The Benefits of T'ai Chi for Older Adults with Chronic Back Pain: A Qualitative Study

Abstract

Objective:

To determine the perceived benefits of t'ai chi in older adults with chronic low-back pain (cLBP).

Design:

A qualitative analysis from a randomized controlled feasibility trial.

Subjects:

Eighteen participants (65+ years old) with cLBP of at least moderate intensity.

Intervention:

A 36-week intervention beginning with twice weekly classes for 12 weeks, weekly classes for 6 weeks, biweekly classes for 6 weeks, and monthly classes for 12 weeks. Participants were asked to practice at home on nonclass days and videos were provided to assist in that process.

Outcome Measures:

Participants in the focus groups were asked to provide feedback on their experiences with the study as well as the benefits of their t'ai chi practice. We used demographic and class attendance data to describe the sample.

Results:

Regarding the benefits of t'ai chi practice, five major themes were identified: functional benefits, pain reduction/pain relief, psychospiritual benefits, the importance of social support in learning t'ai chi, and the integration of t'ai chi into daily activities. The most common functional benefits were improvements in balance, flexibility, leg strength, and posture. Some reported pain reduction or pain relief, but others did not. Increased relaxation, mindfulness, and a sense of connectedness were subthemes that emerged from psychospiritual benefits. Social support benefits included motivation to attend class and group support while learning a new skill. Finally, improved body awareness allowed participants to integrate t'ai chi skills into their daily activities.

Conclusions:

This qualitative analysis demonstrates the multifaceted benefits of t'ai chi for older adults living with cLBP.

Introduction

Chronic low-back pain (cLBP) is a common problem among older adults and is the leading cause of years lived with disability in the United States.¹ There is a need for effective low-risk therapies for this problem in this population. Medications commonly prescribed for pain have increased risks for older adults.^2

–6 Some nonpharmacological therapies (e.g., high-velocity spinal manipulation^7,8 and some forms of yoga⁹) may also have greater risks for older adults. As the population of older adults increases, the need to identify effective low-risk therapies for cLBP in this age group becomes more pressing.

There is some evidence that t'ai chi is beneficial for cLBP in adults,^10
–12 but evidence is limited, and few studies have focused specifically on older adults. In a Consumer Reports survey of more than 3500 adults who had back pain in the past 3 years, nearly 90% of respondents who used t'ai chi for back pain reported that it was helpful.¹³ t'ai chi, a gentle form of Chinese martial arts practice,^14,15 has a number of therapeutic elements that make it a promising treatment for older adults with cLBP. t'ai chi may be helpful for back pain by strengthening the abdominal and pelvic muscles and improving balance, flexibility, and posture; other therapeutic ingredients may include visualization, focused attention, breathing, and dynamic structural integration.^16,17 Previous studies also suggest that t'ai chi may be beneficial for balance and falls prevention,¹⁸ cardiorespiratory fitness,¹⁹ cognitive performance,²⁰ bone health,²¹ and osteoarthritis,²² preventive needs or conditions that are typically more common in older adults.

As part of a feasibility trial comparing t'ai chi with two different control groups in older adults with cLBP, we collected qualitative data on the benefits of t'ai chi and suggestions to improve our study processes. In this article, we report on the qualitative benefits of t'ai chi.

Materials and Methods

Recruitment procedure

Study methods are described in more detail elsewhere,²³ and the most pertinent details are provided here. Most participants were recruited from Kaiser Permanente Washington, an integrated health care system located in Washington State, with others responding to recruitment flyers placed in community settings that older adults frequent. Electronic administrative and clinical databases were used to identify patients aged 65+ years with ICD-10 codes consistent with uncomplicated low-back pain. Information about the study was mailed to these patients. Interested patients were asked to return a statement of interest or call a toll-free telephone number.

A research interviewer called interested patients to obtain oral consent for screening and asked a series of preliminary screening questions. Provisionally eligible patients were scheduled for an in-person assessment at a Kaiser Permanente Washington clinic, during which we completed eligibility screening, obtained informed consent, and administered baseline physical assessments and questionnaires. In this report, we focus on the qualitative benefits reported in the t'ai chi groups. This study was approved by the Kaiser Permanente Washington Institutional Review Board.

