randomized Moderate 19 (2/17) 77.55 (TC) Simplified tai chi exercises (VT) Balance education, Clinical/behavioral:
Woollacott control (3 points) and repetition of 12 traditional awareness education, 1. Timed Up and Go
(2006) Control/ postures stress reduction, deep 2. Functional Reach
cross-over (90 min, 5 times weekly for breathing, and axial 3. Single Stance Time
3 weeks; n = 11 (1/10)) mobility exercise (90 min, 4. Tandem Stance Time
5 times weekly for Lab:
3 weeks; n = 8 (1/7)) Electromyography
1. tabialis anterior
2. medial gastrocnemius
Lee et al. Quasi- Low 37 (6/31) 72.30 (2, 3, 4) 16 Movements of Yang (1) 16 Movements of Yang 1. Activities-Specific
(2012) experimental (2 points) 1: Normal style with modification to suit style (45 min, 1 time Balance Scale
2: Vestibular each participant’s needs weekly for 8 weeks; 2. Dynamic Gait Index
Pre and post 3: Central (45 min, 1 time weekly for 8 weeks; n = 6)
4: Indeterminate n = 31)
Maciaszek & Randomized Low 40 69.70 (E) 5 sequences of movement (K) No tai chi intervention 1. 8 Foot Up and Go
Osinski control (2 points) chosen from the simplified (n = 20) 2. Computer Posturographic
(2012) 24 forms of tai chi System PE 90
(45 min, 2 times weekly for
18 weeks; n = 20)
McGibbon Randomized High 36 (16/20) 59.50 (TC) 5 movements of Yang-style (VR) eye–head coordination 1. Time–distance measure
et al. control (4 points) short form exercise, VOR training, for dynamic
(2005) (70 min, 1 time weekly for balance retraining exercise gait function
10 weeks; n = 19) (70 min, 1 time weekly 2. Mechanical energy
for 10 weeks; n = 17) expenditures for lower
extremity neuromuscular
control
3. Kinematics for trunk stability
Note. GRADE = Grading of Recommendations, Assessment, Development, and Evaluation; TC = tai chi; VT = vestibular training; E = experimental group with tai chi exercise;
K = control group; VR = vestibular rehabilitation; vestibulo-ocular reflex.
Total
Study Style session Movement Rationales of selection
Gatts & Yang 90 min, 12 Postures:commencement, white stork Traditional tai chi training
Woollacott Simplified 5 times cools its wing, brush knee, play the Tai chi chuan: the 27 forms
(2006) weekly for guitar, repulse monkey, heel kick,
3 weeks toe kick, golden cockerel, fair lady
21 hr total works the shuttles, part the wild
horses’ mane, cloud hands, cross
hands
Lee et al. Yang 45 min, 16 Movements: Traditional Yang style
(2012) Modified 1 time bow stance, bow and arrow, first tai chi
weekly for movement, gathering, polishing the
8 weeks table top, gathering energy, punching,
6 hr total stepping, stoking the fire, pitching,
turning the wheel, embrace the moon,
crane spreads wings, swimming, rooster
stands on 1 leg, repulse monkey
Maciaszek & Wuduan 45 min, 5 Sequences: 24-Form tai chi chuan
Osinski tai chi 2 times commencement, part the wild horses’ Yang style
(2012) chuan weekly for mane, white stork cools its wing,
Simplified 18 weeks brush knee, strums the lute, repulse
27 hr total monkey, grasp the bird’s tail, cloud
hands, single whip, high pat on horse,
rooster stands on 1 leg, needle to the
bottom of the sea, cross hands
McGibbon Yang 70 min, 5 Movements: Cheng Man-Ching’s
et al. Simplified 1 time rising the power, withdraw and push, Yang-style short form
(2005) weekly for cloud hands, brush knee twist step,
10 weeks separate right and left legs
11 hr total
(CDC, 2006). Research suggests that participation in bal- in this systematic review, the lack of homogeneity in terms
ance or muscle strengthening exercises can reduce the fall of outcome measures, styles, duration, and frequency of
rate of this population (Bergamaschi, Ferrari, Gallamini, the tai chi intervention among studies selected made it dif-
& Scoppa, 2011; CDC, 2006; Li et al., 2016). Tai chi is a ficult to establish the best protocol, other ideal parameters,
long-established martial art form that has been recognized or time of intervention to optimize health outcomes.
