PO BOX 13305 · PORTLAND, OR 97213 · FAX: (503) 229-8064 · (800) 837-8428 · [email protected] · WWW.VESTIBULAR.ORG Improving Balance with Tai Chi By the Vestibular Disorders Association with contributions by Gaye Cronin, OTD, OTR, Atlanta Ear Clinic, Atlanta, GA The profound dizziness, vertigo, and exercises that focus on postural imbalance symptoms commonly experi- orientation (positioning the trunk and enced with vestibular (inner ear balance) head in alignment to each other as well disorders can cause overwhelming fatigue as to the ground and to the visual field) and anxiety. Many people suffering from and postural equilibrium (coordinating vestibular disorders limit their activities movement strategies to center and because of these factors as well as fear of stabilize the body).3 Extensive medical falling, a risk that increases eight-fold in literature, as well as the direct experience those actively experiencing the symptoms of physical therapists and other clinicians, of their disorder.1 supports Tai Chi as an excellent complementary therapy to vestibular Falling can cause injuries that severely rehabilitation. impair mobility or end lives, especially for people aged 65 and older, for whom falls What is Tai Chi? are the leading cause of both fatal and Originating in China centuries ago, Tai non-fatal injuries.2 However, prolonged Chi (a shortened version of the more inactivity reduces one’s ability to compen- traditional name tai chi chuan) is a sate for a vestibular disorder and often martial art characterized by gracefully contributes to other problems, including flowing movements and postures. Tai Chi loss of bone and muscle mass, heart is popularly practiced throughout the disease, and obesity. The emotional pain world, often with an emphasis on of social isolation and the loss of formerly maintaining good health and promoting enjoyed activities can be no less profound. longevity. It emphasizes the intercon- nected nature of the body and mind Fortunately, many types of vestibular dis- (Figure 1), combining “physical orders respond well to vestibular rehabili- movement, breathing techniques, and tation therapy (VRT). VRT exercises are cognitive tools to strengthen the body, designed to help recalibrate the complex relax the mind, and balance the flow of interaction of sensory and motor life force,”4 also known as chi (also functions required for good balance. Tai spelled ki or qi). Chi loosely means Chi also challenges this same complex “energy,” and people performing Tai Chi interaction. Both VRT and Tai Chi involve postures and movements—also called © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 1 of 7 forms—are encouraged to visualize or from touch sensors in the muscles and imagine their own Chi in order to improve joints—in the balancing process.6 their movements and focus.  It generally promotes a greater awareness of body and movement.7 Figure 1. The interconnected nature of body and mind and In addition to balance benefits, Tai Chi concept of balance is symbolized by offers a broad range of well studied the yin-yang symbol traditionally associated with Tai Chi. positive health impacts for cardiovascular, respiratory, and immune system As is common with martial arts, there are improvement.6 Increased endurance and several different schools and styles of mental focus, as well as an improved practice, some more vigorous and chal- sense of well-being, have also been lenging than others. However, all share reported from programs using Tai Chi the same forms, which depending on activities. With the right style and style, instructor, or level of experience program, Tai Chi is a gentle, low-impact can be performed in combinations ranging activity easily enjoyed by a wide range of in complexity from just a few to over a people, including older adults, who are hundred. The most popular type of Tai Chi disproportionally affected by vestibular is the simplified 24-form version devel- disorders coupled with complicating oped from the Yang style by the Chinese factors affecting compensation. These Sports Committee in 1956 as a public factors include multi-sensory loss and health program. It offers the advantage of general mobility limitations.8 Tai Chi maintaining many traditional Tai Chi prin- improves performance of the activities of ciples while being simple and gentle daily living, and is also particularly helpful enough to be practiced by people of all in reducing the fear of falling and the ages and physical ability. general stress that so often accompany symptoms of dizziness and vertigo.7 Balance benefits of Tai Chi Tai Chi improves balance in several ways: Clinical observation of Tai Chi  It strengthens and improves ankle One of us (G.C.) has observed the flexibility, creating a more stable positive affects of Tai Chi in clinical stance.4,5 practice (Atlanta Ear Clinic, GA) from  It helps to distribute movement more working with many patients requiring evenly among the ankle, knee, and vestibular rehabilitation and balance hip joints, enabling faster and retraining. Before beginning any smoother walking.4 treatment plan, patients who present with  It helps reduce postural sway by balance disorders are carefully evaluated optimizing the use of proprioception— with a sensory organization test (SOT) for sensory input received by the