Participants

We randomized 57 participants in 2 consecutive recruitment cohorts: 28 participants were allocated to the t'ai chi group, 12 to Health Education, and 17 to Usual Care. The t'ai chi participants included 15 participants in the first cohort and 13 in the second cohort.

All but one participants were Kaiser Permanente members aged at least 65 years with the National Institutes of Health (NIH) definition of cLBP (in the past 6 months, at least 3 months of back pain on at least half the days),²⁴ of at least moderate intensity (4+ on a 0–10 back pain intensity scale and rated their activity limitations due to back pain at least a 3 on a 0–10 scale). We excluded people with possible cognitive impairment (score of <3 on a 6-item Callahan screener).²⁵

Using ICD-10 codes and screening of patients by phone and in-person, we excluded patients with indications of serious underlying illness (i.e., fever, recent unexplained weight loss of at least 10 pounds, or uncontrolled cardiac arrhythmia), complicated back pain (i.e., metastatic cancer, infectious or inflammatory causes, or sciatica), and prior lumbar spine surgery. We also required participants to not have received t'ai chi training in the last 12 months. All participants gave informed consent.

T'ai chi protocol

The t'ai chi intervention consisted of 36 weeks of classes plus recommended home practice on nonclass days. The number of classes tapered over the course of 36 weeks: 12 weeks of twice weekly classes, 6 weeks of weekly classes, 6 weeks of biweekly classes, and then 12 weeks of monthly classes.

Yang style was chosen because it is the gentlest form of t'ai chi and can easily be modified to the physical capabilities of any individual. The 60-min t'ai chi intervention was taught by two different instructors with more than 25 years of experience each. Classes began with an initial check-in about the home practice, warm-up exercises focused on posture and abdominal breathing, followed by six simple t'ai chi movement sequences taught over the course of 12 weeks. Each class ended with a closing breathing exercise. DVDs (or online videos) of the movement sequences were provided to participants to support t'ai chi home practice. All movements included modifications to enhance safety.

Self-administered questionnaires were obtained from participants at 3, 6, and 12 months after randomization.

Focus groups

At the 52-week follow-up, 27 participants randomized to t'ai chi were invited to participate in a 2-h focus group. Ten of the 14 invited participants from t'ai chi Cohort 1, and 8 of the 13 invited participants from t'ai chi Cohort 2 attended a focus group. Participants received $50 for their attendance. Participants were asked to provide feedback on their experiences with the study, the benefits of their t'ai chi practice, the integration of t'ai chi into daily life, and suggestions for improvement. Here, we focus on the perceived benefits of t'ai chi and its integration into daily life.

To encourage group discussion about participants' experiences, including their benefits, in learning t'ai chi in a group setting, focus groups were selected as the method to capture these experiences. The focus groups were led by a project manager with experience conducting focus groups. She asked probing questions as needed to explore all topics in-depth and to encourage less talkative participants to share. Furthermore, each topic was briefly summarized before moving onto the next topic to ensure that participants' experiences were correctly understood. Each session was audiotaped.

Data analysis plan

The qualitative data analysis was conducted based on Strauss and Corbin's version of grounded theory.²⁶ Focus group sessions were transcribed verbatim from audiotapes. Transcripts from both focus groups were read independently by each member of the multidisciplinary study team. Two researchers (T.L.L. and K.J.S.) then reread the transcripts and met to discuss the coding process. One reviewer coded the text into broad categories. Similar text segments were then placed together in the same broad category. Each broad category was further refined into subcategories. Our categories described the major themes present in both groups, and subthemes. A second reviewer carefully reviewed each stage of the coding process.

This iterative approach to analysis was conducted until no new codes emerged and saturation was achieved. A coding memo was created with a brief summary of each theme and supporting quotes from participants. This coding memo was shared with the study team to review independently. Themes were further discussed until consensus was achieved. Demographic characteristics and number of t'ai chi sessions were obtained from baseline data and t'ai chi attendance data, respectively.

Results

Participant characteristics

Two focus groups were conducted with a total of 18 individuals who were randomized to t'ai chi. Table 1 summarizes some key participant characteristics.

Table 1.

