Evidence Map of Tai Chi

Many Veterans desire complementary and alternative medicine or integrative medicine modalities, both for treatment and for the promotion of wellness. Tai Chi was developed as an ancient Chinese martial art and, today, is widely practiced for its health benefits. Results from a national survey conducted on a representative sample of adults in the U.S. estimate that approximately 2.3 million adults had practiced Tai Chi in the past 12 months. Many forms of Tai Chi exist, but in Western culture, it is most commonly taught as a series of slow, gentle, low-impact movements that integrate the breath, mind, and physical activity to achieve greater awareness and a sense of inner peace and well-being. There is no official licensure granted by national or state professional boards, and Tai Chi training programs vary.

This evidence mapping project aims to help provide guidance to VA leadership about the distribution of evidence about Tai Chi to inform policy and clinical decision-making. Investigators with the Evidence-based Synthesis Program located in West Los Angeles reviewed the literature and identified 107 systematic reviews. Investigators created the following bubble plot to graphically display the research field.

Bubble Plot:

Summary:
Reviews addressing general health effects, psychological wellbeing, or interventions in older adults included between 31 and 51 Tai Chi randomized controlled trials (RCTs). The topic areas of balance, hypertension, falls, quality of life, cognitive performance, and vestibulopathy also have been the focus of research. Included reviews identified 10 or more pertinent RCTs per topic. A summary of findings follows for research on Tai Chi in areas with the most promising results, as well as in areas regarded as VA priorities.

Most promising areas
The most promising results across existing reviews were documented for three research areas with a large research base: hypertension, fall prevention outside of institutions, and cognitive performance. However, reviews in all three areas stated reservations in the conclusions due to the poor quality of the included studies, or conflicting results across outcomes, comparators, and settings.

Statistically significant health effects also were reported for osteoarthritis, COPD (chronic obstructive pulmonary disease), pain, balance confidence, depression, and muscle strength. However, review authors cautioned that the existing evidence is based on insufficient numbers of RCTs and/or poor quality RCTs, and is not strong enough to provide definitive answers on the effectiveness of Tai Chi for patient health outcomes.

VA priority areas 
VA priority areas related to Tai Chi include pain, PTSD, and fall prevention.

Pain
Pain was the primary outcome focus of four systematic reviews. Of these, the largest one (2009) identified seven relevant RCTs. Six of these studies involved patients with chronic arthritis, while the seventh included patients with chronic tension headaches. The individual studies tested Tai Chi practiced from 1 to 3 times per week, and the intervention duration ranged from 6 to 15 weeks. This largest review found a positive effect of Tai Chi on self-reported pain using different assessment scales across studies. Adverse events were not addressed.

The outcome pain was addressed in 21 systematic reviews. Summary estimates of the size of the effect of Tai Chi on pain across at least two RCTs were reported in five reviews, including the above discussed review with the primary outcome of pain. A 2013 meta-analysis in patients with osteoarthritis reported statistically significant and clinically important effects for pain across studies comparing Tai Chi to waiting list, Bingo, attention control programs, routine treatment, self-help programs, or wellness education and stretching. A subgroup analysis also showed significant effects on pain and physical function in studies of 12 weeks or fewer, but not in studies of longer duration. The review concluded that 12-week Tai Chi should be included in rehabilitation programs, but that the evidence may be limited by potential biases. Of the 21 systematic reviews reporting on the outcome pain, 43% did not address adverse events. Of those reviews that addressed adverse events, one did not report on adverse events in included studies, but stated that the included interventions were not associated with adverse side effects.

PTSD
The effects of Tai Chi on PTSD, the second VA priority area, have not been rigorously studied. No studies in combat-related PTSD were identified.

Fall Prevention
The effects of Tai Chi on fall prevention in unselected studies or populations living in the community were addressed in 10 independent reviews, and the largest included 15 RCTs. This large 2010 review reported no statistically significant benefit of Tai Chi compared to non-exercise controls. However, a significant pooled estimate on fall rates was found, favoring Tai Chi compared to exercise. A Cochrane review found a significantly reduced risk of falling associated with Tai Chi group exercises compared to low level stretching, fall prevention brochures, waiting list, wellness education, and other comparators, but no reduction using an alternative measure of falls (rate of falls). Of the 23 reviews that reported the outcome falls, 70% did not address adverse events.

Future Research:
This broad overview of the evidence on Tai Chi concentrated on research on the clinical effectiveness of Tai Chi to improve patient outcomes; it did not consider more refined questions, such as the effect of different styles of Tai Chi or the effect of the practitioner's training and skill level. Evidence on the role of Tai Chi in chronic conditions, cardiovascular disease, cancer care, heart disease, cystic fibrosis, infections, stroke rehabilitation, osteoporosis, Parkinson's disease, cardiopulmonary interventions, rheumatoid arthritis, fibromyalgia, and insomnia is very limited due to the small number of published studies. The evidence map also indicated that adverse events have not been investigated systematically and are hindered by poor and inconsistent reporting of adverse events. A number of authors also have indicated that more research on long-term effects is warranted. In addition, across topic areas, reviews concluded that more rigorous research on the clinical effectiveness of Tai Chi is needed.

Investigators also documented ongoing systematic reviews registered in review registries that will become available to summarize a topic area in the near future. In addition, they identified Cochrane review protocols published in the Cochrane Database of Systematic Reviews in the last three years that have not yet been published as a review, indicating an ongoing review. PROSPERO, the international registry of systematic reviews, also was searched to identify ongoing systematic reviews on Tai Chi.

Reference:
Hempel S, Taylor SL, Solloway M, Miake-Lye IM, Beroes JM, Shanman R, Shekelle PG. Evidence Map of Tai Chi. VA-ESP Project #ESP 05-226; 2014.

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This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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