The Effects of T'ai Chi with Asynchronous Music on the Health of Older Women: A Pilot Study

Abstract

Background:

This pilot study sought to explore the impact of adding music to t'ai chi practice in older women.

Materials and Methods:

Eighteen active older women (nine Caucasian, nine African American) were assigned to either the t'ai chi-silence (control) or the t'ai chi-music (experimental) class and were interviewed before and after a 15-week t'ai chi program. All classes, interviews, and tests were conducted at an older adult activity center in a U.S. metropolitan city. All classes were held in a well-lit exercise studio with a solid-wood floor, mirrored wall, and sound system. T'ai chi classes using a modified 24-form Yang Style were held for one hour per week. One group was conducted in silence, while the other used the same Western music only during rehearsal of previously learned class material. Interviews emphasized participants' experience and perceived health benefits from t'ai chi. Interviews were conducted, transcribed, coded, and analyzed for code co-occurrence, relationships, and association using modified grounded theory.

Results:

Both groups self-reported improved balance and described the importance of the social aspect of t'ai chi. Analysis revealed that participants in the t'ai chi-music group discussed mental health in tandem with music, spontaneously mentioned spirituality, and had a higher compliance than the t'ai chi-silence group.

Conclusions:

This study showed that t'ai chi practice with music associates positively with older women's mental and physical health experience. Also, t'ai chi programs contribute to increased social interactions among older adults, a critical aspect of healthy aging. Further study is needed regarding t'ai chi practice among older adults, including musical parameters.

Introduction

The increase in the size and proportion of older adults in the U.S. population has created a need to address aging-associated pain, discomfort, disability, and rehabilitation. Complementary and alternative medicine (CAM) interventions such as prayer, meditation, and t'ai chi continue to gain acceptance in both the medical and lay communities as an alternative route to addressing both mental and physical health in a variety of populations.^1,2 According to the National Center for Complementary and Integrative Health, “‘Complementary’ generally refers to using a non-mainstream approach together with conventional medicine.”¹ Older adults report using CAM in increasing numbers,³ and in general, awareness of CAM as both an alternative and complement to conventional treatments for aging-associated ailments and conditions is growing. Many nursing facilities, for example, offer creative arts therapies, and most also offer group exercise combined with music.⁴

In particular, spirituality has been linked to improved physical and mental health in several studies. Although the means are not clear, the benefits of spiritual practice and benefits associated with medicinal placebo effects activate shared neural systems,⁵ suggesting a common mechanism. Functionally, better perception of spiritual well-being has been associated with lower systolic and diastolic ambulatory blood pressure⁶ and participants in a spiritual-based meditation practice demonstrated higher pain tolerance and lower anxiety than those who practiced secular-based relaxation techniques did.⁷ Older adults with a strong spiritual practice described their relationship with a higher power as the foundation of their own positive mental health,⁸ and religion may serve as a resource in coping with stress.⁹ Several studies have attempted to separate the elements of CAM into physical exercise,¹⁰ social engagement,¹¹ spiritual practice,¹² and novel experiences.^13,14 The literature, however, suggests that the combination of factors engenders the most change.¹⁵

T'ai chi is a branch of Traditional Chinese Medicine (TCM) that is well known in China but which is just beginning to be understood in Western society. T'ai chi has been shown to improve balance and other fall risk factors across cultures in both healthy^16

–20 older adults^16

–19 and those with specific diagnoses.²⁰ In particular, the Yang Style of t'ai chi utilizes slow and fluid movements, lending itself well to the older adult population.²¹ T'ai chi has also been shown to impact psychological outcome variables positively, possibly due to mindfulness. Mindfulness, “paying attention in a purposeful way: on purpose, in the present moment,”²² has effects on mental health measures^23,24 and has an excellent adherence rate.²⁵ T'ai chi is an outstanding option for practicing mindfulness due to its inherent demand on the present moment through slow, fluid moment and high concentration.

Both passive music listening²⁶ and music therapy²⁷ have been shown to improve mental health outcomes and increase concentration^28,29 in a variety of populations and have been extensively described in the medical and psychological literature.³⁰ Although music is often used in t'ai chi classes in China, a preliminary review of Western scientific literature found only one English publication¹⁸ mentioning music. Therefore, a research gap remains in the Western literature in understanding if music impacts the efficacy of a t'ai chi intervention. This study aims to understand better possible interactions between Eastern-rooted t'ai chi practice and the addition of culturally appropriate (i.e., 12 tones and European instrumentation) music in a Western audience. Specifically, the current study explores the experience of older Western adults with t'ai chi and music, and examines whether the combination of t'ai chi and music contributes to improved physical and mental health.