Characteristics of T'ai Chi Focus Group Participants

Characteristic	n	%
Age (years)
65–74	15	83
75–84	3	17
85+	0	0
Gender
Female	11	61
Male	7	39
Race
Asian	2	11
Black	2	11
White	14	78
No. of classes attended
0–4	1	6
5–9	0	0
10–14	0	0
15–19	6	33
20–24	11	61

Qualitative findings

Five principal benefits were identified: functional benefits, pain reduction and pain relief, psychospiritual benefits, social support for learning t'ai chi, and the integration of t'ai chi into daily activities.

Functional benefits

Participants most commonly reported functional benefits including improvements in leg strength, balance, flexibility, and posture (Table 2). t'ai chi did not always lead to improvements in their back: “My back is still the same as far as I'm concerned, I'm not sure that I could say it's had much of a difference there, but my balance and feeling that I have just standing erect is a great deal different. I might have joined for the back problem but I think I got other benefits from it.” P3, Focus Group 1.

Table 2.

Qualitative Findings

Themes	Subcategories	Exemplars
Functional benefits	Balance, flexibility	“… the balance and flexibility both have vastly improved” P2, Focus Group 1
	Balance, posture	“my balance and the feeling I have just standing erect is a great deal different.” P3, Focus Group 1
	Can do simple tasks	“Now I can walk up the stairs. I still hold onto the railing but I can walk up the stairs now like a normal person, not one step at a time holding on, pulling myself up. And I can carry my groceries up.” P1, Focus Group 2
		“I have noticed a change in my leg strength, and I was so surprised because I did not really feel like I had been using my quads. Not that I can squat all the way down and stand up without holding onto something, but even getting up and out of chairs and stuff, I think I am more conscious of it too.” P1, Focus Group 1
Pain reduction/pain relief		“I don't have to take as many pain meds as I used to I have had back problems that I had to take pain medicine in the morning and at night. And I would wake up in the morning and I would be in horrible pain. I couldn't get out of bed until I did certain physical exercises to loosen myself up. And I got used that. It was automatic. When I woke up, I did 30 minutes of stretching exercises before I could even get out of bed. And then I had to roll off the bed to get up. It wasn't until recently that I began to notice that I wake up in the morning and I don't have any pain. It's not every day, because it depends on what I do … I know what triggers my back, but I began to notice that I woke up this morning at 6:00 and I don't have to do my stretching if I don't want to. I am not having the pain as bad. So I lay off the pain meds. And I mark my calendar, how many days I can go without taking a pain med. And it's increasing.” P2, Focus Group 2
Psychospiritual benefits	Relaxation	“I couldn't ever imagine an exercise that would make me feel relaxed, and these things do. It really does feel good.” P3, Focus Group 1
Psychospiritual benefits	Mindfulness	“Even to recognize – hey, you're having back pain, you know. So I feel like it made me a lot more mindful of what's going on with my body that I wasn't really thinking about before.” P1, Focus Group 2
Social support for learning t'ai chi	Commitment to practice	“But the whole idea is … that if I am in the group, I am doing it every week with people. If I'm on my own, I lose my motivation. I can't do it on my own. So I need somebody to tell me to do it. That would help.” P4, Focus Group 1
	Learning a new skill	“… t'ai chi is a social activity and it's meant to be done with other people. And I couldn't practice on my own, I was getting bored, doing the same thing over and over again, so I really wanted to go to class to try and learn something different. I figured also I was probably just doing the same thing, getting worse and worse because of bad habits.” P1, Focus Group 1
	Instructor interactive and friendly	“And [the instructor] was great. I don't know if I would have been enthusiastic if we'd had an instructor – a friend of mine went to a community class and had a terrible instructor and decided not to pursue it. When I talked to him about what [the instructor] would talk to us about, he was like she never mentioned that, she never got into breathing or standing or posture and alignment, energy from earth.” P7, Focus Group 1
Integration of t'ai chi into daily life	Improved body awareness	“Whether it's the line at the grocery store, even waiting for a walk light, shoulders down. Head back, it becomes almost second nature.” P2, Focus Group 1

Multiple functional benefits were noted by some, “The balance and flexibility have vastly improved.” P2, Focus Group 2. Another said, “To me, I find more strength in my daily chores. It used to be this side is better and this side's weak, and now I'm balanced so I could do more things.” P4, Focus Group 1.