as an exercise, especially for elderly people (Chang et al., Two of the three RCTs were found to be of moder-
2011; Kuramoto, 2006; Tse & Bailey, 1992; Wolf et al., ate to low quality according to the GRADE scoring system
1996; Wolf, Coogler, et al., 1997). The literature demon- due to lack of clear reporting of allocation concealment or
strates that tai chi offers numerous cardiopulmonary, blinding of participants. None of the three RCTs blinded
musculoskeletal, and postural benefits to its practitioners the outcomes assessors or therapists, or if blinding was
(Kuramoto, 2006; Tse & Bailey, 1992; Wolf, Coogler, et al., used, it was poorly described. Lack of blinding increases
1997). Many studies have revealed that performance on the risk of biased results; thus, the strength of the evi-
balance outcome measures can be improved by practicing dence coming from these studies decreased. Although
tai chi (Kuramoto, 2006; Liu & Frank, 2010; Verhagen, the quasi-experimental study employed adequate methods
Immink, van der Meulen, & Bierma-Zeinstra, 2004; Wu, to show clearly the reliability, it was found to be of low
2002). Furthermore, tai chi has been utilized as a rehabilita- quality according to the GRADE scoring. This rating
tive technique for stroke patients (Au-Yeung et al., 2009; scale downgrades the research design because it was not
Taylor-Piliae et al., 2014), Parkinson’s disease (Hackney & an RCT and only provided observational evidence. In
Earhart, 2008; Li et al., 2012, 2014), and arthritis (Fransen addition, the sample size (ranged from 19 to 40 subjects)
et al., 2007; Song et al., 2003). may not have been sufficient to establish the validity of
Collectively, the results of the existing studies suggest the results found due to the variability in assessments and
that tai chi can be a practical complementary therapy interventions.
for vestibular rehabilitation as it is beneficial to individ- Although all studies selected (three RCTs and one
uals with symptoms, complaints, or a diagnosis of balance quasi-experimental study) reported positive significant
and vestibular impairment. Tai chi is a helpful practice findings on dynamic balance and improved gait and pos-
that can be used to improve flexibility and balance control tural performance, different parameters were used to as-
(Li et al., 2005; Nguyen et al., 2013; Tsang et al., 2004; sess body balance function. In the Gatts and Woollacott
Wayne et al., 2004; Wu, 2002; Zwick et al., 2000). However, (2006) study, functional mobility was examined using
Gatts &
Woollacott Lee et al. Maciaszek & McGibbon
Study (2006) (2012) Osinski (2012) et al. (2005)
Note. Questions of quality assessment are based on the Joanna Briggs Institute critical appraisal checklist. Y = yes; N = no; U = unclear;
H = high; M = moderate; L = low.
