Abstract
Introduction:
Tai Chi is a moderate mindful physical activity with long historical practice. There are new and novel types and forms of Tai Chi with promising results. The aim of this narrative review was to assess the quantity of the presence of Tai Chi in clinical guidelines that recommended or mentioned Tai Chi globally.
Materials and Methods:
Three medical databases were searched from inception to November 1, 2021, the retrieved search results were screened by two authors according to inclusion and exclusion criteria. Literature in English language, which is a clinical guideline, and Tai Chi was mentioned or recommended in the text of the guideline were included.
Results:
A total of 1539 articles were retrieved after searching medical databases. Retrieved articles were screened by two authors for possible inclusion in this review. Finally, 50 clinical guidelines that mentioned Tai Chi were included. Tai Chi was recommended 38 times of the 50 included clinical guidelines that mentioned Tai Chi (76%). Tai Chi was mentioned mostly in clinical guidelines for pain management (n = 5), osteoarthritis (n = 5), and cancer (n = 5). Furthermore, Tai Chi was recommended in all included clinical guidelines for (pain management, low back pain, stroke, and Parkinson's disease).
Conclusions:
Tai Chi was recommended mostly in the management of pain and musculoskeletal diseases. Updating health promotion and chronic diseases management programs to include the new forms and types of mindful exercises according to the best scientific evidence is suggested. This review recommended performing future research and critical analysis assessing the quality of evidence of included clinical guidelines.
Introduction
Tai Chi has a long history as a martial art in China and was practiced for centuries. 1 Nowadays, Tai Chi is a widely practiced mindful exercise for its health benefits. 2 Tai Chi has many old forms. Tai Chi consisted of gentle, slow, and low-impact meditative movements with focus on breath, mind, and body to achieve well-being and inner peace. 2 Likewise, Tai Chi was traditionally practiced for promotion of internal balance, stress management, and internal healing. 3
New simplified forms were developed for easy practice of Tai Chi such as Tai Chi short forms, Tai Chi Six forms, Yang eight form easy, and others.2,3
In addition, Tai Chi is a wellness tool and one of the balance exercises that is used successfully in the management of various diseases and conditions. 1
Consequently, there are many reported benefits of Tai Chi in published literature. Tai Chi can improve balance, aerobic capacity, lower limb strength, and flexibility. 1 Furthermore, there is excellent evidence that Tai Chi is beneficial in preventing falls, osteoarthritis, Parkinson disease, rehabilitation for chronic obstructive pulmonary disease, and improving cognitive functioning in older adults.1–3 As well, Tai Chi has many health benefits to populations in need of cost-effective moderate physical activity. 3
Clinical guidelines are defined as evidence-based statements that can be used to assist health care providers and patient decisions about the best medical or health intervention for a specific condition or disease. 4 In addition, clinical guidelines are developed by various governmental, nongovernmental organizations, and health care societies.
The aim of this narrative review is to assess the mentions and recommendations of Tai Chi in the clinical guidelines that were developed worldwide for management of any disease (physically and mentally), and for any population or age groups.
To the best of the authors' knowledge, this is the first review to assess the mentions of Tai Chi in published clinical guidelines. This review fills the gap of the need of cost-effective physical activity that can be practiced easily in community groups or homes especially for older people. In addition, the results of this review can present a simple solution for increasing physical activity even at homes and encourage health care providers to prescribe moderate evidence-based physical activity for their patients.
Furthermore, it highlighted the importance of updating rehabilitation and chronic disease management programs around the world for possible inclusion of Tai Chi and related exercises.
This review highly recommended conducting clinical trials and research in the field of novel and new alternative mindful forms of exercises such as Tai Chi for possible consideration in health promotion programs and management of various chronic diseases.
Materials and Methods
Three medical databases (PubMed, Trip medical database, and Google scholar) were searched from inception to November 1, 2021. Search keywords were “Tai Chi,” “Tai Chee,” “Clinical guideline,” “Guideline.” The Boolean operators and keywords used in electronic searches were “Tai Chi” AND “Clinical guideline,” “Tai Chi” AND “guideline,” “Tai Chee” AND “Clinical guideline,” “Tai Chee” AND “guideline,” “Tai Chi” OR “Tai Chee” AND “clinical guideline,” “Tai Chi” OR “Tai Chee” AND “guideline.” Search Boolean was modified according to the searched medical database. The retrieved search results were screened by two authors for possible inclusion in this review.
The authors' aim was to include all clinical guidelines that mentioned Tai Chi, which were developed for management of any condition, and for any population or age groups. The inclusion criteria were (1) English language articles, (2) a clinical guideline, (3) Tai Chi was mentioned or recommended in the text of the guideline. Furthermore, exclusion criteria were (1) non-English articles, (2) not a clinical guideline, and (3) Tai Chi was not mentioned or recommended in text of the clinical guideline.