Materials and Methods

Semi-structured qualitative interviews were used with active older women who participated in either of two 15-week t'ai chi programs: t'ai chi with music (t'ai chi-music) and t'ai chi with silence (t'ai chi-silence). Qualitative interviews collected data regarding participants' experience, perceptions, and opinions of t'ai chi exercise, assessments of physical and mental health, evaluation of the use of music in t'ai chi practice, and impressions of group experience. Participants were recruited from an older adult activity center in the greater New Orleans area. Eighteen older adults (n=9 white; n=9 African American) participated in the t'ai chi programs, and five dropped out. Therefore, 13 interviews (nine in t'ai chi-music and four in t'ai chi-silence) were conducted and included in this analysis. Enrollment was not restricted by sex. However, only female participants registered. A wide variety of ages (50–84 years) were represented, with an average age of 68.6 years (SD=8.7). Out of these 13 older women, 11 had prior t'ai chi experience, but only one had previously used music during t'ai chi classes. The Tulane University Institutional Review Board approved the study, and informed consent was obtained from all participants.

The research site was an activity center for older adults offering a wide variety of mentally and physically challenging classes. Participants recruited for this study had to be English speaking, aged ≥50 years, and able to participate per the facility's established guidelines. Subjects were excluded if they had experienced more than two falls in the past six months, had a suspected or confirmed diagnosis of dementia, or had any health condition for which t'ai chi may be contraindicated. Announcements of two t'ai chi class times were posted and distributed in the activity center. The blinded participants were block randomly assigned to either the music (experimental) or silence (control) group according to the time slot selected.

The t'ai chi program was 15 weeks in total duration, with planned holidays at weeks 13 and 14, resulting in a total of 13 weeks of exercise. All classes were one hour in length and took place in the facility's exercise room. This studio was mirrored on one wall, with a wooden floor and handrails along one wall. The same t'ai chi teacher, with 14 years of prior t'ai chi instruction and who had previously worked with older adults as a registered nurse, taught all classes. A modified 24-form Yang Style t'ai chi form was used. Each session consisted of gentle warm-up exercises, instruction related to the specialized walking (the “t'ai chi walk”) and arm movements, reviewing previous class material, learning between one and three new t'ai chi forms, and, finally, combining both old and new t'ai chi forms. Posture correction and form assistance was constant.

Music was selected by a Board-Certified music therapist, played in the music (experimental) group only, and used only during rehearsal of previously learned material. All new material was presented in silence. The music was Western in instrumentation, asynchronous, and instrumental, with a variety of nature sounds assimilated into the recording. The same recorded music was used at each trial (Anzan, 2005, track 2).³¹

Quantitative pre- and post-tests were administered before the start and after completion of the program and consisted of the Dynamic Gait Index (DGI) and the Falls Efficacy Scale-International. These results have been reported in detail elsewhere.³² A qualitative interview was conducted post intervention. Interview questions emphasized experience and perception of the t'ai chi program, evaluation of the t'ai chi program, musical preference, subjects' assessment of mental and physical health, and overall commentary. All interviews were audio recorded with participant permission, allowing interviewers to ensure correct transcription and to review documents as necessary.

The qualitative analysis software ATLAS.ti was used to organize and analyze interview data. Data were coded in both category and subcategories, and content was analyzed for code co-occurrence, relationship, and association. Two researchers with backgrounds in nursing, healthcare services, and aging coded all transcriptions independently, and codes were compared. Coding strategies were discussed and agreed upon consistently prior to and during analysis. Efforts to improve trustworthiness were guided by Guba³³ and included overlapping of methodology (mixed methods data collection), prolonged engagement at the research site, and member checks (clarifying interviewees' statements).

Results

In interviews, participants in both groups reported a desire to increase their overall physical movement as the most common reason they chose to participate in the t'ai chi programs. The t'ai chi-music group was composed of participants who had previous t'ai chi experience, and this group largely stated enjoyment of prior instruction as another frequent reason they chose to continue. Interestingly, both groups reported balance and mind–body benefits as being minimal drivers influencing activity choice. However, both were mentioned as direct benefits from this study.