Several participants noted that their functional improvements allowed them to carry out simple daily activities, for example: “I couldn't get myself out of the tub. I now get myself out of the tub. I reach the third shelf in my kitchen without using a grabber. I bend over and pick something off of the floor. I don't have to get a stool, sit down and pick it up. I've seen a remarkable change in me. And my children have noticed it too.” P2, Focus Group 2.

Pain reduction and pain relief

Some participants reported improvement in their pain, “Well I know if I don't do them [t'ai chi movements] I start having back pain.” P4, Focus Group 2. Another mentioned being aware of how she stands prevents triggering her pain, “I was standing so badly and that it really did make a difference in terms of onset. Because like cooking, just standing there, I would be in pain afterwards, and now I'm changing my position, learning to stand better, it's changed a lot.” P1, Focus Group 1.

However, pain did not improve for everyone, “I think my pain level changes, sometimes it's more, but I keep doing different things that tweak it again.” P2, Focus Group 2.

Some reported improved body awareness helped them to recognize the importance of postural adjustments to reduce their pain. For example, “I don't think about those things but it was just a reminder to get myself aligned and then the pain goes away magically, or at least diminishes.” P1, Focus Group 2.

Psychospiritual benefits

Common subthemes derived from psychospiritual benefits were relaxation, mindfulness, and a sense of connectedness. Several participants reported feeling relaxed and/or breathing more consciously (Table 2). Some used the relaxation techniques in stressful situations such as traffic, “… I did feel some urgency, but now I can just be relaxed and listen to something on the radio that I like, and not let it get me upset …” P3, Focus Group 2.

Several participants reported increased mindfulness and awareness of their body posture, muscle tension, and breathing. One participant noted that improved mindfulness helped her cope with pain better (Table 2). Another shared being more mindful helped them to breathe deeply, “And this slowed me down. That was the hardest thing. That and breathing. And I became very aware that I hold my breath a lot and that was the worst coordination ….” P2, Focus Group 2. Other participants agreed that they were more aware of their breath and breathing.

Two participants also noted that enhanced mindfulness improved cognition. As one noted, “And I really think mindfulness carries over not just physicalness, but in other parts of my daily activities. It makes me stop and think about things, going back – oh, I forgot about that, you know. Let me go back and do that. And it helps me to stay more focused.” P1, Focus Group 1. Another participant agreed their “mind seems sharper” and “Learning something new, especially at our age, is so beneficial to our cognitive skills.” P2, Focus Group 1.

One participant commented on the meditative aspect of t'ai chi, “For me, it was very meditative. It had for me anyway a kind of spirituality to it, that wasn't churchy or anything like that, just connectedness to the planet and the earth and these are things that I found meaningful. I was so happy to find an activity that gave me so many different things on different levels for myself.” P7, Focus Group 1.

Importance of social support for learning t'ai chi

Participants reported that a key motivator for attending class was practicing with a group (Table 2). Attending class gave one participant a valuable sense of commitment, “I think it's going to the class and being with people and feeling an obligation to something you commit to … Seeing myself and the other people in the class and watching them grow in terms of being able to do something.” P2, Focus Group 1. Several participants reported difficulty in maintaining their practice as the classes began to taper, “I'm not practicing nearly as much as I was. I still do three or four times a week, but I was practicing every day when I was taking the classes.” P1, Focus Group 1. For another, practicing alone was challenging, “I have a difficult time going alone. … It motivates me.”

For others, group support was helpful in learning a new skill and honing their practice (Table 2). One noted, “I like watching my group do their exercises too, as opposed to just the teachers because I learned from my group.” P5, Focus Group 2.

Several participants also reported the importance of having an instructor who was personable, knowledgeable, and interactive. One participant noted, “I feel like [the instructor] was a huge part of it. I just thought she is an amazing teacher …” P1, Focus Group 1. Participants found the individual attention they received from the instructor particularly helpful. “And she gave me a real point, because when she looked at you individually she would say something like, your hand should be down or you know, the thing that you weren't doing real well. And it didn't feel like criticism, it was helpful.” P3, Focus Group 2.

Another stated, “[The instructor] checked with everybody at the end of each movement. Hi, how was it? How are you doing? All of that was really personal connection, which really was motivating.” They also appreciated the instructor's ability to compare t'ai chi postures with daily activities, “I think that was [the instructor's], one of her greatest things is she could put a movement in everyday terms of vacuuming or sweeping or standing. She really could compare a movement to an everyday thing.” P1, Focus Group 1.

