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Original article
Effects of therapeutic Tai Chi on balance, gait, and quality of life in chronic stroke patients HoYoung Kim, You Lim Kim and Suk Min Lee The aim of this study was to analyze the effects of therapeutic Tai Chi on balance, gait, and quality of life in chronic stroke patients. Twenty-two inpatients diagnosed with stroke were divided randomly into two groups: one treated with both general physical therapy and Tai Chi exercise (11 patients) and one treated with only general physical therapy (11 patients). Therapeutic Tai Chi included 10 different movements and was performed for 60 min, twice per week, for 6 weeks. Pretest and post-test measurements were recorded for sway length and sway velocity using Gaitview, the functional reach test, the dynamic gait index, the 10-m walking test, the timed upand-go test, and SF-36 survey. Both the Tai Chi group and the control group showed a significant improvement in sway length and sway velocity, and the Tai Chi group showed greater improvement than the control group in degree of variation. In addition, only the Tai Chi group showed a significant result for functional reach test, the dynamic gait index, the 10-m walking test, the timed up-and-go test, and the Tai Chi group improved. In the quality of life, the
Introduction Compared with healthy individuals, postural perturbations of a standing position increased two-fold in hemiplegic patients with stroke (Nichols, 1997). Moreover, the ability to adjust the center of gravity while maintaining balance is decreased. Accordingly, the decreased balance ability limits the scope of activities of daily living of the patient and secondarily increases the risk of injury (Teasell et al., 2002). To maintain balance, vision, vestibular function, and proprioception must be properly integrated with metacognitive skills. However, in the case of stroke patients, the problem occurs in the integration of motor nerve function to adjust position in response to visual, vestibulosensory, and somatosensory input. These problems decrease the balance of stroke patients and reduce gait ability significantly (Barclay-Goddard et al., 2004). Dean et al. (2009) reported the importance of balance training to increase physical activity capacity and reduce the risk of fall in stroke patients. The balance training improved attitude control capability and weight shift of the paralyzed side in the gait of stroke patients (Yavuzer et al., 2006). Recently, healthcare systems worldwide have been struggling to provide medical services for the fundamental treatment of patients. As part of an effort, many countries including advanced countries suggest integrating complementary and 0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
therapeutic Tai Chi group showed a significant improvement in five items (physical function, pain, vitality, general health, mental health) among eight items in SF-36. This study confirmed that therapeutic Tai Chi influences the balance, gait, and life quality of stroke patients. Therefore, therapeutic Tai Chi can be used as an effective exercise in combination with general physical therapy to improve the balance, gait, and quality of life in stroke patients. International Journal of Rehabilitation Research 38:156–161 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. International Journal of Rehabilitation Research 2015, 38:156–161 Keywords: balance, Tai Chi, gait, quality of life, stroke Department of Physical Therapy, Sahmyook University, Seoul, Republic of Korea Correspondence to Suk Min Lee, PT, PhD, Department of Physical Therapy, Sahmyook University, 26-21, Gongneung2-dong, Nowon-gu, Seoul, 139-742, Republic of Korea Tel: + 82 2 3399 1632; fax: + 82 2 3399 1639; e-mail:
[email protected] Received 18 September 2014 Accepted 18 September 2014
alternative medicine and conventional medicine (Maizes et al., 2009). In the National Center for Complementary and Alternative Medicine of the United States National Institutes of Health, a Tai Chi in Mind and Body Medicine is incorporated into the three categories of alternative medicine (Park, 2013). Tai Chi is a low-intensity aerobic exercise comparable with walking. It is suitable for patients with chronic disease and the elderly, and has various recognized health benefits (Voukelatos et al., 2007). As a natural healing operation, Tai Chi heals tired muscles and relaxes muscles and increases its flexibility. Because muscle actions and balance during Tai Chi are maintained for a long time, muscles related to the maintenance of equilibrium are developed. In addition, Tai Chi can be accessed easily and performed at any time (Lam, 2000). Moreover, it is a discipline that helps improve mental and physical poststroke aspects such as depression and health-related quality of life (Cheng, 2007). Studies report the use of Tai Chi in chronic heart disease (Yeh et al., 2008), depression in the elderly (Lavretsky et al., 2011), Parkinson’s disease (Lu et al., 2013), chronic obstructive pulmonary disease (Chan et al., 2010), and rheumatoid arthritis (Wang, 2011). However, there are insufficient studies in stroke patients (Hart et al., 2004; Taylor-Piliae and Coull, 2012). Hart et al., (2004) suggested DOI: 10.1097/MRR.0000000000000103
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Effects of therapeutic Tai Chi in chronic stroke patients Kim et al. 157
that follow-up studies are needed to verify the effectiveness of Tai Chi training in stroke patients. The aim of this study was to investigate the effect of therapeutic Tai Chi on the balance, gait, and quality of life in chronic stroke patients.