A large number of participants (10/13) in both groups felt their balance had improved. Participants referred both to t'ai chi class examples, such as the t'ai chi walk in which one must walk extremely slowly while shifting balance between feet, and to daily life examples. When replying about balance changes over the course of the semester, one participant said, “…the t'ai chi walk … I couldn't do it [at first], but now I can do it,” while another remarked, “I don't stumble anymore.” No negative physical experience was reported. Participants stated they could not tell changes due to the short program, or were hesitant to separate t'ai chi's impact from that of other exercise routines.

It is interesting to note that the way participants described their balance improvements differed between the two groups. Participants in the t'ai chi-music group discussed their balance improvements with real-life examples and expressed it with feelings of control and achievement. One participant described a particular wheeled chair with which she struggled prior to t'ai chi, saying she felt her balance had improved because she had recently noticed, “When I went to get up I was losing my balance, [but] I was able to straighten myself up in time.” Another participant noticed changes in performance when completing activities of daily living, saying, “I notice that when I'm standing … especially in the kitchen, I don't stumble anymore.”³⁴ The participants in the t'ai chi-silence group, by comparison, discussed class examples, making no connections between skills gained during intervention and everyday life.

In this study, the music and the environment it created evolved to be almost as important as the exercise form itself. Many of the participants in the t'ai chi-music group reported that they “loved the music,” and followed this comment almost immediately with a description of the music that included the words “calming,” “peaceful,” or “soothing.” “Music” was mentioned frequently during interviews, only behind the nouns “t'ai” and “chi,” indicating music remained a focus of the participants. CAM meant combining the sensory element of auditory stimulation, the kinetic element of physical exercise, and opportunities for mental health management via mindfulness.

Positive mental health effects were clearly demonstrated by t'ai chi-music participants. The codes—mental health and music—were positively related, co-occurring in conversation 37% of the time. That is, many participants in the music group discussed their feelings about the music and also mentioned mental health in the same sentence or paragraph of the interview. For instance, when asked about music, one subject replied, “So relaxing, soothing, really relieving stress. My whole body feels different.” Here, the participant combines her response about the music while simultaneously and spontaneously discussing a physical response to and measurement of stress, a true mind–body response. This kind of mind–body connection was manifested only among the t'ai chi-music participants, even though almost all participants did not have prior awareness that t'ai chi is a mind–body exercise.

Additionally, participants in the t'ai chi-music group frequently made comments indicating a close relationship to mindfulness practice such as, “I'm not thinking about anything else but being there in the class,” “I'm not thinking about work or nothing else, I'm just thinking about being there,” and “With music, you are in the moment; without music, you are exercising.” Here, subjects clearly express that the t'ai chi-music intervention has assisted with mindfulness. Because increases in mindfulness positively correlate with mental health,³⁵ these statements can be interpreted as indicative of mental health. The t'ai chi-silence group had only one participant who mentioned a mental health benefit in the same way the t'ai chi-music group did, mentioning the calm she felt in t'ai chi. This participant, however, stated she had a separate meditation practice and so may have had a prior awareness of the mindfulness benefit t'ai chi offered. The t'ai chi-music group may have experienced an implicit accessibility to mindfulness.

Additionally, many of the participants in the t'ai chi-music group reported that they “loved the music,” and followed this comment almost immediately with a description of the music that included the words “calming,” “peaceful” or “soothing.” Participants in the t'ai chi-music group also mentioned spirituality as a domain addressed by this intervention, saying things such as, “[in] dancing … we hold hands. That's more social. This is more spiritual … it's more of a spiritual kind of movement” and “[T'ai chi is] very encouraging for your life and for your own spiritual life too.” These comments suggest that although it was not explicitly presented as a spiritual activity, the t'ai chi-music combination provided a spiritual expression component for participants who sought or became aware of the opportunity. This is a key advantage to using music with t'ai chi, as spirituality has been linked to improved physical health in measures that affect older adults such as blood pressure and cholesterol.³⁶

Social interaction, support, and enjoyment were common themes in the t'ai chi-music group in particular. One participant remarked, “We're social, we're socializing, and laughing about it and then trying to move together, you know, as a unit.” Several participants recalled the laughter the group shared when someone experienced difficulty with movement, or when a subject found herself doing something completely opposite from everyone else. One participant remarked, “I think with other people you have tendency to do it more often, and you get support from other people. You know, you can laugh at yourself if you are doing something wrong.” Another subject noted, “Sometimes I'm just really not feeling like it, you know? But once I get here … I'm talking and I'm communicating and I'm kind of forgetting about it and I just enjoy coming and interacting with people.” It is noted that “enjoy,” “laughter,” or their derivatives were mentioned almost as often as “exercise,” indicating that for the t'ai chi-music group, exercise may have been among the drivers to begin the class, but by the end was not always the foremost motivation of t'ai chi practice.

