TH Improving Balance With Tai Chi - VeDA

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TH5018 NE 15 AVE · PORTLAND, OR 97211 · FAX: (503) 229-8064 · (800) 837-8428 · INFO@VESTIBULAR.ORG · VESTIBULAR.ORGImproving Balance with Tai ChiBy the Vestibular Disorders Association with contributions by Gaye Cronin, OTD, OTR, AtlantaEar Clinic, Atlanta, GAThe profound dizziness, vertigo, andimbalance symptoms commonly experienced with vestibular (inner ear balance)disorders can cause overwhelming fatigueand anxiety. Many people suffering fromvestibular disorders limit their activitiesbecause of these factors as well as fear offalling, a risk that increases eight-fold inthose actively experiencing the symptomsof their disorder.1Falling can cause injuries that severelyimpair mobility or end lives, especially forpeople aged 65 and older, for whom fallsare the leading cause of both fatal andnon-fatal injuries.2 However, prolongedinactivity reduces one’s ability to compensate for a vestibular disorder and oftencontributes to other problems, includingloss of bone and muscle mass, heartdisease, and obesity. The emotional painof social isolation and the loss of formerlyenjoyed activities can be no less profound.Fortunately, many types of vestibular disorders respond well to vestibular rehabilitation therapy (VRT). VRT exercises aredesigned to help recalibrate the complexinteraction of sensory and motorfunctions required for good balance. TaiChi also challenges this same complexinteraction. Both VRT and Tai Chi involveexercises that focus on posturalorientation (positioning the trunk andhead in alignment to each other as wellas to the ground and to the visual field)and postural equilibrium (coordinatingmovement strategies to center andstabilize the body).3 Extensive medicalliterature, as well as the direct experienceof physical therapists and other clinicians,supports Tai Chi as an excellentcomplementary therapy to vestibularrehabilitation.What is Tai Chi?Originating in China centuries ago, TaiChi (a shortened version of the moretraditional name tai chi chuan) is amartial art characterized by gracefullyflowing movements and postures. Tai Chiis popularly practiced throughout theworld, often with an emphasis onmaintaining good health and promotinglongevity. It emphasizes the interconnected nature of the body and mind(Figure 1), combining “physicalmovement, breathing techniques, andcognitive tools to strengthen the body,relax the mind, and balance the flow oflife force,”4 also known as chi (alsospelled ki or qi). Chi loosely means“energy,” and people performing Tai Chipostures and movements—also called Vestibular Disorders Association vestibular.org Page 1 of 7

forms—are encouraged to visualize orimagine their own Chi in order to improvetheir movements and focus.Figure 1. The interconnectednature of body and mind andconcept of balance is symbolized bythe yin-yang symbol traditionallyassociated with Tai Chi.As is common with martial arts, there areseveral different schools and styles ofpractice, some more vigorous and challenging than others. However, all sharethe same forms, which depending onstyle, instructor, or level of experiencecan be performed in combinations rangingin complexity from just a few to over ahundred. The most popular type of Tai Chiis the simplified 24-form version developed from the Yang style by the ChineseSports Committee in 1956 as a publichealth program. It offers the advantage ofmaintaining many traditional Tai Chi principles while being simple and gentleenough to be practiced by people of allages and physical ability.Balance benefits of Tai ChiTai Chi improves balance in several ways: It strengthens and improves ankleflexibility, creating a more stablestance.4,5 It helps to distribute movement moreevenly among the ankle, knee, andhip joints, enabling faster andsmoother walking.4 It helps reduce postural sway byoptimizing the use of proprioception—sensory input received by the brainfrom touch sensors in the muscles andjoints—in the balancing process.6 It generally promotes a greaterawareness of body and movement.7In addition to balance benefits, Tai Chioffers a broad range of well studiedpositive health impacts for cardiovascular,respiratory, and immune systemimprovement.6 Increased endurance andmental focus, as well as an improvedsense of well-being, have also beenreported from programs using Tai Chiactivities. With the right style andprogram, Tai Chi is a gentle, low-impactactivity easily enjoyed by a wide range ofpeople, including older adults, who aredisproportionally affected by vestibulardisorders coupled with complicatingfactors affecting compensation. Thesefactors include multi-sensory loss andgeneral mobility limitations.8 Tai Chiimproves performance of the activities ofdaily living, and is also particularly helpfulin reducing the fear of falling and thegeneral stress that so often accompanysymptoms of dizziness and vertigo.7Clinical observation of Tai ChiOne of us (G.C.) has observed thepositive affects of Tai Chi in clinicalpractice (Atlanta Ear Clinic, GA) fromworking with many patients requiringvestibular rehabilitation and balanceretraining. Before beginning anytreatment plan, patients who present withbalance disorders are carefully evaluatedwith a sensory organization test (SOT) fortheir skill in organizing visual, vestibular,and proprioceptive information during six Vestibular Disorders Association vestibular.org Page 2 of 7