Participants and methods This study was carried out on 24 stroke patients hospitalized in the rehabilitation hospital in Gyeonggido, with the approval of the Institutional Review Board of Sahmyook University. The inclusion criteria were as follows: ability to walk 10 m independently, Brunnstrom recovery stage of 4 or more, a score of less than 3 on the Modified Ashworth Scale-plantar flexor muscle of the lower extremity, with altered muscle tone, a score of 24 points or more on the Mini-Mental Status Examination – Korea, and those without any visual abnormalities. Patients with morbidity associated with orthopedic disorders and neurological disease that affected walking were excluded. A pretest was performed to assess static balance, dynamic balance, gait, and quality of life. The experimental group performed therapeutic Tai Chi 60 min/session, twice per week, for 6 weeks, and both experimental and control groups underwent 30 min of general physical therapy twice per day, 10 times/week, for 6 weeks. After 6 weeks of therapy, a post-test was carried out. Therapeutic Tai Chi
For the Tai Chi training, 10 Tai Chi movements proposed from a therapeutic approach by Wolf et al. (1997) were performed, on the basis of advice from professors of Tai Chi-related departments and a doctor of rehabilitation medicine, and led by an experienced researcher and research assistant. Participants followed the posture and movements of the researcher at the same speed during the training period. For warm-up and cool-down, abdominal breathing and whole-body stretching were repeated at the beginning and at the end of the training. Basic Tai Chi posture and 10 movements were taught repeatedly until the fourth week, with three to four movements per week; during the fifth and sixth weeks, all movements were used. Considering fatigue and pain of the patients, Tai Chi training was performed in a standing position, and in 40 min of exercise, patients took a break of a total of three times for 3 min at 10-min intervals. General physical therapy
For general physical therapy, neurodevelopmental treatment, Bobath therapy, and proprioceptive neuromuscular facilitation were performed one on one with a physical therapist. Measurements Static balance
Static balance was measured using Gaitview AFA-50 (Alfoots, Seoul, Korea). Gaitview measures static and
dynamic pressure while standing or walking using 2304 force sensors on a 410 × 410 × 3 mm panel. All sensors measure the body’s center of pressure (COP). For static balance, sway length and sway velocity were measured using pressure of the feet while the participants stood still on Gaitview. Static balance was measured with the eyes open and measured with the eyes closed. With the eyes open, the participant was asked to look forward; with the eyes closed, the participant was asked to close the eyes for about two to three seconds before measurement. The measurement was performed three times for 15 s each, and 3 min of rest was allowed between measurements to minimize the effect of muscle fatigue. Dynamic balance
The functional reach test (FRT) (Fuzhong et al., 2012) and the dynamic gait index (DGI) (Li et al. 2005) were used to measure dynamic balance. On a fixed plate, participants were asked to stand with the feet at shoulder width. Then, in a 90° forward-bending posture with extended elbow joint and clenched fists, they were asked to maintain balance with a stick placed horizontally at the height of the acromion and stretch their arms as far as possible; the distance between the first and the last points of the third distal metacarpal bone was measured (Behrman et al., 2002). A research assistant performed the measurement three times and calculated the average. Gait ability
To examine walking ability, the 10-m walking test (10MWT) and the timed up-and-go test (TUG) were used. A 14-m walking path was created using a 10-cm wide tape between two points. Two meters after start and 2 m before arrival were excluded from measurement. The measurement was repeated three times and averaged. TUG was used to examine functional mobility, and participants were asked to sit in a chair with elbow rests, and upon the signal given by the researcher, stand up and walk 3 m. As they returned to sit, the velocity was measured. At the 3-m point, a sign was placed, and a research assistant performed measurements three times and calculated the average. Quality of life
In this study, the SF-36, a quality-of-life measurement tool designed by Ware (1993), was used to measure the quality of life. The SF-36 includes questions related to the participants’ emotional state, and it provides a summarized index of questions for overall health evaluation while indirectly assessing the health issues that are not directly included in other questions (Ware, 1993). The SF-36 includes eight areas including physical functioning, role limitation-physical, body pain, general health,
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158 International Journal of Rehabilitation Research 2015, Vol 38 No 2
vitality, social functioning, role limitations-emotional, and mental health. Each item is measured as a score from 0 (worst) to 100 (best).
