Tai Chi and Whole-Person Health

Tai Chi for Whole-Person Health in Coronary Heart Disease: Multicomponent Intervention with Multisystem Impacts

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 Gloria Y Yeh, MD, MPH

Director of Clinical Research

Osher Center for Integrative Medicine

Harvard Medical School and Brigham and Women's Hospital

Director, Research Fellowship in Integrative Medicine

Division of General Medicine, Beth Israel Deaconess Medical Center

One of the key features of mind–body movement interventions is that they are inherently multimodal or multicomponent in nature. These interventions (e.g., Tai Chi, qigong, yoga) are often characterized as wholistic therapies that integrate multiple potentially active components, such as the commonly described triad of breathing (attention to breath), meditation (mindful awareness), and physical movement. Given these multiple components, it is no surprise that mind–body interventions have demonstrated impact on different outcomes across multiple physiological systems (from cardiac, pulmonary, neuroendocrine, to immune function, cognition, and the musculoskeletal system). A multicomponent intervention such as Tai Chi, thus, fits perfectly within the context of whole-person health.

The concept of whole-person health has been reinvigorated in recent years fueled by the growth of integrative health care and major government stakeholders (e.g., in the United States, the National Institutes of Health National Center for Complementary and Integrative Health [NCCIH], and VA Medical System) reifying its importance as a key direction/priority. Whole-person health provides a framework within which to better understand the benefits of mind–body movement; it recognizes the interconnected physiological systems within each individual and the broader socioecological domains that all impact health in an integrated way and that may be ideal targets for an intervention such as Tai Chi.

A recent study by Liu et al.¹ illustrates the promise of Tai Chi as whole-person health in coronary heart disease (CHD). The staggering statistics for morbidity and mortality caused by CHD are well known; CHD is the leading cause of death worldwide. Compared with age-matched individuals, those with CHD have unequivocal disabilities across the board in multiple physical and psychological domains. Management of the disease highlights the importance of self-modifiable risk factors, health behavior change to impact multiple health outcomes, and the major influence of biopsychosocial determinants.

In this randomized controlled study conducted in China, investigators randomized 98 relatively sedentary older adults (age range 56–80 years) with history of CHD to either 12 weeks of Tai Chi or an attention control. The supervised group-based Yang-style Tai Chi program was designed to gradually ramp up class frequency over time to build self-confidence to exercise (starting 60 min per class twice weekly in weeks 1–2, then three times weekly in weeks 3–4, up to four times weekly by weeks 5–6), followed by a home self-Tai Chi maintenance program with video, handouts, and weekly investigator-facilitated telephone feedback for an additional 6 weeks.

The control group attended “nonexercise community activities” for 60 min weekly consisting of an education class and other recreational activity (e.g., Chinese paper cutting or chess) to control for attention and social interaction.

Outcome measures spanning cardiopulmonary, musculoskeletal, and neurocognitive-emotional domains included aerobic endurance (2-min step test), lower extremity strength (chair stand), flexibility (chair sit and reach), agility and dynamic balance (8 foot up-and-go), body mass index (BMI), %body fat, lipid profiles, blood pressure, fasting blood glucose, and questionnaire-based exercise self-efficacy. Using generalized estimating equations (GEEs) modeling, compared with control, the Tai Chi group showed improvements in aerobic endurance (primary outcome), strength, dynamic balance, diastolic blood pressure, and exercise self-efficacy that were seen at 12 weeks and sustained to 24 weeks (all p < 0.05).

Improvements in BMI, %body fat, and total cholesterol were observed only at 6 weeks, and improvement in lower body flexibility and blood glucose at 12 weeks. Limitations of the study included a 20% drop out rate and lack of gender diversity (mostly women). The active control was a methodologic strength, although it was not entirely time matched.

Investigators focus discussion on Tai Chi's independent effects on physical function, cardiometabolic indices, and self-efficacy, but begin to hint at a more interconnected nature of these measures that suggests an integrated network of interactions: Tai Chi has the potential to improve physical function (endurance, muscle strength, flexibility, and balance) that allows deconditioned cardiac patients to perform daily activities with less physiological stress, supporting functional independence.

Tai Chi also fosters self-efficacy and empowerment, which together with improved function and capacity facilitates healthful behaviors such as increasing physical activity. These healthful behaviors, together with Tai Chi exercise itself, can modify cardiovascular risk (high blood pressure, hyperglycemia, dyslipidemia, and being overweight or obese) and beneficially impact important metabolic indices.

In 2021 and 2022, the NCCIH held a series of virtual workshops on Methodologic Approaches for Whole-Person Health^2,3 focused on how to study multimodal interventions that impact multiple outcomes. Studies that evaluate multiple cross-system measures are no longer necessarily branded “fishing expeditions.” The field will advance as we broaden how we think about and study multicomponent multidimensional mind–body interventions. This may not, nor should it, fundamentally change how we design primary outcome randomized clinical trials. The conversation simply allows us to think a little outside the box, perhaps draw upon existing knowledge (e.g., systems biology and network science) but also foster innovative new ways to approach the study of integrated mind–body interventions.

Connecting Symptom Dots to Treat the Whole Person: A Pilot Study of Tai Chi Targeting Fatigue-Sleep Disturbance-Depression Symptom Clusters in Breast Cancer Patients

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 Peter M Wayne, PhD

Director

Osher Center for Integrative Medicine

Harvard Medical School and Brigham and Women's Hospital

Emerging models of whole-person health advocate for care that extends beyond the treatment of individual symptoms. However, the design, conduct, and analysis of most clinical trials reflect a more reductionistic framework––one which emphasizes the impact of well-defined single active ingredients on clearly defined isolated outcomes that can be accurately measured. This narrow focus is particularly limiting for understanding treatment effects in complex and chronic diseases, where multiple symptoms are present, often with different degrees of interdependence, and the potential of a unimodal intervention having therapeutic impact across multiple systems is unlikely.

Yao et al. based in Australia and China propose a more wholistic approach in a recent pilot study evaluating Tai Chi for the management of multiple comorbid symptoms among breast cancer survivors (BCSs).¹ Building on prior systematic reviews and some epidemiological and empirical evidence supporting shared biological processes underlying symptoms in BCSs, they aimed to study the impact of Tai Chi on a fatigue-sleep disturbance-depression symptom cluster (FSDSC). They specifically chose to evaluate Tai Chi based on prior evidence of its benefits for each of the symptom cluster components, and more fundamentally, the potential of Tai Chi's suite of therapeutic components (e.g., physical, cognitive, and breath training) to impart cross-system psychophysiological benefits in cancer patients.

This study was framed as a pilot randomized controlled trial including 72 BCSs equally allocated to one of two treatment arms––routine care (control group) or Tai Chi plus routine care. Of note, eligibility criteria required at least moderate deficits in all domains of FSDSC. Routine care included an evidence-based education booklet advising on self-management of cancer symptoms. The Tai Chi intervention was based on a simplified Yang style training protocol, developed specifically for targeting FSDSC among BCSs—using a formal validation process described elsewhere.² Tai Chi training took place in two phases.

In an initial phase, each participant underwent a minimum of three 60-min training sessions complemented with a home learning video package. This stage of training aimed to ensure baseline competency skills before self-directed home training (details of how competency was assessed not provided). Participants then were exposed to an 8-week Tai Chi intervention with two prescribed 60-min sessions per week. Adherence was assessed with participant-reported practice logs (data not reported).

The most unique feature of this study is its apriori goal to evaluate fatigue, sleep disturbance, and depression as a cluster of symptoms. Each component of this cluster was assessed with validated instruments including the Brief Fatigue Inventory (BFI), the Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale-Depression (HADS-D). GEE modeling was used to evaluate average longitudinal changes in individual symptom cluster components, taking into account the statistical impact of other cluster components, along with the impact of other relevant covariates. Outcomes were evaluated postintervention and also 4 weeks postintervention.

Positive regression coefficients of the adjusted GEE model support that fatigue, sleep disturbance, and depression can have impacts on each other (all at p < 0.05). Unadjusted models suggest that compared with the control group, participants in the Tai Chi group showed significant reductions in fatigue (p < 0.001), sleep disturbance (p < 0.001), and depression (p = 0.006) immediately postintervention and at 4-week follow-up. Adjusted models accounting for other cluster components still supported trends toward positive and clinically meaningful effects at 4-week follow-up for fatigue (BFI, Cohen's d = 0.61), sleep disturbance (PSQI, Cohen's d = 0.62), and depression (HADS-D, Cohen's d = 0.44).

The primary strength of this small pilot study is its research question, focused on the impact of a validated multimodal mind–body intervention on clusters of (vs. individual) BCS-related symptoms. GEE may be one statistical tool for elucidating the interdependence psychophysiological outcomes, however, the rationale for using this approach (vs. others) is not well described, and tables summarizing findings are not clearly presented. Importantly, as stated in a separate protocol article,³ because of limited power, the primary outcomes of this pilot study were appropriately intended to center around feasibility metrics, but these were not mentioned in this apparent first outcome article.

Thus, specific findings from GEE should be interpreted cautiously. Nevertheless, these preliminary findings support the value of studying the impact of Tai Chi on FSDSC in a larger and more adequately powered trial. More generally, this study should serve as a call to mind–body researchers to think creatively about how to pragmatically frame whole-person health research questions within the context of clinical trials, including optimal trial design, outcomes, and statistical and mixed-methods analyses.

Moving Through Menopause: Examining the Effect of Tai Chi and Brisk Walking in Perimenopausal Women

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 Darshan H Mehta, MD, MPH

Director of Education

Osher Center for Integrative Medicine

Harvard Medical School and Brigham and Women's Hospital

Medical Director, Benson-Henry Institute for Mind Body Medicine

Massachusetts General Hospital

The menopausal transition is often quite difficult for many women. Changes in the hypothalamic–pituitary–ovarian axis result in various physiological changes across the individual's lived experience. Addressing this transition requires a whole-person approach, including pharmacology, diet, movement, sleep hygiene, and stress reduction. One significant change that women experience is a decrease in bone density. During this period, studies have shown that bone density can be improved by resistance and aerobic exercise. However, predicting who can stay with the exercise regimen is hard.

We do not know what can increase adherence. Studies of Tai Chi, a moderate-intensity activity, have shown that 48 weeks or more can increase bone density in postmenopausal older adults. Although research has looked at older individuals, what happens in perimenopausal women is still being determined. Furthermore, less is known as to what occurs when individuals stop exercising. Is the effect maintained?

In this prospective randomized controlled study by Cheng et al.,¹ the authors examined the effect of Tai Chi and brisk walking on the bone density of the lumbar spine and femur in perimenopausal women and what happens after exercise cessation. Participants were recruited from community centers and could not have already been diagnosed with osteoporosis. They were randomized to Tai Chi, brisk walking, and control groups. The Tai Chi and brisk walking groups performed 60-min exercise sessions three times a week for 48 weeks in a park near the investigators' university.

The investigators employed a 24-movement manualized Tai Chi form for the Tai Chi group led by the research group. The brisk walking group's walking rate was no less than 90 steps per minute. The participants measured their heart rate immediately after the session, and the exercise intensity of the next session was adjusted to 55%–65% of the maximum heart rate (220–age). The control group was matched for time—they came together three times per week for 1 h to discuss knowledge related to bone density, exercise, or any other topic of interest.

The study's primary outcomes were bone mineral density at four sites: lumbar spine (L2–L4), femoral neck, greater trochanter, and Ward's triangle measured by a dual X-ray absorptiometry scan. Measurements of the proximal femur were done on the dominant side of the study participant. All participants underwent bone density testing at four time points: weeks 0, 48, 52 (4 weeks after exercise cessation), and 56 (8 weeks after exercise cessation). In addition, the study investigators conducted telephone interviews every week to record various factors of all study participants, including the duration of exposure to sunshine, dietary habits, performance of additional physical exercise, and any medication that may affect bone density.

There were several significant findings in this study. Compared with baseline, at week 48, the bone density of the lumbar spine in the Tai Chi group was significantly increased by 5.05% (p = 0.031), and the bone density of the femoral neck in the brisk walking group significantly increased by 8.23% (p = 0.031). To put this in context, this is similar to the change in bone density seen with an individual taking alendronate. Although there were increases in bone density in all other areas in both intervention groups, these were not significant. After exercise cessation, this increase in bone density was sustained at 4 and 8 weeks: 5.05% and 5.05%, respectively, for the Tai Chi group; 8.23% and 9.41%, respectively, in the brisk walking group.

These findings are noteworthy for several reasons. First, this study showed that brisk walking and Tai Chi can lead to clinically relevant changes in bone density. Other studies have shown that bone density changes little during the pre- or early perimenopause years but then begins to decline substantially during the late perimenopause years. This decline continues rapidly during the early postmenopausal years. And so, these findings suggest that these changes can be mitigated. Second, these changes in bone density are sustained for at least 8 weeks after exercise cessation. Finally, it is interesting that Tai Chi and brisk walking affect bone density differently. The Tai Chi group had changes in the lumbar spine, whereas the brisk walking group had changes in the femoral neck.

And so, what does this study teach us? Movement-based interventions are an essential prescription for women going through menopause. These low-cost interventions can be done individually or in the community. As these are whole-person interventions, other benefits include improvements in fall risk, cardiovascular health, balance, mood, and cognition—without pharmacologic agents' well-known debilitating side effects. Furthermore, there are differential effects. Not all movement-based interventions are created equally. And this study suggests that both types of movement are necessary and should be combined. Last, these effects appear to last beyond the intervention itself. Now, exactly how long these effects last—that remains to be seen.