tasks of increasing difficulty. Otherclinical norm-referenced balanceassessments are also used to evaluatepatients’ static and dynamic balanceabilities.week version of program has been shownto be effective in improving functionalbalance and reducing falls by 55% inphysically inactive persons aged 70 orolder.10Our interest in using Tai Chi in treatmentwas prompted in part by following eightpatients who enrolled in a six-week TaiChi class. Prior to the class, all haddemonstrated abnormal SOT scores. Inaddition, four had experienced falls, andtwo were using assistive devices forwalking (one cane and one walker). Aftercompleting the six-week Tai Chi class, alleight patients scored within normalranges on the SOT and exhibitedincreased confidence and activity levels.The two using assistive devices were ableto discontinue using them, and six monthslater, none of the patients had experienced falls.8 Since then, many patients atthe Atlanta Ear Clinic have significantlyimproved their balance and overall qualityof life by incorporating Tai Chi into theirvestibular rehabilitation program.To facilitate this program’s implementation at community and seniorcenters, a simplified version of the TCMBBprogram is being taught to instructtors.One of us (M.R.) attended this training atEmanuel Legacy Hospital (Portland, OR)led by Suman Sensei Barkhas, anationally certified yoga therapist and TaiChi teacher-trainer. The program modifiesthe 24-form Yang style even further to agentle, easily performed eight-form style.The eight forms were chosen for theiraccessibility as well as their focus on“weight-bearing and non-weight-bearingstances, posturally correct bodyalignment, and multiple, coordinatedmovements executed in a continuous,circular, and flowing manner.”11Implementing a Tai Chi program forfall preventionA variety of Tai Chi programs areavailable for implementing at a clinic orcommunity level. One example is Tai Chi:Moving for Better Balance (TCMBB), aYang-style program developed byFuzhong Li, PhD, of the Oregon ResearchInstitute (Eugene, OR). It is supportedwith a grant from the Centers for DiseaseControl to help create clinically appropriate, evidence-supported fall-preventionstrategies.9 A six-month, three-times perThe lynchpin of this eight-form style isthe first form students learn, and is calledhold a ball (Figure 2). This form begins byfirmly rooting and centering the stance,then focusing on visualizing chi, drawingit out from the center of the body andthen shaping the hands in a circle aroundit. Students then gently step from sideto-side, a movement often repeatedthroughout the rest of the forms. Thenext seven forms—part the wild horse’smane, single whip, hands like clouds,repulse monkey, brush knee, fair ladyworks the shuttles, and grasp thepeacock’s tail—borrow their names and Vestibular Disorders Association vestibular.org Page 3 of 7