Data were extracted from retrieved articles on predefined tables. Clinical guidelines' titles, developers, development countries, and status of Tai Chi were extracted in a table.
Results
A total of 1539 articles were retrieved after searching medical databases. Retrieved articles were screened by two authors for possible inclusion in this review. In total, 1481 articles were excluded for various reasons such as duplication = 435, applying inclusion/exclusion criteria = 1041, getting full articles and reapplying inclusion/exclusion criteria = 14. Finally, 50 articles (clinical guidelines) were included in this review. Figure 1 showed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart for identification of articles in medical databases.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart for identification of articles in medical databases.
Tai Chi was mentioned in 50 clinical guidelines and recommended 38/50 of them (76%). Table 1 provides a summary of characteristics of included clinical guidelines that mentioned Tai Chi and the status of recommendations.
A Summary of Characteristics of Included Clinical Guidelines
AHA, American Heart Association; ASA, American Stroke Association; COPE, Centre of Perinatal Excellence; SIGN, Scottish Intercollegiate Guidelines Network; WHO, World Health Organization.
In addition, 48/50 included clinical guidelines were developed in 10 countries (Australia, Belgium, Canada, Germany, Korea, Malaysia, Singapore, Switzerland, United Kingdom, and United States).5–52 In addition, one clinical guideline was developed by cooperation between United States and United Kingdom, 53 and another clinical guideline was developed by the World Health Organization. 54 The most contributed country in developing clinical guidelines that mentioned or recommended Tai Chi was United States (number of clinical guidelines = 22) for 14 diseases and conditions31–52 followed by Australia (n = 6),5–10 Canada (n = 6),12–17 United Kingdom (n = 6),25–30 and then Malaysia (n = 3).20–22 Table 2 represented the included clinical guidelines by country.
Included Clinical Guidelines by Country
The included clinical guidelines were for various diseases and clinical conditions. Tai Chi was recommended or mentioned as a part of the management, prevention, or rehabilitation after recovery. In addition, Tai Chi was recommended or mentioned mostly in clinical guidelines for chronic pain management (n = 5),28,29,31,37,51 osteoarthritis (n = 5),7,15,32,45,48 and cancer management (n = 5).9,18,24,25,40 Furthermore, Tai Chi was recommended in all included clinical guidelines for (pain management, low back pain, stroke, and Parkinson's disease). Table 3 represented the included clinical guidelines by condition.
Included Clinical Guidelines by Condition
The level of evidence was not assessed in some included clinical guidelines.9,21,22,27,32,37,44,47,51 Conversely, the level of evidence was heterogeneously assessed by different methods and criteria in the other included clinical guidelines. Level of evidence of using Tai Chi was grade (A) for fall prevention14,23,53 and hypertension. 12 In addition, level of evidence was grade (B) in stroke,17,35 osteoarthritis, 15 cancer management, 18 Parkinson's disease, 19 and management of chronic pain. 29 Furthermore, level of evidence was grade (C) for osteoarthritis, 7 rheumatoid arthritis, 8 and hip fracture. 52
As well, Tai Chi was strongly recommended for osteoarthritis of the hand, hip, and knee, 48 had low to medium evidence level in acute, subacute, and chronic low back pain, 36 and moderate to high evidence level in nonspecific back pain. 39
Discussion
The aim of this study was to assess the Tai Chi recommendations and mentions in clinical guidelines. This study identified evidence-based resources that can be used by decision makers and health care professionals globally in their decisions about implementing Tai Chi as one of suitable physical activities in the management of various diseases and ailments. To the best of the authors' knowledge, this is the first review in this subject. This study identified 50 eligible clinical guidelines published between 2002 and 2021 that mentioned Tai Chi, of which 38 (76%) made Tai Chi recommendations.
