Tai Chi

Abstract and key points

Tai chi combines breathing techniques with sequences of slow graceful movements. It is sometimes referred to as a ‘meditation in motion’. 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 survivors.

Six systematic reviews (SRs) and three subsequent randomised controlled trials (RCTs) of tai chi for cancer published in the last five years/since 2017 are available: three including breast cancer patients, one generally in cancer patients, one in cancer-related fatigue and one in anxiety and depression in cancer patients among other patient populations (Cai 2022). All SRs include meta-analyses except Yang 2021. 

All but one SRs suffered methodological shortcomings including significant heterogeneity, high risk of bias of the primary studies, or small number of patients in the analyses. The only acceptable quality SR evaluated cancer-related fatigue in breast, prostate and lung cancer patients (Song 2018). 

  • Quality of life: Evidence favours tai chi. Of the overall, six SRs, five reported favourable findings and one showed little or no effect (low-quality evidence). 
  • Fatigue: Evidence favours tai chi. Two SRs suggest that it may reduce short-term cancer-related fatigue in breast, lung, head and neck, and prostate cancer.
  • Insomnia: Evidence is inconclusive. Evidence from one high-quality RCT found tai chi to be equally effective as cognitive behavioural therapy resulting in clinically meaningful improvements. Two SRs reported conflicting results (low-quality evidence).
  • Depression and anxiety: Findings are inconclusive. One SR of six trials concluded that tai chi has no effects on depression, however the intervention may slightly reduce anxiety levels (based on pooled analyses of two low-quality trials). 
  • Physical health parameters: Two SRs reported improved upper limb function with tai chi. One trial (n=100) reported improved lung function, reduced pain scores and inflammatory markers following tai chi.

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.

 

Citation

Pawel Posadzki, Ava Lorenc, CAM Cancer Consortium. Tai Chi [online document], March 23rd, 2022.

Document history

Last updated and revised in January 2022 by Pawel Posadzki.
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.

What is it?

Description

Tai chi (short for tai chi chuan) combines breathing techniques with sequences of slow graceful movements for health and well-being. It is sometimes categorised as a mind-body intervention (Mansky 2006) and referred to as a ‘meditation in motion’ (Peters 2005).

Background and prevalence

Tai chi has its roots in ancient Chinese philosophy and martial arts (Peters 2005) and is also used in Traditional Chinese Medicine (TCM). It dates back to the Ming Dynasty (1368-1644 AD) and since then 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 105 postures/sequences (Mansky 2006). Although the Yang style was used in many of the studies reviewed for this summary, not all of them mention the tai chi style taught. 

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 chi (Fouladbakhsh 2010). Precise prevalence figures are not available for Europe or other countries.

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 populations (Mustian 2004).

Application and dosage

Tai chi is usually taught in groups by an individual who is either trained or experienced in tai chi. Sometimes an instructional DVD is provided. 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, sequence of tai chi movements 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.

Mechanism 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 survivors (Janelsins 2011). Proponents of TCM 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 focused (TCUGB 2022).

Legal issues and cost

Although various organisations offer certification worldwide, there is no standardised training or recognised credentialing/licensing process in place for tai chi instructors at present. In 2018 the Medical Tai chi and Qigong Association published accreditation standard guidelines for instructors and training institutions, which they hope will help to guide professionals and the public (Oh 2018).

The cost of sessions varies between countries, but an approximate cost of EUR 8-20 is generally charged.

Does it work?

Supportive/palliative care

Six systematic reviews (SRs) of tai chi for cancer published in the last five years/since 2017 are available: three including breast cancer patients (Luo 2020, Liu 2020, Ni 2019), one generally in cancer patients (Yang 2021), one in cancer-related fatigue (Song 2018) and one on anxiety and depression in cancer patients among other patient populations (Cai 2022). All SRs include meta-analyses except Yang 2021. 

Two recent SRs assessing both qigong and tai chi for health-related outcomes of cancer patients (Wayne 2018; Zeng 2019) have been excluded. Wayne et al present results as one body of evidence, which does not allow any conclusions about tai chi itself and Zeng et al include only one RCT on tai chi, which is also included in the above-mentioned SRs (Zeng 2019 update of Zeng 2014).