movements from the natural world aswell as activities historically common toChinese life. Fair lady works the shuttles,for instance, references hands rising upand down as if working a loom.Figure 2. The hold a ball form is the basis formany of the movements in the “Tai Chi:Moving for Better Balance” program. Photoused with permission from Juliette McCawleyand distributed under a Creative Commonslicense viawww.flickr.com/photos/75304241@N00/.Each form coordinates multiplemovements of the hands and feet withslow, relaxed breathing; for example,hold a ball consists of 14 separate postures. The TCCMB program is designed tointroduce only one or two forms in eachclass and to build to increasing levels ofcomplexity. The last form students learn,grasp the peacock’s tail, consists of 23separate postures—a level of complexitymade possible by the program’scareful attention to building on previousprogress.A user-friendly resource package11 forimplementing the TCCMB programadvises class instructors to devote severalminutes of each class to warming up andcooling down and to progress slowly,having students practice each form for 8–10 times as needed. The program’s focusis on building core strength and focusingthought on balance so that participantscan become more aware of the body andits movements. Safety is emphasized,with instructors trained to encourage theirstudents to consult a health care providerbefore engaging in the program and toadapt the forms to their uniquecircumstances and physical limitations.Those with low or no mobility can start byparticipating from a seated position. Alsoemphasized is the sense of Tai Chi as fun,a form of play with psychological benefitsas profound as the physical ones. Instructors are to encourage their students totake pleasure from performing the forms,and to focus their energy and breathingon achieving a calm but alert state ofmind.Enrolling in a Tai Chi programBefore enrolling in a Tai Chi program,seeking advice from a physical therapistor physician with vestibular disorderexpertise is strongly recommended tomake sure that the forms can beperformed safely. Additionally, becauseTai Chi instructors use varied programsand have different levels of expertise inhelping people with balance disorders,asking for recommendations from ahealth care provider can be useful when Vestibular Disorders Association vestibular.org Page 4 of 7

selecting the particular course to take.Senior centers and balance and wellnessprograms are also good resources forfinding qualified instructors.what level of mobility or physical abilitythat individuals bring with them to TaiChi, improvement—and just as important,enjoyment—is possible for everyone.It is important to take a class forbeginners that is taught in a gentle stylesuch as Yang, with session lengths nolonger than an hour. Ideally, the courseshould be taught by a qualified instructorwho is widely experienced with teachingpeople with balance disorders or limitedmobility. Once a program is selected, adiscussion with the Tai Chi instructor isimportant so that he or she is aware of allbalance challenges or other physicalproblems that may limit mobility. Tai Chiemphasizes deliberate and gentlemovement, but it is still possible toperform the forms incorrectly, leading tostrain or injury. A Tai Chi instructor wellexperienced in teaching people withvestibular disorders can provide carefulone-on-one instruction to correct errors inmovement and help to preventoverstrain. The instructor may also helpto adapt the program as needed.Additional resourcesSome helpful publications from theVestibular Disorders Association (VEDA)include Balance and Aging and VestibularRehabilitation: An Effective, EvidenceBased Treatment. For more informationon Tai Chi: Moving for Better Balance,contact Li Fuzhong (www.ori.org) orSuman Sensei Barkhas(http://shantalaya.com).Finally, anyone starting a Tai Chi courseshould be prepared to commit to an 8–12week program, because benefits taketime to become noticeable. Classes do notrequire wearing special athleticequipment or clothing, although wearingloose-fitting clothing and flat comfortableshoes or going barefoot is recommended.Programs with an accompanying DVD,such as is available for the TCMBBprogram, make home practice easier oncethe Tai Chi class concludes. No matterReferences1. Agrawal Y, Carey JP, Della Santina CC,2.3.4.5.6.Schubert MC, Minor LB. Disorders of balanceand vestibular function in US adults. ArchIntern Med. 2009;169(10):938–944.Self-reported falls and fall-related injuriesamong persons aged 65 years—UnitedStates, 2006. MMWR Morb Mortal Wkly Rep.2008; 57:225–229.Horak FB. Postural orientation and equilibrium: what dowe need to know about neural control ofbalance to prevent falls? Age Ageing.2006;35(suppl 2):ii7–ii11.McGibbon CA, Krebs DE, Parker SW,Scarborough DM, Wayne PM, Wolf SL. TaiChi and vestibular rehabilitation improvevestibulopathic gait via different neuromuscular mechanisms: preliminary report.Bio Med Neurol. 2005;5(3).Gauchard GC, Jeandel C, Tessier A, PerrinPP. Beneficial effect of proprioceptive physical activities on balance control in elderlyhuman subjects. Neuroscience Lett.1999;273:81–84.Gauchard CG, Gangloff P, Jeandel C, PerrinPP. Influence of regular proprioceptive andbioenergetic physical activities on balancecontrol in elderly women. J Gerontol. 2003;58(9):846–850. Vestibular Disorders Association vestibular.org Page 5 of 7

7. Wayne PM, Krebs DE, Wolf SL, Gill-BodyKM, Scarborough DM, McGibbon CA,Kaptchuk TJ, Parker SW. Can Tai Chiimprove vestibulopathic postural control?Arch Phys Med Rehabil. 2004;85:142–152.8. Cronin GW. Clinician Handbook for theTreatment of Vestibular Disorders. Atlanta,GA: Atlanta Ear Clinic; 2000.9. Stevens J, Sogolow ED. Preventing Falls:What Works—A Compendium of EffectiveCommunity-based Interventions fromAround the World. National Center for InjuryPrevention and Control. Atlanta, GA; 2008.10. Fuzhong L, Harmer P, Fisher KJ, McAuleyE, Chaumeton N, Eckstrom E. Tai Chi andfall reductions in older adults: a randomizedcontrolled trial. J Gerontol. 2005;60A:187–194.11. Fuzhong L, Harmer P, Glasgow R, Mack K,Sleet D, Fisher J, Kohn MA, Millet LM, MeadJ, Xu J, Lin M, Tingzhong Y, Sutton B,Tompkins Y. Translation of an effective TaiChi intervention into a community-basedfalls-prevention program. Am J Pub Health.2008;98(7):1195–1198.12. Tai Chi: Moving for Better Balance [Version5]. Eugene, OR: Oregon Research Institute;2008. Vestibular Disorders AssociationVEDA’s publications are protected undercopyright. For more information, see ourpermissions guide at www.vestibular.org.This document is not intended as a substitutefor professional health care. Vestibular Disorders Association vestibular.org Page 6 of 7

TH5018 NE 15 AVE · PORTLAND, OR 97211 · FAX: (503) 229-8064 · (800) 837-8428 · INFO@VESTIBULAR.ORG · VESTIBULAR.ORGDid this free publication from VEDA help you?Thanks to VEDA, vestibular disorders are becoming widely recognized, rapidly diagnosed,and effectively treated.VEDA’s mission is to inform, support, and advocate for the vestibular community.You can help! Your tax-deductible gift makes sure that VEDA’s valuable resources reachthe people who can benefit from them most – vestibular patients like you!JOIN VEDA TO DEFEAT DIZZINESS By making a donation of: 40 75Senior discounts are available; contact us for details. 100 250 1,000 2,500Members receive a Patient Toolkit, a subscription to VEDA’s newsletter, On the Level containing information on diagnosis, treatment, research, and coping strategies - accessto VEDA’s online member forum, the opportunity to join V-PALS, a pen-pals network forvestibular patients, and more!For healthcare professionals: Individual and clinic/hospital memberships are available.Professional members receive a subscription to VEDA’s newsletter, a listing in VEDA’sprovider directory, co-branded educational publications for their patients, access to amulti-specialty online forum, and the opportunity to publish articles on VEDA’s website.For details, call (800) 837-8428, email info@vestibular.org or visithttps://vestibular.org/membership.MAILING INFORMATIONNameAddress CityState/Province Zip/Postal code CountryTelephone E-mail Send my newsletter by email (Free) Send my newsletter by mail (U.S. – Free; 25 outside the U.S.)PAYMENT INFORMATION Check or money order in U.S. funds, payable to VEDA (enclosed) Visa MC AmexCard numberExp. date (mo./yr.)CSV CodeBilling address of card (if different from mailing information)Or visit us on our website at https://vestibular.org to make a secure online contribution.

Chi also challenges this same complex interaction. Both VRT and Tai Chi involve exercises that focus on postural orientation (positioning the trunk and . hold a ball (Figure 2). This form begins by firmly rooting and centering the stance, t

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