To Contact Dr. Penny Roberts

Penny Roberts, PhD, MT-BC

Tulane University Center for Aging

School of Medicine

1430 Tulane Ave., 8513

New Orleans, LA 70112

E-mail: probert1@tulane.edu

Discussion

Concurring with existing literature, this study identifies similar interactions between social engagement, exercise, and stimulation that created a rich and motivating environment benefiting older adult's physical and psychological health. This study revealed that older women enrolled to increase balance-associated and other physical health benefits. However, additional social and psychosocial aspects were reaped and may have contributed to higher attendance. The addition of music to t'ai chi has not been previously studied in detail in the English literature—it was often added as an afterthought—but results suggest that practicing t'ai chi with music enabled participants to increase mindfulness and social cohesion, possibly due to improved mental health during practice. Additionally, self-awareness of improvement is essential, as both fear of falling and self-efficacy have both been shown to be inversely correlated with increased fall occurrence: the higher one's self-efficacy and confidence, the lower the fall risk.³⁴ This speaks to the efficacy of the t'ai chi-music intervention, as those subjects were able to transfer skills gleaned during t'ai chi practice to other activities of daily life.

Significantly, this study confirmed that the music contributes to attendance in the older adult population;^37,38 the t'ai chi-music group participants were more compliant than their t'ai chi-silence peers. The frequency of the nouns mentioned (laughter, music, enjoyed) suggest that although physical health (exercise, balance) may have been among the initial reasons subjects signed up for t'ai chi, social interaction and pleasurable musical experience may have been additionally reinforcing and therefore contributed to higher compliance. The relationship between music and exercise adherence has been extensively documented. A recent sports medicine study indicated that the use of personalized music increases adherence to cardiac rehabilitation by almost 70%.³⁹ The mechanisms of the psychological effect of music on exercise continue to be studied.⁴⁰ However, it is commonly focused on typical young or mature adults. Additional research is needed for people with disabilities and/or older groups of people.

Taken together, the results of this study indicate a role for TCM and/or mind–body practices in the Western population of older adults. Adding appropriate music may smooth any cultural differences, provide implicit opportunities for mental health²³ and social engagement, and explicitly focus on physical health performance in balance, increased movement, and so on. Further, as the older adult population continues to grow, an intervention that provides a route to address additional mental health domains (e.g., spirituality) in a group format such as t'ai chi-music is a cost-effective and laborsaving option.

This study was not without limitations, including a small sample size and pre-existing sample differences such as prior t'ai chi experience. A Board-Certified music therapist oversaw the addition of music in this project, but the end result was not the live music frequently used in music therapy interventions. Rather, recorded music was used. Although this allowed for stricter control and reproducibility of the auditory element, this is neither generalized listening nor music therapy and is therefore difficult to characterize. Music therapy and other music research articles typically include information that would allow for reproducibility such as volume, tempo, and instrumentation. It is possible that manipulating any of these elements could in turn change the result of the music/t'ai chi interaction, and this should be further explored.

Despite these limitations, this study is an example of interdisciplinary collaboration that holistic, mind–body medicine requires. The search for group interventions that address several dimensions is a judicious endeavor, and this study shows that t'ai chi-music can address several issues simultaneously. The Western population has begun to explore and accept the mind–body connection, and the older adult/elderly population is also eager to pursue this trend. This study suggests that using t'ai chi with music may provide comprehensible entrances to improvements in spirituality and physical and mental health in the older adult population by combining, rather than replacing, Eastern and Western elements.

Conclusions

The growing diversity of the elderly population calls for innovative policies and practices to aid the promotion of healthy and successful aging. Implications of this research point to the wide applicability of t'ai chi across many ages and ability levels and the ease with which the addition of music may increase mental and physical health benefits in older adults. Studies such as this one confirm that medical professionals in a wide variety of clinical settings can comfortably recommend t'ai chi to their older adult clients and patients, and the careful use of specific music may increase benefits.

Footnotes

Acknowledgments

The authors wish to acknowledge the Tulane University Center for Aging, the New Orleans People Program, and the subject participants.

Author Disclosure Statement

No competing financial interests exist. ■

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