0.771 and the post-test value was 0.794, and the corresponding values of the control group were 0.872 and 0.88, respectively.
Statistical analysis
Discussion
All results and statistics in this study were coded and converted into data using SPSS ver. 18.0 (SPSS, Chicago, USA). Frequency analysis was carried out for the general characteristics of the participants and a paired t-test examined pretest and post-test differences. An independent two-sample t-test was used to determine between-group differences, and, for all data, statistical significance was set at 0.05.
Results Table 1 shows the general characteristics of the participants. Sway length and velocity of the experimental and control groups before and after the treatment are shown in Table 2. With the eyes closed, the experimental group showed a statistically larger change after the test in both sway length and sway velocity. The results for dynamic balance are shown in Table 3. The experimental group showed a statistically larger change in both FRT and DGI. The results for the 10MWT are shown in Table 4. The control group did not show a significant decrease after the treatment, whereas the experimental group showed a significant reduction (P < 0.05). The average change after treatment was statistically larger in the experimental group (P < 0.05). In TUG, the experimental group showed a significant reduction. In addition, the average change after treatment was statistically larger in the experimental group (P < 0.05). The quality of life of the experimental and control groups after training was measured, and the results obtained from the SF-36 scores and subcategories are shown in Tables 5 and 6. The changes in the quality of life according to the SF-36 scores for physical functioning, bodily pain, general health, vitality, and mental health categories were significant for the experimental group, and the result from the experimental and control groups after training was significant, except for social functioning and role limitations owing to emotional problems. In the present study, Cronbach’s α, which indicates internal consistency, was calculated to measure reliability. The pretest Cronbach’s α value of the experimental group was
Table 1
General characteristics of the participants
Sex [n (%)] Male Female Age [mean ± SD (years)] Height (cm) Weight (kg) MMSE-K (score)
Experimental group (n = 11)
Control group (n = 11)
7 (63.6) 4 (36.4) 53.45 ± 11.54 165.55 ± 6.47 67.55 ± 9.45 27.18 ± 0.98
6 (54.5) 5 (45.5) 55.18 ± 10.20 164.45 ± 8.48 71.90 ± 10.26 27.09 ± 0.83
In a series of studies on the effect of Tai Chi (Lan et al., 2000; Xu et al., 2004), Tai Chi training improved proprioception, muscle strength, and balance. There is a strong correlation between the movement range of COP, which is related to balance maintenance and weight bearing in a static state (Anker et al., 2008); moreover, weight bearing must be symmetrical to maintain balance. Therefore, in this study, to examine changes in static balance after 6 weeks of therapeutic Tai Chi, measuring equipment was used to measure sway length and velocity of COP in a standing posture. The results showed a change in sway length and velocity of the experimental group after the test, which supports previous research. The significant improvement in static balance of the experimental group in the present study appears to be because of improved proprioception of the trunk and lower limb and an enhanced ability to subtly control muscle and joints as a consequence of the Tai Chi training, which is performed slowly in a static posture, and also because repetitive weight shift to the paralyzed side had a significant effect on the asymmetrical posture of stroke patients. Therefore, it seemed that combining therapeutic Tai Chi with general physical therapy was more effective for improving static balance of stroke patients. Although the lack of previous research on Tai Chi training of stroke patients using FRT and DGI makes a direct comparison difficult, Li et al. (2005) reported that, after 6 months of Tai Chi training of three times per week in 256 local elderly individuals, FRT improved by 13.5% and DGI improved by 10.4%. The change was larger than that of the control group, who only performed