Integration of t'ai chi into daily activities

Participants reported benefits of integrating aspects of their t'ai chi practice into their daily activities such as driving, folding laundry, and cooking.

One participant shared how she integrated the t'ai chi movements into her daily activities, “There are movements that I do throughout the day when I'm washing dishes, when I'm cooking or doing [things] like that, where I'll actually do a movement.” P5, Focus Group 2. Another reported, “Like in the supermarket when I'm pushing the cart, I would be leaning on the cart because my back was bothering me, instead of breathing into it and relaxing my back and now when I walk I hold onto it, or standing in line waiting for something, to get into that relaxed mode.” P1, Focus Group 2.

Others noted that functional improvements in leg strength and posture improved their body awareness to perform daily movements. For example, “I have noticed a change in my leg strength, and I was surprised because I didn't really feel like I'd been using my quads … I think I'm more conscious of it too. I try not to push on the arms when I get up, I try to just use my legs, which I never have before.” P1, Focus Group 1.

While some participants reported integrating their t'ai chi skills and practice into their daily activities as a conscious effort resulting from increased body awareness, one reported that this integration occurred naturally: “The nice thing about t'ai chi as far as I'm concerned is that there was no application that happened in my particular case. It was not that I had to apply t'ai chi skills. It's just that they resided in my body, I guess.” P6, Focus Group 1.

Discussion

Our study found multiple benefits from t'ai chi reported by older adults with cLBP. The most common benefits reported were functional including improvements in balance, flexibility, leg strength, posture, and ability to engage in activities of daily living. Some reported improvements in pain, but others did not. Psychospiritual benefits were also reported, most commonly greater attention to breathing and increased relaxation. Several participants reported greater mindfulness. Social support was useful for several reasons. For one, the instructors gave personalized instructions to help participants correct their t'ai chi form. In addition, participants commented on the value of the class for encouraging their class attendance, motivating their home practice and improving their skills by watching others practice. Some participants reported multiple benefits.

Previous studies on younger adults have also reported multiple functional improvements from t'ai chi.^{12,21,27

–30} Other qualitative studies found that t'ai chi improved self-efficacy, confidence, and ability to make healthier lifestyle choices.^31
–33 A novel finding in our study is that participants specifically reported that they integrated t'ai chi skills into their daily activities to manage their pain.

Some studies have reported that t'ai chi helps with relaxation and improved awareness of breathing, bodily sensation, and symptoms.³⁴ Other studies reported that t'ai chi improved mindfulness, which increased awareness and appreciation for family, nature, and life in general.^32,35 Similarly, a few participants in this study reported a sense of spirituality with their t'ai chi practice.

Prior studies have noted that both a positive relationship with the instructor and a strong sense of group support facilitate learning t'ai chi.^32,34 For older adults, engaging in exercises in a social setting helps to maintain their physical activity and reduce the risks associated with social isolation.^36
–38

This study benefited from relatively high participation in the focus groups (18 of the 27 participants) and engaged participants during the discussions. Also, the qualitative data analysis was conducted in a thorough manner with a team of multidisciplinary researchers.

There were several limitations with this study. Participants were almost all members of Kaiser Permanente Washington and findings may not apply to other populations. Additionally, participants were informed the study focused on a t'ai chi intervention, and they may have been predisposed to find benefits. Furthermore, the results from this study present the benefits of practicing a simple t'ai chi series for up to a year. Thus, the long-term effects of an extended practice are unknown.

Conclusions

This study suggests that t'ai chi provides several functional, psychospiritual, and social support benefits for older adults with cLBP. The most common benefits reported were functional improvements such as improved balance, leg strength, and flexibility. Future research with larger samples and objective measures of the benefits described here is needed to determine the long-term impact of t'ai chi.

Footnotes

Acknowledgments

We thank Kim Ivy for development of the TC protocol, Kim Ivy and Viola Brumbaugh for teaching TC classes, and Bill Laprade for substitute teaching when needed. We also thank John Ewing, Karen Walker, and Margie Wilcox for staffing the classes and other assistance with the study.

Disclaimer

The contents are the sole responsibility of the authors and do not necessarily reflect the official view of the National Center for Complementary and Integrative Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This project was supported by grant R34 AT009052 from the National Center for Complementary and Integrative Health.

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