clinical/behavioral and electromyography measures. In the Some authors suggest that individuals with balance/
Lee et al. (2012) experiment, the ABC and the DGI were vestibular dysfunction and reduced memory ability may be
used to evaluate the utility of tai chi as an effective form better to start with short forms (Liu & Frank, 2010). Which
of vestibular rehabilitation. Body balance was studied by form should be selected depends on the individual tai chi
using the 8 Foot Up and Go Test and Computer Posturo- practitioner’s ability to perform particular body move-
graphy for the limits of stability in the Maciaszek and ments, which may vary extensively between forms and im-
Osinski (2012) study. Dynamic gait function, MEEs, and pact the practitioners’ ability to receive benefit from tai chi
trunk kinematics were the parameters used in the McGibbon (Liu & Frank, 2010). As Liu and Frank (2010) suggested,
et al. (2005) study. Moreover, uncertain vestibular dysfunc- shorter duration (< 12 weeks) may be better for more func-
tion limited the comparison; only the quasi-experimental tionally independent individuals, but it usually requires
study (Lee et al., 2012) demonstrated group-specific re- increased frequency and session length. On the contrary,
sponses of change attributed to tai chi therapy (Group 1: long duration with less frequency may provide supportive
normal vestibular; Group 2: abnormal vestibular; Group 3: effect on those who have a balance/vestibular deficit (Wolf
central; Group 4: indeterminate). et al., 1996). Several studies proposed that the selection
The duration and frequency of the exercise protocols of tai chi exercise parameters could have an impact on the
were variable among the studies (ranged from 6 to 27 hr outcome measures after tai chi training (Liu & Frank, 2010;
in total). As demonstrated in this review, the Yang style is Wolf et al., 1996). Additional research is needed to deter-
the most common style used for tai chi training. Numbers of mine the influence of practice frequency and intensity on
tai chi forms vary from short (five forms) to long (108 forms). balance and/or vestibular outcomes.
Appendix A ( p. 1 of 2)
Search Strategies 12/08/2016
Recent queries
Search Add to builder Query Items found Time
Search ID# Search terms Search options Last run via Results
Search ID# Search terms Search options Last run via Results
Web of Science
Set Results
#5 471 #3 AND #2
Indexes = SCI-EXPANDED, SSCI Timespan = All years
#4 796 #3 AND #1
Indexes = SCI-EXPANDED, SSCI Timespan = All years
#3 728,089 TOPIC: (vestibular OR vertigo OR balance OR dizzy OR dizziness
OR falls OR falling OR proprioception)
Indexes = SCI-EXPANDED, SSCI Timespan = All years
#2 19,462 TOPIC: (acupuncture OR meridians)
Indexes = SCI-EXPANDED, SSCI Timespan = All years
#1 1,914 TOPIC: (“tai chi” OR “tai ji” OR taiji OR taijiquan OR “t’ai chi”)
Indexes = SCI-EXPANDED, SSCI Timespan = All years
GRADE Scores: ☐ High (at least 4) ☐ Moderate (3) ☐ Low (2) ☐ Very Low (1 or less)
Study Design: ☐ Randomized control trial ☐ One group pretest posttest design
☐ Pretest posttest design with a control group ☐ Posttest design ☐ Mixed Research
Type of evidence
Initial score based on type of +4RCTs/ SR of RCTs, +/− other types of evidence
evidence +2Observational evidence (e.g., cohort, case-control)
Quality
Based on Blinding and allocation process
Follow-up and withdrawals
Sparse data
Other methodological concerns (e.g., incomplete reporting, subjective outcomes)
Score 0 No problems
−1Problem with 1 element
−2Problem with 2 elements
−3Problem with 3 or more elements
Consistency
Based on Degree of consistency of effect between or within studies
Score +1Evidence of dose response across or within studies (or inconsistency across studies is explained by a dose
response); also 1 point added if adjustment for confounders would have increased the effect size
0 All/most studies show similar results
−1Lack of agreement between studies (e.g., statistical heterogeneity between RCTs, conflicting results)
Directness
Based on The generalizability of population and outcomes from each study to our population of interest
Score 0 Population and outcomes broadly generalizable
−1Problem with 1 element
−2Problem with 2 or more elements
Effect size
Based on The reported OR/RR/HR for comparison
Score 0 Not all effect sizes > 2 or < 0.5 and significant; or if OR/RR/HR not significant
+1Effect size > 2 or < 0.5 for all studies/meta-analyses included in comparison and significant
+2Effect size > 5 or < 0.2 for all studies/meta-analyses included in comparison and significant