All but one SRs suffered methodological shortcomings including significant heterogeneity, high risk of bias of the primary studies, or small number of patients in the analyses. The only acceptable quality SR evaluated cancer-related fatigue in breast, prostate and lung cancer patients (Song 2018). Table 1 summarises the results of SRs.

Three randomized controlled trials (RCTs) have subsequently been published. These trials are described in Table 2

  • Quality of life: Evidence favours tai chi. Of the overall, six SRs, five reported favourable findings and one showed little or no effect.
  • Fatigue: Evidence favours tai chi. Two SRs suggest that it may reduce short-term cancer-related fatigue in breast, lung, head and neck, and prostate cancer.
  • Insomnia: Evidence is inconclusive. Evidence from one high-quality RCT found tai chi to be equally effective as cognitive behavioural therapy resulting in clinically meaningful improvements. Two SRs reported conflicting results. 
  • Depression and anxiety: Findings are inconclusive. One SR of six trials concluded that tai chi has no effects on depression, however the intervention may slightly reduce anxiety levels (based on pooled analyses of two low-quality trials). 
  • Physical health parameters: Two SRs reported improved upper limb function. One trial (n=100) reported improved lung function, reduced pain scores and inflammatory markers following tai chi.

Quality of life

Overall, six SRs assessed quality of life. The first SR (Luo 2020) aimed to evaluate the effects of tai chi on quality of life in breast cancer patients. Fifteen trials (total sample size n= 885) were examined. They found that in breast cancer patients, tai chi improved quality of life when compared with non-exercised therapy post-intervention, and at 12- and 25-week follow-ups. This review was judged to be the most rigorous and comprehensive one. Another SR (Liu 2020) aimed to evaluate the current evidence for the effectiveness of tai chi in breast cancer patients. Sixteen 16 trials (with a total of 1268 patients) were examined. They reported that when compared with the controls, the interventions may improve overall quality of life as measured with SF-36 at 3 months. The review suffered from high clinical and methodological heterogeneity. Another SR (Ni 2019) evaluated the effects of Tai Chi on quality of life of cancer (breast and lung) survivors. Twenty-two trials with a total of 1410 patients were assessed. They showed that when compared with various controls, tai chi may improve quality of life (physical and mental domains) based on low-quality evidence. The primary studies were judged to be at a high or very high risk of bias. A SR by Yang (2021) evaluated the therapeutic efficacy of tai chi among breast, head and neck, prostate and lung cancer patients. Twenty-six studies of various designs (RCTs, non-RCTs, before and after studies) were examined. They reported that tai chi had no effect on health related QoL when compared with various controls. The primary studies were judged to be at a variable risk of bias (high, low and unclear); and the quality of the evidence was low or very low. 

Fatigue

A SR assessing the effects of tai chi on cancer-related fatigue included six RCTs involving 373 patients (Song 2018). 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).

A SR by Yang (2021) evaluated the therapeutic efficacy of Tai Chi among breast, head and neck, prostate and lung cancer patients. In their narrative synthesis, the authors included 26 studies of various designs (RCTs, non-RCTs, before and after studies) with a multitude of clinical and patient-centred outcomes. They reported that various Tai Chi interventions improved fatigue and sleep quality in cancer survivors and had no effect on anxiety, depressive symptoms, health related QoL, physical function, bone health, cognitive function, pain, when compared with various controls. The primary studies were judged to be at a variable risk of bias (high, low and unclear); and the quality of the evidence was low or very low.  

One subsequently published randomised controlled trial (n=83) on the effects of tai chi for cancer-related fatigue has been published since the SR above (Zhou 2018). It confirms the positive results of the review, although the only comparator was usual care and the study has many limitations. 

Anxiety and depression

One SR reported effects of tai chi compared with various controls (Cai 2022).  When compared with exercise training or usual care, tai chi reduced slightly the symptoms of anxiety (SMD 0.69, 95% CI -1.22 to -0.17, 2 RCTs) in breast cancer patients. However, when compared with exercise training, usual care or sham, tai chi had little effect or no difference in reducing depressive symptoms (SMD -0.63, 95% CI: -0.42 to 0.16, 4 RCTs). The quality of the evidence was not evaluated; however, both studies were judged to be at a very high risk of bias, and considerable amount of heterogeneity was detected.