brain their skill in organizing visual, vestibular, and proprioceptive information during six © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 2 of 7 tasks of increasing difficulty. Other week version of program has been shown clinical norm-referenced balance to be effective in improving functional assessments are also used to evaluate balance and reducing falls by 55% in patients’ static and dynamic balance physically inactive persons aged 70 or abilities. older.10 Our interest in using Tai Chi in treatment To facilitate this program’s imple- was prompted in part by following eight mentation at community and senior patients who enrolled in a six-week Tai centers, a simplified version of the TCMBB Chi class. Prior to the class, all had program is being taught to instructtors. demonstrated abnormal SOT scores. In One of us (M.R.) attended this training at addition, four had experienced falls, and Emanuel Legacy Hospital (Portland, OR) two were using assistive devices for led by Suman Sensei Barkhas, a walking (one cane and one walker). After nationally certified yoga therapist and Tai completing the six-week Tai Chi class, all Chi teacher-trainer. The program modifies eight patients scored within normal the 24-form Yang style even further to a ranges on the SOT and exhibited gentle, easily performed eight-form style. increased confidence and activity levels. The eight forms were chosen for their The two using assistive devices were able accessibility as well as their focus on to discontinue using them, and six months “weight-bearing and non-weight-bearing later, none of the patients had experi- stances, posturally correct body enced falls.8 Since then, many patients at alignment, and multiple, coordinated the Atlanta Ear Clinic have significantly movements executed in a continuous, improved their balance and overall quality circular, and flowing manner.”11 of life by incorporating Tai Chi into their vestibular rehabilitation program. The lynchpin of this eight-form style is the first form students learn, and is called Implementing a Tai Chi program for hold a ball (Figure 2). This form begins by fall prevention firmly rooting and centering the stance, A variety of Tai Chi programs are then focusing on visualizing chi, drawing available for implementing at a clinic or it out from the center of the body and community level. One example is Tai Chi: then shaping the hands in a circle around Moving for Better Balance (TCMBB), a it. Students then gently step from side- Yang-style program developed by to-side, a movement often repeated Fuzhong Li, PhD, of the Oregon Research throughout the rest of the forms. The Institute (Eugene, OR). It is supported next seven forms—part the wild horse’s with a grant from the Centers for Disease mane, single whip, hands like clouds, Control to help create clinically appropri- repulse monkey, brush knee, fair lady ate, evidence-supported fall-prevention works the shuttles, and grasp the strategies.9 A six-month, three-times per peacock’s tail—borrow their names and © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 3 of 7 movements from the natural world as well as activities historically common to A user-friendly resource package11 for Chinese life. Fair lady works the shuttles, implementing the TCCMB program for instance, references hands rising up advises class instructors to devote several and down as if working a loom. minutes of each class to warming up and cooling down and to progress slowly, having students practice each form for 8– 10 times as needed. The program’s focus is on building core strength and focusing thought on balance so that participants can become more aware of the body and its movements. Safety is emphasized, with instructors trained to encourage their students to consult a health care provider before engaging in the program and to adapt the forms to their unique circumstances and physical limitations. Those with low or no mobility can start by participating from a seated position. Also emphasized is the sense of Tai Chi as fun, a form of play with psychological benefits Figure 2. The hold a ball form is the basis for as profound as the physical ones. Instruc- many of the movements in the “Tai Chi: Moving for Better Balance” program. Photo tors are to encourage their students to used with permission from Juliette McCawley take pleasure from performing the forms, and distributed under a Creative Commons and to focus their energy and breathing license via www.flickr.com/photos/75304241@N00/. on achieving a calm but alert state of mind. Each form coordinates multiple movements of the hands and feet with Enrolling in a Tai Chi program slow, relaxed breathing; for example, Before enrolling in a Tai Chi program, hold a ball consists of 14 separate pos- seeking advice from a physical therapist tures. The TCCMB program is designed to or physician with vestibular disorder introduce only one or two forms in each expertise is strongly recommended to class and to build to increasing levels of make sure that the forms can be complexity. The last form students learn, performed safely. Additionally, because grasp the peacock’s tail, consists of 23 Tai Chi instructors use varied programs separate postures—a level of complexity and have different levels of expertise in made possible by the program’s