The U.S. National Center for Injury Prevention and Control, which is a part of U.S. Centers for Disease Control and Prevention, published a “how to” guide in 2015 about preventing falls. This guide provided information on how to implement effective community-based fall prevention programs. Tai Chi was one of the recommended physical activities in this guide and repeated 23 times. 55 This review identified four clinical guidelines on fall prevention.6,14,23,53 Three of them recommended Tai Chi for fall prevention (75%) of clinical guidelines that mentioned Tai Chi.14,23,53 American Heart Association (AHA) and American Stroke Association recommended Tai Chi for fall prevention on their guidelines for adult stroke rehabilitation and recovery. 35
Tai Chi is used for fall prevention due to its reported benefits of improving strength and balance, increasing patient's satisfaction, enhancement of quality of life, improving flexibility, and reduction of incidence of falls and related injuries and fractures. 14 Other physical activities that can be considered for fall prevention may include stepping, core strength, Pilates, yoga, exergaming, and perturbation-based balance training. 14
In addition, AHA recommended Tai Chi as a physical activity for patients with ventricular dysfunction in its scientific statement about promotion of physical activity for children and adults with congenital heart disease. Furthermore, the scientific statement encouraged patients with syncope to practice Tai Chi. 56 AHA published a scientific statement about older adults with cardiovascular diseases and reported that Tai Chi may improve outcome and may be beneficial for older adults with cardiovascular diseases. 57
In addition, AHA suggested conducting more studies to determine the benefits of Tai Chi for heart failure management. Furthermore, AHA reported that Tai Chi may not be effective in improving peak oxygen consumption or submaximal aerobic performance while seeming effective in improving muscle strength and quality of life. 58 In addition, AHA reported that Tai Chi may improve the management of atrial fibrillation in its scientific statement. 59
This study identified three clinical guidelines in the field of stroke management,17,35,43 three in the field of heart failure management,21,26,44 and two for hypertension.12,46 3/3 of stroke management included clinical guidelines, 3/3 of heart failure management clinical guidelines, and 2/2 of hypertension management clinical guidelines recommended Tai Chi.
Tai Chi reported benefits for cardiovascular diseases included reduction of systolic and diastolic blood pressure, 12 reduction in depression and anxiety symptoms for stroke patients, 43 and improving quality of life for stroke and heart failure patients.26,43,44 Other considered alternative therapies for management of stroke were functional electrical stimulation, robot-assisted movement therapy, cognitive behavioral therapy, yoga, and exercise. 43
Tai Chi was recommended in all included clinical guidelines for chronic pain management (n = 5)28,29,31,37,51 and in all included clinical guidelines for low back pain (n = 4).36,38,39,47 In addition, Tai Chi was recommended in 4/5 (80%) of osteoarthritis clinical guidelines,7,15,32,45,48 and in 2/3 of osteoporosis clinical guidelines.5,20,30
Tai Chi may improve range of motion of rheumatoid arthritis patients, 37 improve pain symptoms, 37 decrease disability for patients of chronic low back pain, 37 and improve balance, coordination, and flexibility for patients of nonspecific back pain. 39 In addition, low-impact activities such as walking, hot backs or baths, meditation, progressive muscle relaxation, yoga, acupuncture, spinal manipulation, cognitive behavioral therapy, massage, and physiotherapy were recommended nonpharmacologic interventions for management of back pain. 39
Moreover, American Diabetes Association (ADA) recommended Tai Chi as a physical activity in its standards about the management of diabetes 2021. In addition, ADA reported that Tai Chi can make significant impact on average blood sugar levels for the previous 3 months (A1C). 60
This review identified two clinical guidelines in the field of diabetes management that were published in 2015 and 2018. Tai Chi was recommended in 1/2 of the included clinical guidelines that mentioned Tai Chi.16,34 Tai Chi can help in preventing falls, injuries, improving balance, coordination, and improving muscle strength for diabetic patients with large fiber neuropathy. 34
Importantly, health care providers should work to promote physical activity for their patients considering all available options, including low-impact exercises such as Tai Chi. In addition, efforts should be done to increase the knowledge, and skills of health care providers to prescribe these exercises safely for their patients.
This review has various strengths and limitations. This review is the first study of its kind to assess the presence of Tai Chi in published clinical guidelines. It assessed the quantity of recommendations of Tai Chi in clinical guidelines globally. Furthermore, it highlighted the importance of implementation of new models of exercise such as Tai Chi into rehabilitation and management of chronic diseases programs that can lead to increased physical activity and quality of life.
The limitations of this study were numerous. Clinical guidelines in languages other than English were not included. The assessment of the quality of evidence was a limitation because of the nature of this narrative review. Furthermore, authors encourage future assessment of the quality of included clinical guidelines and evidence in future systematic reviews.
This review highlighted the importance of updating the rehabilitation and management of chronic diseases programs. In addition, it identified the use and recommendations of Tai Chi for various diseases for future research and clinical trials. Finally, it gave information for decision makers for future implementation of new models of exercises into clinical guidelines and health promotion programs.
Conclusion
Tai Chi was mentioned in 50 globally developed guidelines and recommended in 76% of them. Tai Chi was recommended mostly in the management of pain and musculoskeletal diseases. Updating health promotion, rehabilitation, and chronic diseases management programs to include the new forms and types of mindful exercises according to the best scientific evidence is suggested. Future research for assessing the quality of included clinical guidelines in this review is highly recommended.
Footnotes
Authors' Contributions
T.A. suggested the idea and design, and wrote the first draft. M.Q. and S.B. reviewed and approved the idea and design, and reviewed the article critically. T.A. and M.Q. conducted the search and select articles according to inclusion criteria. S.B. reviewed and approved the selected articles. All authors approved the final article for publication.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.