stretching, suggesting that Tai Chi training had an effect on dynamic balance. In addition, Fuzhong et al. (2012) reported that in Parkinson’s disease patients undergoing Tai Chi training twice per week for 24 weeks, the Tai Chi training group showed an improvement in FRT from 24.4 cm before training to 29.4 cm after training and had a lower risk of fall (22%) compared with resistance exercise and stretching groups (51 and 62%, respectively). This suggests that Tai Chi training increases the effective performance of functional activities such as standing up from a sitting position, sitting down from a standing position, and walking in a standing posture, and reduces the risk of fall when changing movement or direction. Although participants from previous research were different, the results were similar to those of the present study: significantly improved dynamic balance following Tai Chi training (Tse and Bailey, 1992; Wolfson et al., 1996). Furthermore, in view of these study results, Tai Chi movements such as repeated weight shifts, trunk
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Effects of therapeutic Tai Chi in chronic stroke patients Kim et al. 159
Table 2
Pretest and post-test for static balance (n = 22)
EO sway length (mm)
EO sway velocity (mm/s)
EC sway length (mm)
EC sway velocity (mm/s)
Test
Experimental group (n = 11)
Control group (n = 11)
t (P)
Pre Post Post − pre t (P) Pre Post Post − pre t (P) Pre Post Post − pre t (P) Pre Post Post–pre t (P)
377.68 ± 93.12 230.19 ± 50.99 147.49 ± 78.46 8.859 (0.000) 21.46 ± 5.74 13.15 ± 2.81 8.32 ± 4.45 6.203 (0.000) 437.59 ± 89.49 285.84 ± 67.49 151.75 ± 122.53 4.107 (0.002) 23.64 ± 4.76 17.78 ± 2.81 5.86 ± 5.49 3.543 (0.005)
319.62 ± 67.31 280.57 ± 51.47 39.05 ± 67.14 1.929 (0.083) 17.35 ± 3.35 15.04 ± 3.64 2.31 ± 2.57 2.975 (0.014) 379.08 ± 111.75 328.97 ± 82.98 50.12 ± 67.58 2.460 (0.034) 19.07 ± 6.71 17.97 ± 6.18 1.10 ± 3.25 1.124 (0.287)
3.483 (0.002)
3.881 (0.001)
2.505 (0.021)
2.478 (0.022)
Values are given as mean ± SD. EC, eyes closed; EO, eyes opened.
Table 3
Pretest and post-test for dynamic balance (n = 22) Test
Experimental group (n = 11)
Control group (n = 11)
FRT (cm)
Pre Post Post − pre t (P)
19.36 ± 3.32 23.45 ± 2.84 − 4.09 ± 1.70 − 7.980 (0.000)
DGI (score)
Pre Post Post − pre t (P)
16.09 ± 2.66 18.36 ± 2.29 − 2.27 ± 1.01 − 7.470 (0.000)
20.18 ± 3.22 20.64 ± 3.17 − 0.45 ± 1.13 − 1.336 (0.211) 16.64 ± 1.43 16.91 ± 1.22 − 0.27 ± 0.65 − 1.399 (0.192)
t (P) − 5.911 (0.000)
− 5.535 (0.000)
Values are given as mean ± SD. DGI, dynamic gait index; FRT, functional reach test.
Table 4
Pretest and post-test for gait ability (n = 22)
10MWT (s)
TUG (s)
Test
Experimental group (n = 11)
Control group (n = 11)
Pre Post Post − pre t (P) Pre Post Post − pre t (P)
19.91 ± 4.06 16.45 ± 3.05 3.45 ± 1.99 8.859 (0.000) 23.64 ± 4.67 19.91 ± 3.53 3.73 ± 1.27 9.718 (0.000)
18.73 ± 3.04 18.18 ± 3.37 0.54 ± 1.04 1.747 (0.111) 22.00 ± 4.05 21.18 ± 4.21 0.82 ± 1.25 2.170 (0.055)
t (P) 5.823 (0.000)
5.409 (0.000)
Values are given as mean ± SD. 10MWT, 10-m walking test; TUG, timed up-and-go.
rotation, fine muscle adjustments, and standing on one leg markedly improved trunk stability and flexibility and stability against external stimulation. In this study, walking ability was evaluated using 10MWT and TUG, which evaluate walking velocity and functional movement. In 10MWT, the walking time of the experimental group decreased by 18.7% after treatment, and the change was larger than that of the control group, 2.9%. In addition, in TUG, the walking speed of the experimental group decreased by 15.7% after the treatment, and the change was larger than that of the control group, 3.7%.
This is in agreement with previous research, including that of Au-Yeung et al. (2009), who reported a 16% improvement in walking speed during TUG in stroke patients who performed Tai Chi once per week for 12 weeks. In addition, Taylor-Piliae and Coull (2012) reported that, in 28 stroke patients who performed Tai Chi three times per week for 12 weeks, balance and walking speed improved by 9.1%. In contrast, Hart et al. (2004) reported that there was no significant difference in TUG between a group undergoing Tai Chi training and general physical therapy, but improved (P