helping people with balance disorders, careful attention to building on previous asking for recommendations from a progress. health care provider can be useful when © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 4 of 7 selecting the particular course to take. what level of mobility or physical ability Senior centers and balance and wellness that individuals bring with them to Tai programs are also good resources for Chi, improvement—and just as important, finding qualified instructors. enjoyment—is possible for everyone. It is important to take a class for Additional resources beginners that is taught in a gentle style Some helpful publications from the such as Yang, with session lengths no Vestibular Disorders Association (VEDA) longer than an hour. Ideally, the course include Balance and Aging and Vestibular should be taught by a qualified instructor Rehabilitation: An Effective, Evidence- who is widely experienced with teaching Based Treatment. For more information people with balance disorders or limited on Tai Chi: Moving for Better Balance, mobility. Once a program is selected, a contact Li Fuzhong (www.ori.org) or discussion with the Tai Chi instructor is Suman Sensei Barkhas important so that he or she is aware of all (http://shantalaya.com). balance challenges or other physical problems that may limit mobility. Tai Chi References emphasizes deliberate and gentle 1. Agrawal Y, Carey JP, Della Santina CC, movement, but it is still possible to Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults. Arch perform the forms incorrectly, leading to Intern Med. 2009;169(10):938–944. strain or injury. A Tai Chi instructor well 2. Self-reported falls and fall-related injuries experienced in teaching people with among persons aged >65 years—United States, 2006. MMWR Morb Mortal Wkly Rep. vestibular disorders can provide careful 2008; 57:225–229. one-on-one instruction to correct errors in 3. Horak FB. Postural orientation and equilib- movement and help to prevent rium: what do we need to know about neural control of overstrain. The instructor may also help balance to prevent falls? Age Ageing. to adapt the program as needed. 2006;35(suppl 2):ii7–ii11. 4. McGibbon CA, Krebs DE, Parker SW, Scarborough DM, Wayne PM, Wolf SL. Tai Finally, anyone starting a Tai Chi course Chi and vestibular rehabilitation improve should be prepared to commit to an 8–12 vestibulopathic gait via different neuro- week program, because benefits take muscular mechanisms: preliminary report. Bio Med Neurol. 2005;5(3). time to become noticeable. Classes do not 5. Gauchard GC, Jeandel C, Tessier A, Perrin require wearing special athletic PP. Beneficial effect of proprioceptive physi- equipment or clothing, although wearing cal activities on balance control in elderly human subjects. Neuroscience Lett. loose-fitting clothing and flat comfortable 1999;273:81–84. shoes or going barefoot is recommended. 6. Gauchard CG, Gangloff P, Jeandel C, Perrin Programs with an accompanying DVD, PP. Influence of regular proprioceptive and bioenergetic physical activities on balance such as is available for the TCMBB control in elderly women. J Gerontol. 2003; program, make home practice easier once 58(9):846–850. the Tai Chi class concludes. No matter © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 5 of 7 7. Wayne PM, Krebs DE, Wolf SL, Gill-Body J, Xu J, Lin M, Tingzhong Y, Sutton B, KM, Scarborough DM, McGibbon CA, Tompkins Y. Translation of an effective Tai Kaptchuk TJ, Parker SW. Can Tai Chi Chi intervention into a community-based improve vestibulopathic postural control? falls-prevention program. Am J Pub Health. Arch Phys Med Rehabil. 2004;85:142–152. 2008;98(7):1195–1198. 8. Cronin GW. Clinician Handbook for the 12. Tai Chi: Moving for Better Balance [Version Treatment of Vestibular Disorders. Atlanta, 5]. Eugene, OR: Oregon Research Institute; GA: Atlanta Ear Clinic; 2000. 2008. 9. Stevens J, Sogolow ED. Preventing Falls: What Works—A Compendium of Effective © Vestibular Disorders Association Community-based Interventions from Around the World. National Center for Injury Prevention and Control. Atlanta, GA; 2008. VEDA’s publications are protected under 10. Fuzhong L, Harmer P, Fisher KJ, McAuley copyright. For more information, see our E, Chaumeton N, Eckstrom E. Tai Chi and permissions guide at www.vestibular.org. fall reductions in older adults: a randomized controlled trial. J Gerontol. 2005;60A:187– This document is not intended as a substitute 194. for professional health care. 11. Fuzhong L, Harmer P, Glasgow R, Mack K, Sleet D, Fisher J, Kohn MA, Millet LM, Mead © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 6 of 7 PO BOX 13305 · PORTLAND, OR 97213 · FAX: (503) 229-8064 · (800) 837-8428 · [email protected] · WWW.VESTIBULAR.ORG Did this free publication from VEDA help you? Thanks to VEDA, vestibular disorders are becoming S SUPPORT VEDA A recognized for their impacts on lives and our economy. We see new diagnostic tools and research studies, more Membership, 1-year $ 40  Basic accessible treatments, and a growing respect for how $110  Professional life-changing vestibular disorders can be. Memberships include electronic & online newsletter & free publications. For hard copies, include optional shipping fees. 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