Tai Chi | Cam-Cancer

Tai Chi

Abstract and key points

Tai chi is a non-combative martial art that combines breathing techniques with sequences of slow graceful movements. It is sometimes referred to as a ‘meditation in motion’.

There is some evidence from one systematic review of nine randomized clinical trials that tai chi may increase joint mobility and handgrip dynamometer strength. Another systematic review of six trials suggests that it may reduce short-term cancer-related fatigue in breast and lung cancer.

For quality of life the evidence is inconclusive. One systematic review of five RCTs in breast cancer concluded that there was insufficient evidence to support tai chi for quality of life-related outcome measures. One systematic review of 15 randomized clinical trials in various cancer populations reports evidence that a tai chi/qigong combination may improve fatigue, sleep, depression and  quality of life. The findings of most of the reviews are however limited by the methodological shortcomings of the included trials.

Only preliminary evidence from individual controlled clinical trials of tai chi is available for systolic blood pressure reduction, improvement of immune function, inflammatory responses and insomnia as well as a tai chi/qigong combination for balance performance, improved joint mobility and higher blood flow velocity.

Tai chi appears to be safe, although safety aspects are often not reported in reviews/trials.  As it is a moderate form of aerobic exercise, it may be beneficial for people to check with their health practitioner if they have a known heart condition, severe osteoporosis or musculoskeletal difficulties.

Document history

Last updated and revised in March 2019 by Ava Lorenc.
Summary updated and revised in June 2016 by Helen Cooke.
Summary updated in November 2013 by Helen Cooke.
Summary first published in August 2012, authored by Helen Cooke.

Citation

Ava Lorenc, Helen Cooke, CAM-Cancer Consortium. Tai Chi [online document], http://cam-cancer.org/en/tai-chi. March 27th, 2019.

What is it?

Description

Tai chi (short for tai chi chuan) is a non-combative martial art that combines breathing techniques with sequences of slow graceful movements. It is sometimes categorised as a mind-body intervention1 and referred to as a ‘meditation in motion’2.

Application and dosage

Tai chi is usually taught in groups by an individual who is either trained or experienced in tai chi. Sessions normally last around 60 minutes. The lengths of the teaching courses vary, but they typically last 10-12 weeks. The classes generally include warm-up exercises, a tai chi practice and a cool-down. Some sessions include breathing and meditation exercises. It is suggested that people carry out tai chi exercises at home as part of a daily practice.

History/provider(s)

Tai chi has its roots in ancient Chinese philosophy and martial arts2 and is one of the approaches used in traditional Chinese medicine. It had developed a unique style by the end of the Ming Dynasty (1368-1644 AD). Many different styles of tai chi have evolved during its development. These include Chen, Wu, Sun, Li and Yang style. Variations have been derived from these styles, including Wudang, the Hao, and the Cheng Man-ching. Whilst Chen is the oldest style, Yang is the most popular. A 24-posture tai chi form was compiled in 1956 based on a more complicated Yang form style, which involves 105 postures1. Although the Yang style was used in many of the studies reviewed for this summary, not all list the style of tai chi taught.

Claims of efficacy/ mechanism(s) of action

It has been proposed that partaking in tai chi may result in energy expenditure equivalent to that of brisk walking, which may improve the aerobic capacity, flexibility, strength, mood and quality of life of cancer survivors3. This has yet to be verified by research. Proponents of traditional Chinese medicine believe there are meridians (pathways) that travel through the body carrying chi (life energy). Tai chi is purported to smooth the flow of chi, to aid relaxation and keep the mind calm and focused4.

Alleged indication

Tai chi is reported to have positive effects on health related quality of life, self-esteem, mood, anxiety, blood pressure, osteoporosis, natural killer cells, cardio-respiratory function, flexibility, balance and strength in the elderly, but studies are lacking across different cancer populations5.

Prevalence of use

A 2010 survey reported that 0.8% of male (n=891) and 2.4% of female (n=1371) cancer survivors in the US use tai chi6. Precise prevalence figures are not available for Europe or other countries.

Legal issues

Although various organisations offer certification worldwide, there is no standardised training or recognised credentialing/licensing process in place for tai chi instructors at present. Traditionally, students are taught and authorised by ‘master teachers/instructors’. In 2018 the Medical Tai chi and Qigong Association published accreditation standard guidelines for TQ instructors and training institutions, which they hope will help to guide professionals and the public16.

Cost(s) and expenditures

The cost of sessions varies between countries, but an approximate cost of €8-15/US $15-20 is generally charged.

Does it work?

Supportive/palliative care

Four systematic reviews of tai chi for cancer all including meta-analyses are available: one assessing tai chi in relieving treatment-related side effects and quality of life in women with breast cancer7, one of improving quality of life in breast cancer patients17, one on cancer-related fatigue19, and one of qigong and tai chi (combined as one body of evidence) on the health-related outcomes of cancer patients20. Five randomised and three non-randomised controlled trials have subsequently been published. These trials are described in Table 1.

There is some evidence from one systematic review of nine randomized clinical trials that tai chi may increase joint mobility and handgrip dynamometer strength. Another systematic review of six trials suggests that it may reduce short-term cancer-related fatigue in breast and lung cancer.

For quality of life the evidence is inconclusive. One systematic review of five RCTs in breast cancer concluded that there was insufficient evidence to support tai chi for quality of life-related outcome measures. One systematic review of 15 randomized clinical trials in various cancer populations reports evidence that a tai chi/qigong combination may improve fatigue, sleep, depression and quality of life. The findings of most of the reviews are however limited by the methodological shortcomings of the included trials.

Only preliminary evidence from individual controlled clinical trials of tai chi is available for systolic blood pressure reduction, improvement of immune function, inflammatory responses and insomnia as well as a tai chi/qigong combination for balance performance, improved joint mobility and higher blood flow velocity.

Quality of life

The first systematic review (2015) analysed the available randomized controlled trials (RCTs) on the effects of tai chi Chuan (TCC) in relieving treatment-related side effects and quality of life in women with breast cancer7. Nine trials (total sample size n=322) were examined. Compared with control therapies, the pooled results suggested that TCC showed significant effects in improving handgrip dynamometer strength, limb elbow flexion (elbow extension, abduction, and horizontal adduction). No significant differences were observed in pain, interleukin-6, insulin-like growth factor, BMI, physical well-being, social or emotional well-being, or general health-related quality of life. Again, these findings need to be interpreted with caution due to the small sample sizes of the included studies and their methodological limitations (including short follow-up periods).

The second systematic review (2014) was fairly well conducted and assessed the effects of tai chi on quality of life as well as other physical outcomes in breast cancer survivors17. Five RCTs involving 407 patients were included in the meta-analysis. The trials all scored 3 or less on the Jadad scale so were poor quality. The trials were also very heterogeneous which limited the meta-analysis. They found insufficient evidence for physical, emotional and functional well-being, body mass index, bone mineral density, and muscle strength.

Fatigue

The third systematic review (2019)19, assessing the effects of tai chi on cancer-related fatigue, included six trials involving 373 patients. This review is of high quality. Pooled results suggested that tai chi had a significant positive effect on short-term fatigue (SMD= − 0.54; p<0.0001), but long-term impact was unclear. Subgroup analyses showed effects for breast and lung cancer but not prostate cancer.  The short-term effects of tai chi were superior to physical exercise and psychological support (SMD=−0.49 and −0.84, respectively; both p<0.05), and a longer intervention duration had a greater benefit than shorter duration (SMD=−1.08 and −0.36, respectively; both p<0.05). The quality of included trials was good, apart from a lack of blinding (very difficult to achieve in tai chi).

One subsequently published randomised controlled trial (n=83) on the effects of tai chi for cancer-related fatigue has been published since the systematic review above18. It confirms the positive results of the review, although the only comparator was usual care and the study has many limitations.

Insomnia

One randomised controlled trial (10) in breast cancer survivorscompared tai chi to Cognitive Behavioural Therapy (CBT; gold standard treatment) for insomnia10. This was a high-quality trial and found that tai chi was noninferior to CBT, i.e. both interventions resulted in clinically meaningful improvements in insomnia.

Physical health parameters

One randomised controlled trial (feasibility study, n=63) of senior female cancer survivors compared tai chi to health education9. They found significant reductions in systolic blood pressure and levels of cortisol9. The authors acknowledge that the outcomes were limited to one-week post intervention. Other limitations include a small, heterogeneous sample of senior cancer survivors.

Two randomised controlled trials reported on immune function. The first was in non-small cell lung cancer patients (n=27)11. They compared tai chi to standard care and reported that tai chi enhanced immune function (peripheral blood mononuclear cell function). The second was in breast cancer patients with insomnia (n=90)12. They compared tai chi to cognitive behavioural therapy and reported that tai chi reduced cellular inflammatory responses, and expression of proinflammatory genes.

Qigong/tai chi combination for various outcomes

Finally, Wayne et al (2018) evaluated the treatment effects of qigong/tai chi on the health-related outcomes of cancer patients20.  The review is well-conducted, although the screening process is not clear and a limited number of sources were searched. The researchers combined qigong and tai chi as one body of evidence. This review has a similar topic and results to a review from 20148. Wayne et al included fifteen trials involving 1283 participants. Only three trials had a high risk of bias. Tai chi/qigong was associated with significant improvement in fatigue (ES =−0.53, p < 0.001), sleep difficulty (ES =−0.49, p=0.018), depression (ES =−0.27, p=0.001), and overall quality of life (ES =0.33, p=0.004); a statistically non-significant trend was observed for pain (ES =−0.38, p=0.136). However, authors conclude that the methodological limitations of the trials prevent any definitive conclusions.  

Three subsequently published non-randomised controlled trials were conducted with nasopharyngeal cancer survivors. The explored the benefits of a tai chi/qigong combination intervention compared to usual care. They reported improved balance performance (n=120)13, improved joint mobility and reduced problems (52)14 and higher blood flow velocity, lower arterial resistance, higher palmer skin temperature and better aerobic capacity in the intervention group (n=52)15. The lack of randomisation and subject self-selection bias affects the reliability of the results.

Is it safe?

Adverse events

No adverse events were reported in the studies included in this summary, although reporting of adverse events in tai chi studies is inconsistent and poor22.

Contraindications

As tai chi is a moderate form of aerobic exercise it may be beneficial for people to check with their health practitioner if they have a known heart condition, severe osteoporosis or musculoskeletal difficulties14.

Interactions

No known interactions.

Warnings

Older people may benefit from a brief health check if they are suffering from any of the conditions mentioned in the contraindication section14.

There may be potential risks if the tai chi is self-taught rather than taught by a qualified instructor21.

References
  1. Mansky P, Sannes T, Wallerstedt D, Ge A, Ryan M, Johnson LL et al. Tai chi chuan: mind-body practice or exercise intervention? Studying the benefit for cancer survivors. Integr Cancer Ther 2006; 5:192-201.
  2. Peters D. The Complete Family Guide to New Medicine. Dorling Kindersley (2005).
  3. Janelsins MC, Davis PG, Wideman L, Katula JA, Sprod LK, Peppone LJ et al. Effects of Tai chi Chuan on insulin and cytokine levels in a randomized controlled pilot study on breast cancer survivors. Clinical Breast Cancer 2011;11:161-170.
  4. Tai chi Union for Great Britain website. [Accessed 28/01/19].
  5. Mustian KM, Katula JA, Gill DL, Roscoe JA, Lang D, Murphy K. Tai chi Chuan, health-related quality of life and self-esteem: a randomized trial with breast cancer survivors. Supportive Care in Cancer 2004;12:871-6.
  6. Fouladbakhsh JM, Stommel M. Gender, symptom experience, and use of complementary and alternative medicine practices among cancer survivors in the U.S. cancer population. Oncology Nursing Forum 2010;37:E7-E15.
  7. Pan Y, Yang K, Shi X, Liang H, Zhang F, Lv Q. Tai chi chuan exercise for patients with breast cancer: a systematic review and meta-analysis. eCAM 2015;2015:535237.
  8. Zeng Y, Luo T, Xie H, Huang M, Cheng AS. Health benefits of qigong or tai chi for cancer patients: a systematic review and meta-analyses. Complement Thera Med 2014;22:173-86.  
  9. Campo RA, Light KC, O'Connor K, Nakamura Y, Lipschitz D, LaStayo PC, et al. Blood pressure, salivary cortisol, and inflammatory cytokine outcomes in senior female cancer survivors enrolled in a tai chi chih randomized controlled trial. J Cancer Survivorship 2015;9:115-25.
  10.  Irwin MR, Olmstead R, Carrillo C, Sadeghi N, Nicassio P, Ganz PA, Bower JE. Tai chi chih compared with cognitive behavioral therapy for the treatment of insomnia in survivors of breast cancer: a randomized, partially blinded, noninferiority trial. J Clin Oncol 2017;35(23): 2656-2665.
  11. Liu J, Chen P, Wang R, Yuan Y, Wang X, Li C. Effect of tai chi on mononuclear cell functions in patients with non-small cell lung cancer. BMC Complement Altern Med 2015;15:3.
  12. Irwin MR, Olmstead R, Breen EC, Witarama T, Carrillo C, Sadeghi N, et al. Tai chi, cellular inflammation, and transcriptome dynamics in breast cancer survivors with insomnia: a randomized controlled trial. J Natl Cancer Inst Monogr. 2014; 295-301.
  13. Fong SS, Chung LM, Tsang WW, Leung JC, Charm CY, Luk WS, et al. Balance Performance in Irradiated Survivors of Nasopharyngeal Cancer with and without Tai chi Qigong Training. eCAM 2014:719437.
  14. Fong SS, Ng SS, Lee HW, Pang MY, Luk WS, Chung JW, et al. The effects of a 6-month Tai chi Qigong training program on temporomandibular, cervical, and shoulder joint mobility and sleep problems in nasopharyngeal cancer survivors. Integr Cancer Ther 2015;14:16-25.
  15. Fong SS, Ng SS, Luk WS, Chung JW, Leung JC, Masters RS. Effects of a 6-month Tai chi Qigong program on arterial hemodynamics and functional aerobic capacity in survivors of nasopharyngeal cancer. J Cancer Survivorship 2014;8:618-26.
  16. Oh B, Yeung A, Klein P, Larkey L, Ee C, Zaslawski C, Knobf T, Payne P, et al. Accreditation standard guideline initiative for tai chi and qigong instructors and training institutions. Medicines (Basel) 2018;5:51
  17. Yan JH, Pan L, Zhang XM, Sun CX, Cui GH. Lack of efficacy of tai chi in improving quality of life in breast cancer survivors: a systematic review and meta-analysis. Asian Pac J Cancer Prev 2014; 15:3715-20.
  18. Zhou W, Wan YH, Chen Q, Qiu YR, Luo XM. Effects of tai chi exercise on cancer-related fatigue in patients with nasopharyngeal carcinoma undergoing chemoradiotherapy: a randomized controlled trial. J Pain Symptom Manage 2018;55(3):737-744.
  19. Song S, Yu J, Ruan Y, Liu X, Xiu L, Yue X. Ameliorative effects of tai chi on cancer-related fatigue: a meta-analysis of randomized controlled trials. Support Care Cancer 2018;26(7): 2091-2102.
  20. Wayne PM, Lee MS, Novakowski J, Osypiuk K, Ligibel J, Carlson LE, Song R. Tai chi and Qigong for cancer-related symptoms and quality of life: a systematic review and meta-analysis. J Cancer Surviv 2018;12(2): 256-267.
  21. NIH. Tai chi and Qi Gong: In Depth. 2016. [accessed 21/01/19]
  22. Wayne PM, Berkowitz DL, Litrownik DE, Buring JE, Yeh GY. What do we really know about the safety of tai chi?: A systematic review of adverse event reports in randomized trials. Arch Phys Med Rehabil 2014; 95(12): 2470-2483.

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