Physical health parameters

Luo 2020 conducted meta-analyses of secondary outcomes showing that 3 weeks TCC increased shoulder function (SMD=1.08, 95% CI 0.28–1.87, p=0.008), 12 weeks TCC improved pain (SMD=0.30, 95% CI 0.08–0.51, p=0.007), shoulder function (SMD=1.34, 95% CI 0.43–2.25, p=0.004), arm strength (SMD=0.44, 95% CI 0.20–0.68, p=0.0004), and anxiety (MD=−4.90, 95% CI −7.83 to −1.98, p=0.001) in breast cancer patients compared with the control group.

The SR by Ni 2019 pooled the data of five trials (n=465 breast cancer survivors) for measures of upper limb function demonstrated significant differences in upper limb function scores between the tai chi intervention group and the control group, with the tai chi group having better limb function (SMD = 1.19, 95%CI [0.63, 1.75]; P < 0.0001; significant heterogeneity (I2= 87%, P < 0.00001).

This is in line with an earlier SR analysed the available randomized controlled trials (RCTs) on the effects of tai chi in various outcomes in women with breast cancer (Pan 2015) reporting significant effects for tai chi 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. 

A subsequently published RCT reported on lung function (n=100) (Jiang 2020). They compared tai chi to standard care and reported that tai chi enhanced lung function and increased blood oxygen level in lung cancer patients (Jiang 2020). They reported improved lung function, reduced pain scores and inflammatory markers as well as increased levels of antioxidant markers in tai chi compared with usual care.

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 poor (Wayne 2014).

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 difficulties (NMD 2020, NIH 2021).

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 section (NMD, NIH 2021).

There may be potential risks if the tai chi is self-taught rather than taught by a qualified instructor  (NIH 2021).

References

Cai Q, Cai SB, Chen JK, Bai XH, Jing CX, Zhang X, et al. Tai Chi for anxiety and depression symptoms in cancer, stroke, heart failure, and chronic obstructive pulmonary disease: A systematic review and meta-analysis. Complement Ther Clin Pract 2021;46:101510.

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.

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.

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.

Jiang M, Zhao H, Liu J, Zhao X, Jin L, Pan R. Does Tai Chi improve antioxidant and anti-inflammatory abilities via the KEAP1-NRF2 pathway and increase blood oxygen level in lung cancer patients: a randomized controlled trial? European journal of integrative medicine 2020;37.

Liu L, Tan H, Yu S, Yin H, Baxter GD. The effectiveness of tai chi in breast cancer patients: A systematic review and meta-analysis. Complement Ther Clin Pract 2020;38:101078.

Luo XC, Liu J, Fu J, Yin HY, Shen L, Liu ML, et al. Effect of Tai Chi Chuan in Breast Cancer Patients: A Systematic Review and Meta-Analysis. Front Oncol 2020;10:607.

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.

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.

NCCIH, National Center for Complementary and Integrative Health, National Institutes of Health. Tai Chi: In Depth [web article], 2016. (accessed 03/03/2022)

Ni X, Chan RJ, Yates P, Hu W, Huang X, Lou Y. The effects of Tai Chi on quality of life of cancer survivors: a systematic review and meta-analysis. Support Care Cancer 2019;27(10):3701-3716.

NMD, Natural Medicines Database. Tai Chi monograph. Online database [requires subscription]. July 2020 (accessed on 3rd March 2022).

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

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.

Peters D. The Complete Family Guide to New Medicine. Dorling Kindersley (2005).

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.

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.

TCUGB, Tai Chi & Qigong Union for Great Britain. What is Tai chi? [website] (Accessed on 3rd March 2022). 

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.

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.

Yang L, Winters-Stone K, Rana B, Cao C, Carlson LE, Courneya KS, et al. Tai Chi for cancer survivors: A systematic review toward consensus-based guidelines. Cancer Med 2021;10(21):7447-7456.

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 Ther Med 2014;22:173-86.  

Zeng Y, Xie X, Cheng ASK. Qigong or Tai Chi in Cancer Care: an Updated Systematic Review and Meta-analysis. Curr Oncol Rep. 2019 Apr 6;21(6):48. 

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.

CAM Cancer is hosted by NAFKAM

Norway's National Research Center in Complementary and Alternative Medicine

Read more about NAFKAM

Other websites from NAFKAM: