This quality research article assesses and supports the usefulness of a Tai Chi practice in relationship to balance, gaze, and visual difficulties.


Can Tai Chi Improve Vestibulopathic Postural Control?

Peter M. Wayne, PhD, David E. Krebs, DPT, PhD, Steven L. Wolf, PhD, PT, FAPTA, Kathleen M. Gill-Body, DPT, MS, NCS, Donna M. Scarborough, PT, MS, Chris A. McGibbon, PhD, Ted J. Kaptchuk, OMD, Stephen W. Parker, MD

ABSTRACT. Wayne PM, Krebs DE, Wolf SL, Gill-Body
KM, Scarborough DM, McGibbon CA, Kaptchuk TJ, Parker
SW. Can Tai Chi improve vestibulopathic postural control?
Arch Phys Med Rehabil 2004;85:142-52.

Objectives: To evaluate the rationale and scientific support
for Tai Chi as an intervention for vestibulopathy and to offer
recommendations for future studies.

Data Sources: A computer-aided search, including MEDLINE and Science Citation Index, to identify original Tai Chi
studies published in English; relevant references cited in the
retrieved articles were also included.

Study Selection: A preliminary screening selected all randomized controlled trials (RCTs), non-RCTs, case-control
studies, and case series that included Tai Chi as an intervention and had at least 1 outcome variable relevant to postural

Data Extraction: Authors critically reviewed studies and
summarized study designs and outcomes in a summary table.

Data Synthesis: Twenty-four Tai Chi studies met screening
criteria. No studies specifically studying Tai Chi for vestibulopathy were found. Collectively, the 24 studies provide sometimes contradictory but generally supportive evidence that Tai
Chi may have beneficial effects for balance and postural impairments, especially those associated with aging. Ten RCTs
were found, of which 8 provide support that Tai Chi practiced
alone, or in combination with other therapies, can reduce risk
of falls, and/or impact factors associated with postural control,
including improved balance and dynamic stability, increased
musculoskeletal strength and flexibility, improved performance
of activities of daily living (ADLs), reduced fear of falling, and
general improvement in psychologic well-being. Studies using
other designs support the results observed in RCTs.

Conclusions: At present, few data exist to support the contention that Tai Chi specifically targets the impairments, functional limitations, disability, and quality of life associated with
peripheral vestibulopathy. There are, however, compelling reasons to further investigate Tai Chi for vestibulopathy, in part
because Tai Chi appears useful for a variety of nonvestibulopathy etiologic balance disorders, and is safe. Especially needed

From the Research Department, New England School of Acupuncture, Watertown,
MA (Wayne); Biomotion Laboratory (Krebs, Scarborough, McGibbon) and Neurology Department (Parker), Massachusetts General Hospital, Boston, MA; MGH Institute of Health Professions, Boston, MA (Wayne, Krebs, Gill-Body Scarborough,
McGibbon, Kaptchuk); Department of Rehabilitation Medicine, Emory University
School of Medicine, Atlanta, GA (Wolf); and Harvard Medical School, Boston, MA
(Krebs, McGibbon, Kaptchuk, Parker).

Supported by the National Center for Complementary and Alternative Medicine
(NCCAM), National Institutes of Health (grant nos. R21AT0(0)0553, 5R25AT0071402). The content of this review is solely the responsibility of the authors and do not
necessarily represent the official views of NCCAM.

No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.

Reprint requests to Peter Wayne, PhD, New England School of Acupuncture, 40
Belmont St, Watertown, MA, 02472, e-mail:



are studies that integrate measures of balance relevant to ADLs
with other psychologic and cognitive measures; these might
help identify specific mechanisms whereby Tai Chi can remedy
balance disorders.

Key Words: Balance; Posture; Rehabilitation; Tai Chi.

© 2004 by the American Congress of Rehabilitation Medicine
and the American Academy of Physical Medicine and

whole body dynamic postural control impairments, functional limitations in locomotor activities, disability in typical
role activities, and decreased quality of life1-3 (QOL). Patients
with vestibulopathy experience a constellation of problems for
which they are often referred to rehabilitation, including unsteady standing and gait and difficulty stabilizing the visual
environment during head movement.4,5 Findings from research
on vestibular rehabilitation provide an understanding about the
benefits and limitations of vestibular rehabilitation for this
patient population.6 Tai Chi, which purports to improve overall
body control, mind-body focus, and psychologic well-being,
may offer an alternative or complementary approach to treating
vestibulopathy-induced balance dysfunction, but, to date, little
such evidence exists to support Tai Chi as an effective intervention for this population.

Tai Chi, also referred to as Tai Chi Chuan and Taijiquan, has
its roots in the martial arts; yet, for centuries millions of
Chinese have practiced Tai Chi’s flowing, meditative movements to cultivate and maintain health and well-being. Numerous anecdotal reports of past and present practitioners claim
that Tai Chi exercise has helped cure a diversity of health
disorders.7,8 Considered a treasure of Chinese medicine, Tai
Chi is based on the same core principles that underlie acupuncture and Chinese herbal therapies.9-11 Although acupuncture
relies on needle insertion and herbal medicine on phytochemical pharmacology, Tai Chi uses detailed regimens of physical
movement, breathing techniques, and cognitive tools (both
visualization and focused internal awareness) to strengthen the
body, to relax the mind, and to “balance the flow of chi” (life

Falls and unsteady gait are critical problems in older
adults.15 Tai Chi has been used extensively among older adults,
but the benefits of Tai Chi for vestibulopathy are largely
unknown. Tai Chi’s reputed health benefits, apparent safety,
low cost, and growing recognition have resulted in this exercise
becoming more prominent as a preventive and rehabilitative
therapeutic tool by the Western, allopathic medical community.
Recent studies have begun to address the safety and efficacy of
Tai Chi as a therapeutic intervention for various health concerns, including postmyocardial infraction,16 coronary artery
bypass surgery cardiac rehabilitation,17 hypertension,18 general
cardiorespiratory function,19-23 multiple sclerosis,24 rheumatoid
arthritis,25 osteoarthritis,26 microcirculation and endothelial
function,27,28 immune function,29 dementia,30 and general stress
management.31-33 These and other Tai Chi uses have been

Arch Phys Med Rehabil Vol 85, January 2004


reviewed in recent articles by Wolf et al,34 Sandlund and
Norlander,35 Li et al,36 Lan et al,37 and Wu.38

The purpose of this review was to evaluate the rationale and
scientific support for Tai Chi as an intervention for vestibulopathy.
We begin by characterizing the functional and psychologic
impairments associated with vestibulopathy and its
current management. We then present a rationale for why Tai
Chi could be a useful intervention to address vestibulopathy
impairments, functional limitations, and disability. Last, we
review the evidence that Tai Chi improves postural control and
balance in various populations.

Vestibulopathy and Vestibular Rehabilitation

The healthy vestibular system is responsible for stabilizing
gaze during head movement, particularly during rapid head
movement. Other eye and body stabilizing mechanisms, such
as visual and proprioceptive inputs, are available during pre-
planned or slow movements, but only the vestibulo-ocular
reflex (VOR) is typically able to control gaze during rapid
(100°/s) head movement. Vestibulopathy symptoms may include
oscillopsia during locomotion and head movements, dizziness,
and unsteadiness during gait and other functional activities.
39 As with many chronic diseases, vestibulopathyinduced
changes in life style and QOL can impact psychologic
well-being, which may further limit functional abilities.40

Persons with chronic, stable vestibulopathy have either unilateral
(UVH) or bilateral vestibular hypofunction (BVH). Individuals
with UVH have damage only on 1 side. The chief
visual function symptom of people with UVH is decreased
gaze stability during ipsilesional head turning. People with
UVH sometimes compensate rather well with the remaining
intact contralesional vestibular apparatus, while those with
BVH function with an overall reduced amount of vestibular
information. People with BVH have damage on both sides,
although the loss may be asymmetric. The primary visual
function symptoms among persons with BVH include decreased
gaze stability with all head movements including oscillopsia.
Typically, caloric responses and VOR gains (ratio of
eye to head movement) are decreased bilaterally in persons
with BVH. Among healthy adults, this VOR gain is close to
1.0, that is, eye movements compensate for head movement.
People with BVH may have near 0 gains, signifying a near-
complete decoupling of eye movement from head displacements.
This VOR gain is quite plastic, being suppressed temporarily
in spinning dancers and ice skaters, and increased or
decreased in subjects wearing Frenzel lenses. Thus, state-ofthe-
art vestibular rehabilitation programs have taken advantage
of this plasticity by attempting to increase VOR gain among
people with UVH and BVH. The extent to which improved
VOR results in improved gaze stability during functional activities
or contributes to balance improvements remains unclear.

Vestibular rehabilitation is an exercise program intended to
remediate the problems of dizziness, gaze instability, and balance
disturbances caused by damage to the vestibular system.
Although common elements of vestibular rehabilitation include

(1) eye-head coordination exercises to reduce gaze instability
and dizziness and (2) balance retraining exercises to reduce
balance impairments, various forms of vestibular rehabilitation
are in use today.4,5,43-48 One approach was originally described
by Cawthorne45 and Cooksey46 in the 1940s for patients with
persistent vestibulopathy symptoms. This Cawthorne–Cooksey
vestibular rehabilitation approach includes general eye-andhead
exercises, total body movements, and balance activities
that are performed repeatedly by the person on a daily basis.
These exercises are not tailored to an individual’s symptoms. A
second vestibular rehabilitation approach more recently described
by Herdman,49 Shumway-Cook and Horak,50,51 and
Krebs et al,3,4 is focused on individualized balance retraining
and on improving the gain, phase, and symmetry of the VOR.
This approach attempts to achieve central nervous system
(CNS) compensation with exercises that enhance VOR adaptation
(when some remaining vestibular function exists) and
vestibulospinal reflexes. This vestibular rehabilitation program
is individually tailored for each individual based on the person’s
signs, symptoms, functional limitations, and amount of
remaining peripheral vestibular function. The VOR-focused
vestibular rehabilitation program has 2 important specific features.
First, it includes exercises that promote gaze stability
during both quiet standing and dynamic functional activities.
One typical exercise is having a patient focus on reading a short
printed word on a piece of paper held at arm’s distance while
moving the head side to side several times and then up and
down several times. This activity is repeated at different speeds
and with various-sized fonts. This and other gaze stability
exercises are performed with progressing levels of difficulty;
that is, the sitting position followed by standing with a narrow
base of support followed by marching in place and walking.
The second feature is balance retraining that incorporates the
use of various sensory cues for postural control. An example of
this feature is the practice of maintaining balance during standing
or walking with eyes open (which requires enhanced use of
somatosensory and vestibular inputs for postural control) or on
a foam surface (which requires enhanced use of visual and
vestibular inputs). Presently, evidence supports the usefulness
of vestibular rehabilitation for persons with vestibulopathy, but
limited evidence supports the long-term effects of vestibular
rehabilitation on function.5,41,43,47-52

In the current health care environment, vestibular rehabilitation
typically ends because patients either show a plateau in
improvement or health insurance coverage limits the number of
vestibular rehabilitation visits provided. Although there are
reports of improved function after vestibular rehabilitation,3,4
often the optimization of functional recovery is not observed or
documented. Current health care restrictions have led many
patients whose vestibular rehabilitation is stopped to seek help
from other sources, such as fitness centers and alternative
medicine therapies. Recent studies addressing the potential
benefits of Tai Chi for older people’s balance and overall health
suggest that Tai Chi is worth exploring as a complement or
alternative way to help patients with vestibulopathy reach their
full functional potential.

Tai Chi for Whole Body Postural Control and Balance

The concept of balance is at the heart of the yin-yang, or tai
chi symbol . Phrases from historical Tai Chi classics such
as—“suspend the spine like a string of pearls from heaven” and
“stand like a balance and move like a cartwheel”53—reflect
inherent, sophisticated insight into human biomechanics. The
movements of Tai Chi are practiced at a slow, gentle, and
continuous pace. A primary goal of Tai Chi is relaxation of the
body and the mind. Even the eyes are relaxed, using a nonfocused
gaze with the “eyelids half closed like curtains.”54
Levandoski and Leyshon,55 Tse and Bailey,56 Wolf et al,34 and
Li et al36 identified a number of characteristics of Tai Chi
practice that might make it an effective therapy for postural
control and balance. These intended characteristics, and their
purported effects, include (1) a continuous, slow, even tempo
facilitates sensory awareness of the speed, force, trajectory, and
execution of movements, as well as awareness of the external
environment; (2) an emphasis on maintaining a vertical posture

Arch Phys Med Rehabil Vol 85, January 2004


with an extended head and trunk position promotes a less
flexed posture; (3) a constant shifting of weight from 1 leg to
the other facilitates improved dynamic standing balance and
lower-extremity strength; (4) the use of different parts of the
body taking turns playing the role of stabilizer and mover
enables movements to be executed smoothly without compromising
balance and stability; (5) the symmetrical and diagonal
arm movements of Tai Chi promote arm swing in gait and
increase trunk rotation around the waist; (6) moderate knee
flexion lowers the body’s center of gravity; and (7) flowing
circular and spiraling movements promote joint flexibility.
Because so many of the fundamental principles of Tai Chi
directly relate to issues of postural control, and because cost-
effective therapies for balance training are needed, especially
for older adults57 and those with balance impairment, researchers
have begun to address scientifically the extent to which Tai
Chi improves postural balance and function, and are also
studying biomechanic, physiologic, and psychologic mechanisms
underlying balance improvements.38,58


We performed a literature search with the use of MEDLINE
and Science Citation Index using the key words Tai Chi and
Taijiquan. The searches were restricted to the English language,
and covered the period January 1966 through June
2002. A manual search through the bibliographies of retrieved
research and review articles was also conducted. Only empirical
studies that included at least 1 outcome relevant to postural
control were included. This search revealed 10 randomized
controlled trials (RCTs) and an additional 14 non-RCTs or
uncontrolled prospective or cross-sectional Tai Chi studies.
These 24 studies are summarized in table 1; the RCTs are
discussed in more detail below. In the literature review section
that follows, all results discussed are statistically significant
(P.05) unless noted otherwise.

Literature Review Results

RCTs with outcomes relevant to postural control. Wolf et
al59 conducted a large sample (N200) RCT evaluating the
efficacy of Tai Chi in balance training and fall prevention. The
study, which focused on community-dwelling older adults,
compared the efficacy of 15 weeks of Tai Chi instruction with
computerized balance training and education. The Tai Chi
intervention included 10 movements from the traditional Yang
style. Tai Chi instruction was administered in weekly, 45minute
group classes. Balance training was done with a computerized
balance system that had force transducers and a
visual cursor that prompted the subject to move his/her center
of mass without foot displacement. Over the course of the
intervention, sway and floor movement were progressively
increased to the limits of postural stability. The education
groups were instructed not to change their exercise regimens
and met weekly to discuss gerontologic and health-related
issues. Balance-related outcome measures included occurrence
of falls (monitored for a minimum of 7mo and a maximum of
20mo), fear of falling, strength (knee, hip, ankle, handgrip),
and lower-extremity flexibility. Results indicated that, after
adjusting for fall risk factors, compared with balance training
and education, Tai Chi delayed the onset of first or multiple
falls by 47.5%. Fear of falling measures were also reduced to
a greater extent in the Tai Chi versus education group. No
significant changes in lower-extremity strength or flexibility
were observed. In a companion study, Wolf et al60 explored
elements of postural stability associated with decreased fall
probabilities in a subset of the original study sample. Platform

balance measures revealed greater static stability after training
for balance training, but not Tai Chi or education. They concluded
that Tai Chi does not improve static postural stability,
and Tai Chi may gain its success in preventing falls by means
other than reductions in sway-based measures. The results and
experience from these studies have been used to design a phase
III, 2-arm RCT comparing the efficacy of intense Tai Chi
training (48wk) versus a wellness education program for reducing
falls in older adults.61

Jacobson et al62 conducted a 12-week RCT comparing a Tai
Chi intervention with a nonexercise control group. Participants
were healthy, young, Tai Chi–naive volunteers. The Tai Chi
intervention included 3 classes weekly (1.0 –1.5h), during
which subjects were taught the entire 108-movement, Yangstyle
form. Control group participants agreed to not engage in
resistance training and activities dependent on balance. Outcomes
measured at baseline and at 12 weeks included lateral
body stability (stability platform test), isometric muscular
strength of dominant knee at 90°, and kinesthetic sense of the
glenohumeral joint at 30°,45°, and 60°. Improvements between
pre-versus posttests in lateral stability and balance were
greater in the Tai Chi group versus control group, as were
improvements in knee strength. Improvements in the kinesthetic
sense of the glenohumeral joint at 60° (but not at 45° or
30°) were also greater for the Tai Chi versus control group. The
investigators argued that lack of improvement in kinesthetic
sense at the more acute angles was justified because the Tai Chi
form did not regularly include these angles of rotations.

Hartman et al26 investigated the benefits of Tai Chi for older
adults with osteoarthritis. The benefits of a Yang-style (9-form)
Tai Chi intervention, including two 1-hour classes for a 12week
period, was compared with a control group that met
socially on 3 occasions and were regularly contacted by telephone
to discuss osteoarthritis issues. Balance-related outcomes
included 1-leg stand time, 50-ft (15-m) walking speed,
and time to rise from a chair. Results indicated that Tai Chi, but
not control, participants exhibited moderate improvements for
these 3 outcomes; differences between groups were not statistically
significant. Li et al63 conducted an RCT with older
individuals comparing the benefits of a 6-month Tai Chi intervention
(Yang-style 24-step) with a wait-list control group.
Results of a 6-item self-reported physical functioning scale, a
subset of the Medical Outcomes Study 20-Item Short-Form
Health Survey, suggested that the Tai Chi group improved
significantly more than the control group across a range of
functional activities, including walking, lifting, and activities
of daily living (ADLs), such as eating, dressing, and bathing.
Finally, Sun et al64 reported that subjects in a 10-week Tai Chi
intervention, but not in a control group, improved shoulder and
knee, but not trunk, flexibility among older Hmong Americans.

Four additional RCTs have evaluated the value of adding Tai
Chi to other therapies. Judge et al65 conducted a 6-month,
2-arm RCT with older women to test the hypothesis that a
vigorous exercise program that was performed frequently and
included resistance training, brisk walking, and flexibility, and
postural control exercises (combined training) would be superior
to a program that was performed once a week and included
only flexibility and postural control exercises (flexibility training).
Simplified Tai Chi movements constituted 1 component
of the flexibility exercises for each arm. Outcome measurement
included double-and single-standing tests performed on a force
platform. The mean displacement of the center of pressure in
single-limb standing improved 18% in the combined training
group but did not change in the flexibility-only training group.
Differences in trends between groups were not statistically
significant when analyzed with a repeated-measure analysis of

Arch Phys Med Rehabil Vol 85, January 2004

Table 1: Summary of Tai Chi Studies That Include Outcomes Related to Postural Stability

Study Design Interventions
Sample Size and
Age Subject Health
Balance-Related Outcome
Measures Results
Wolf et al59 RCT . Tai Chi, YS, 10 TC: n72 Healthy . Occurrence of falls . TC (vs BT and ED)
movements (TC) BT: n64 (monitored a minimum of delayed onset of first or
. Computerized balance ED: n64 7mo, maximum of 20mo) multiple falls by 47.5%
training (BT) Avg age76.2y . Strength (knee, hip, ankle, . TC (vs ED) reduced fear
. Education, nonexercise grip) of falling
control (ED) . Flexibility (lower-extremity . Grip strength declined
ROM) slower in TC (vs BT and
All IN 1h/wk for 15wk . 12-min walk ED)
. Fear of falling . Trend toward greater
. Instrumental ADLs (IADLs) IADL improvement in
TC (vs ED) (P.058)
Wolf et al60 RCT . Tai Chi, YS, 10 TC: n24 Healthy . Platform balance . BT (vs TC and ED)
movements (TC) BT: n24 measures of COB in 4 reduced dispersion
. Computerized balance ED: n24 conditions: (1) quiet index during conditions
training (BT) Avg age76.8y standing EO; (2) quiet 3 and 1; and COB in
. Education, nonexercise standing EC; (3) angular ML axis during
control (ED) Note. Subjects perturbation EO; (4) condition 3 and in AP
were a subset angular perturbation EC. axis during condition 1.
All IN 1h/wk for 15wk of Wolf59
Jacobson et al62 RCT . Tai Chi, YS, 108 TC: n12 Healthy . Lateral stability (stability . TC (vs C) increased
movements (TC) C: n12 platform test) lateral stability and
(three 1/2-h sessions/ Avg age30.4y . Isometric strength of balance
wk for 12 wk) dominant knee at 90° . TC (vs C) improved
. Nonexercise control . KS of glenohumeral joint knee strength
(C) at 30°, 45°, and 60° . TC (vs C) improved KS
in glenohumeral joint
at 60°
Hartman et al26 RCT . Tai Chi, YS, 9 TC: n18 Osteoarthritis . 1 leg standing time . Trends toward greater
movements (TC) C: n15 . 50-ft walking speed improvement in TC vs
(two 1-h sessions/ Avg age30.4y . Time to rise from chair C in standing time
wk for 12wk) (P.054), walking
. Nonexercise control speed (P.086), and
(C) (social gatherings. chair rise time (P.084)
Li et al63 RCT . Tai Chi, YS, 24 TC: n49 Healthy . Physical functioning scale . TC functional status
movements (2 times/ C: n45 (subset of SF-20) improved more than
wk for 24wk) Avg age72.8y control at 12wk and
. Control (not described) 24wk
Sun et al64 RCT . Tai Chi* (ten 2-h TC: n10 Healthy . TC Program Inventory . TC (vs C) increased
sessions, 1 times/wk C: n10 Instrument including flexibility in knee and
education) Avg age66.75y knowledge and shoulder; trend in
. Wait list control (C) expectations of TC, increased flexibility in
perceived stress, heart trunk (P.0767)
rate, BP, skin . TC (vs C) reduced self-
temperature, and perceived stress, skin
goniometry temperature assessment
of stress, resting systolic
BP and diastolic BP
Judge et al65 RCT† . Combined strength COMB: n12 Healthy . Variety of double-and . COMB improved in
trainingbrisk FL: n9 single-stance tests of single-stance tests, but
walkingflexibility Avg age72.8y center of force (sway) on trend not significantly
(including TC-like a force platform with EO different than FL
movements*) (COMB) and EC
(3 sessions/wk for 6mo)
. Flexibility (including
TC-like movements*)
(FL) (3 sessions/wk

Arch Phys Med Rehabil Vol 85, January 2004

Table 1 (Cont’d): Summary of Tai Chi Studies That Include Outcomes Related to Postural Stability

Sample Size and Balance-Related Outcome
Study Design Interventions Age Subject Health Measures Results

Van Deusen and RCT . Tai Chi–like dance
Harlowe66 program* (TC) (90
min/wk for 8wk)

. Wait-list control (with
reading) (C)
Nowalk et al67 RCT . Fit NB Free (FNBF)
(individual strength.

. LL/TC (group
fear behavior
. Basic Enhanced
Program (C)
(education control)
FNBF and TC sessions 3
times/wk for 13–28mo
Wolfson et al68 RCT† . Strength training (ST)

. Balance training (BT)
. Balancestrength
training (BS)
. Education control (C)
. Tai Chi administered
for maintenance
beginning at 3mo
for 6mo (YS, 37
movements, 1h, 1/wk)
Yan75 PNRCT† . Tai Chi: YS, 24
movements (TC)

. Locomotor activity (C)
All IN 45min, 3 times/wk
for 8wk
Yan76 PNRCT . Tai Chi: YS, 24
movements (TC)

. Locomotor activity (C)
All IN 45min, 3 times/wk
for 8wk
Lan et al23 PNRCT . Tai Chi: YS, 108
movements (TC) (daily
practice, 12mo)

. Age-and health-
matched control
group (C)
Schaller70 PNRCT . Tai Chi Chih, 20 form
(TC) (1h/wk for 10wk)

. Control: maintain usual
level of activity (C)
Lan et al77 PNCT . Tai Chi: YS, 108
movements (TC) (daily
practice, 6mo)

TC: n17 Rheumatoid . ROM of upper and lower

C: n16 arthritis extremities
Avg age56y . 5-point rating scale on
enjoyment of exercise
and rest

FNBF: n38
TC: n37
C: n35
Avg age76.8y
Healthy . Time to first fall
. Incidence of falls
. Time to death
. Number of days
. Chair rise stand time
. Walk time (20ft)
. Grip strength
ST: n28
BT: n28
BS: n27
C: n27
Avg age79.8y
Healthy . Loss of balance during
. Functional base of
. Single-stance time
. Lower-extremity isokinetic
. Gait velocity
TC: n28
C: n10
Avg age79.0y
Healthy . Stability platform balance
measures (no details
. Arm movement variability
TC: n12
C: n8
Avg age79.4y
Healthy . Arm movement force
output during linear and
curvilinear tasks
TC: n20
C: n18
Avg age65.5y
Healthy . Knee extensor and flexor
. Thoracolumbar flexibility
TC: n24
C: n22
Avg age70.0y
TC: N20
Avg age61.1y
. Single-leg stance time,
EO, and EC
. Modified sit-and-reach
. Knee strength: concentric
extensor peak torque,
eccentric peak torque,
and endurance ratio

. TC (vs C) greater
increases in shoulder
flexion, shoulder
rotation, elbow and
wrist flexion, ankle
plantarflexion, and hip,
knee, and ankle
. TC greater enjoyment
during exercise and
. LL/TC rate of fall 17%
lower than C, but trend
. All other outcomes NS
between groups
. Pre-vs post-TC
maintenance phase
measures suggest
balance gains in SOT
remained stable across
groups, but gains in
function, base of
support, and stance
times declined
. TC improved time on
balance more than C
. TC increased arm
control more than C
. TC reduced variability in
curvilinear arm
movement force
. TC increased knee
extensor strength and
flexor strength more
than control
. TC increased
flexibility more than
. TC (vs C) improved
balance time with EO
. TC (vs C) sit-and-reach
test (NS)
. TC increased knee
concentric peak torque,
eccentric peak torque,
and endurance ratio
Arch Phys Med Rehabil Vol 85, January 2004

Table 1 (Cont’d): Summary of Tai Chi Studies That Include Outcomes Related to Postural Stability
Sample Size and Balance-Related Outcome
Study Design Interventions Age Subject Health Measures Results
Shih78 PNCT . Tai Chi: YS, 24 N11 Healthy . Force platform measure . TC reduced avg sway
movements (TC) (3 Avg age30.8y of sway velocity during velocities in AP
times/wk for 16wk) static and dynamic tests direction during
dynamic, but not static
balance tests
Forrest79 PNCT . Tai Chi (TC) (16wk; no N8 Healthy . Balance platform . TC reduced APA of
information on Avg age36.5y measures of APA and certain muscles and
frequency) COP decreased COP
movement during load
dropping in both AP
and ML planes
Hain et al73 PNCT . Tai Chi: Combination Total N22 Mild balance . Balance platform tests . TC improved
of Yang, Wu, and Pa Age range, disorder (SOT) posturography during
Kua styles 20–60y (n6) . Romberg tests SOT
Age range, . Reach test . 1 time/wk for 8wk . TC improved tandem
61–75y (n7) . DHI Romberg scores
Age 75y (n9) . SF-36 . TC improved DHI
. TC improved SF-36
Husted et al24 PNCT . Tai Chi* (TC) 8wk (no N19 Multiple . Walking speed (25ft) . 21% increase in walking
information on sclerosis . Hamstring flexibility speed
frequency) . SF-36 . 28% increase in
hamstring flexibility (no
statistical analyses)
Ross et al71 PNCT . Tai Chi* (TC) 8wk (no N11 Healthy . Goniometry (elbow, . All participants showed
information on shoulder, knee, hip) some improvement in
frequency) . Single-leg stance time all measures, but no
. Heel-to-toe walking trends were statistically
Hong et al81 CSS . Tai Chi: YS 108 TC: n28 Healthy . Single-leg stance times, . TC (vs C) greater single-
movements (TC) C: n30 EC stance times with EC,
. Age-matched Avg age66.7y . Sit-and-reach test but not EO
sedentary control (C) . Total body rotation . TC (vs C) greater sit and
Avg 13.2y TC experience reach
. TC (vs C) greater body
Tse and Bailey56 CSS . Tai Chi* (TC) TC: n9 Healthy . Single-leg stance times, . TC greater single-stance
. Age-matched C: n9 EO, and EC time with EO
sedentary control (C) Age range, . Heel-to-toe walking . TC greater heel-toe
Range of 1–20y TC 68–86y distance
Lan et al22 CSS . Tai Chi: YS (TC) TC: n41 Healthy . Thoracolumbar flexibility . TC greater
. Age-matched C: n35 thoracolumbar
sedentary control (C) Age68.5y flexibility
Avg 11.8y TC experience
Wong et al80 CSS . Tai Chi* (TC) TC: n25 Healthy . Platform balance SOT . TC greater maximal
. Age-matched C: n14 stability
sedentary control (C) Age68.9y . TC better avg velocity
Avg 15.6y TC experience of COG

NOTE. All results are statistically significant (P.05) unless noted otherwise. Marginally significant results are followed by P values.
Abbreviations: AP, anteroposterior; APA, anticipatory postural adjustment; Avg, average; BP, blood pressure; COB, center of balance; COG,
center of gravity; COP, center of pressure; CSS, cross-sectional study; DHI, Dizziness Handicap Inventory; EC, eyes closed; EO, eyes open;
FNBF, Fit NB Free; IN, intervention; KS, kinesthetic sense; LL/TC, Living and Learning/Tai Chi; ML, mediolateral; NS, nonsignificant (P.05);
PNCT, prospective, noncontrolled trial; PNRCT, prospective, non-RCT; SF-20/SF-36, Medical Outcomes Study 20-Item/36-Item Short-Form
Health Survey; SOT, Sensory Organization Test; TC, Tai Chi; YS, Yang style.
*No information given on TC intervention.

†TC intervention included in all groups.
Arch Phys Med Rehabil Vol 85, January 2004


variance. Van Deusen and Harlowe66 conducted an RCT in
which participants with rheumatoid arthritis were included in a
therapeutic dance program that combined elements of Tai Chi
with occupational therapy; they compared this intervention
with wait-listed participants. The Tai Chi–like intervention
included dancing, with an emphasis of flowing, relaxed movement,
postural awareness, breathing, and visualization. Instruction
was provided in a group format over an 8-week period
(90min/wk). Participants were given an audiotape and illustrated
instructions for home practice and were encouraged to
practice daily. Outcome measures, which included joint range
of motion (ROM) and a 5-point exercise rating scale that
assessed functional benefits and enjoyment of exercise and rest,
were made before, immediately after, and 4 months after the
intervention. At 4 months, 3 of 4 ROM measures in the upper
extremities were significantly better in the active intervention
as compared with control subjects. Lower-extremity ROM was
also significantly greater in the active intervention group at
week 8, but not at 4 months. Compared with the control group,
the dance group also expressed significantly greater enjoyment
during exercise and rest.

Nowalk et al67 conducted a 3-arm RCT to test whether
exercise programs would reduce falls and fall sequelae among
residents of long-term care facilities. Older individuals were
randomized into 1 of 2 exercise programs or a control group.
The Fit NB Free (FNBF) group received individualized, progressive
strength training combined with conditioning (treadmill,
bicycling) 3 times weekly. The Living and Learning/Tai
Chi (LL/TC) group included 2 components. The LL module
focused on modulating fear of falling by using behavioral and
psychotherapeutic methods and met once per month. The Tai
Chi intervention met 3 times weekly. A program called the
Basic Enhanced Program, served as a control; subjects in this
group participated in 3 educational and therapeutic programs
and were not allowed to participate in study-related exercise
programs. Enrollment took place over 15 months, and all
interventions were offered for 28 months. Consequently, subjects
could participate in the intervention for 13 to 28 months,
depending on enrollment date. Rates of falls were 72%, 58%,
and 75% in the FNBF, LL/TC, and control groups, respectively.
The 17% lower fall rate in the LL/TC group versus
control group was not statistically significant. Time to first fall,
time to death, and number of days hospitalized also did not
differ significantly between groups nor among any other physical
or cognitive outcomes. Finally, Wolfson et al68 conducted
a 4-arm RCT that compared the efficacy of balance training,
strength training, balance plus strength training, and an educational
control for balance in older adults. After each of these
interventions, subjects also participated in a 6-month Tai Chi
maintenance program. Comparisons of measurements made
before and after the Tai Chi maintenance phase suggest that
many, but not all, of the gains in postural stability resulting
from balance and strength training were maintained during the
Tai Chi maintenance intervention.

Psychologic Responses to Tai Chi

A few studies have provided some information regarding the
relationship between Tai Chi, psychologic well-being, and
postural control. Wolf et al59 reported that Tai Chi training
significantly reduced fear of falling. A multivariate model
suggested that fear of falling was a strong predictor of subsequent
falls. This study also reported near-significant trends on
an intrusiveness instrument, suggesting that Tai Chi increased
subject’s sense of being able to do all the activities that they
would like to. A subset of participants in this trial also participated
in a qualitative exit interview to assess perceived ben

efits of participation in the study.69 Both Tai Chi and balance
training participants reported increased confidence in balance
and movement, but only Tai Chi participants reported that their
daily activities and overall lives had been affected. Approximately
50% of these participants subsequently enrolled in Tai
Chi classes. Kutner et al69 concluded that when mental and
physical control are perceived to be enhanced, with a generalized
sense of improvement in overall well-being, older persons’
motivations to continue exercising might also increase. In
another RCT evaluating the effect of exercise and exercise plus
cognitive strategies on psychologic health, Brown et al33 found
that women (but not men) in a 16-week Tai Chi–type program
experienced significant reductions in tension, depression, anger,
confusion, and total mood disturbance and significant
improvement in general mood. In contrast, Schaller70 found no
improvement in mood after 10 weeks of Tai Chi. Ross et al71
also reported that Tai Chi significantly improved composite
scores on the Multiple Affect Adjective Check List. Jin32
measured hormonal levels indexing stress and mood states
before, during, and after participating in a Tai Chi session for
experienced Tai Chi practitioners. Relative to measures taken
beforehand, Tai Chi raised heart rate, increased noradrenaline
excretions in urine, and decreased salivary cortisol concentration.
Participants also reported less tension, depression, anger,
fatigue, confusion, and state anxiety. Sun et al64 reported that
Tai Chi reduced self-preceived stress scores (self-designed Tai
Chi Program Inventory) and stress assessed by skin temperature.
In the RCT by Van Deusen and Harlows66 the Tai Chi–
dance group expressed significantly greater enjoyment during
exercise and rest, compared with control group. Finally, in a
companion study to Li et al,63 the effects of Tai Chi on
perceptions of personal efficacy and exercise behavior were
evaluated.72 Self-efficacy outcomes included 2 components. A
barriers scale characterized subjects’ self-perception of ability
to do Tai Chi, and a time-based performance-efficacy scale
assessed their confidence to perform certain qualities of movements
continuously for various lengths of time. Participants in
the Tai Chi group experienced significant improvements in
self-efficacy over the course of the intervention, and changes in
efficacy were associated with higher levels of program attendance.
Li concluded that self-efficacy can be enhanced through
Tai Chi and that the changes in self-efficacy are likely to
improve exercise adherence.


Our review of the literature suggests that few reports specific
to the application of Tai Chi for patients with vestibulopathy
exist. There is limited, sometimes contradictory but generally
supportive, evidence that Tai Chi may have beneficial effects
on balance and postural impairments associated with aging. Of
the 24 studies we reviewed, 20 (83%) reported significant
beneficial effects (ie, at least 1 significant outcome) of Tai Chi
on reducing falls or in improving parameters associated with
falls, such as balance, strength, or flexibility (see table 1).
Analysis of the results of prospective RCTs in particular supports
the conclusion that Tai Chi may have beneficial effects on
postural control. Of the 10 RCTs reviewed, 8 provide support
that Tai Chi practiced alone, or in combination with other
therapies, can reduce risk of falls,59,60 and/or positively impact
factors associated with postural control, including fear of falling,
59,60 static and/or dynamic balance,62,65,68 strength,59,62,65,68
flexibility,64,66,68 and performance of ADLs.63,64,66,68 Of the
remaining 2 RCTs, one reported near significant trends (P
range, .056 –.84) on static single-leg balance, walking speed, and
chair-rise speed.26 Only 1 RCT, conducted by Nowalk et al,67
reported clear, statistically nonsignificant negative results for

Arch Phys Med Rehabil Vol 85, January 2004


all outcomes. These negative outcomes may result from a
number of factors specific to their study. First, their participants
were older than in any of the other studies we reviewed
(average age, 84.7y). Second, the mean score of participants on
the Mini-Mental State Examination during enrollment was
25.3, reflecting a relatively low level of cognitive function.
Nowalk acknowledged that reduced cognitive function might
have made concentrating, and thus learning and remembering
Tai Chi techniques, more challenging. Third, overall adherence
in the Nowalk study was low (mean, 40%), and was particularly
low in the Tai Chi intervention (25%), yet this variability
in adherence was not accounted for in analyses. With these
limitations in mind, a 17% reduction in fall risk among the Tai
Chi group is noteworthy.

Collectively, the results of the studies reviewed suggest that
Tai Chi may improve balance, especially in the elderly. Their
relevance to vestibulopathy, however, and to postural control in
general must be interpreted cautiously for a number of reasons
discussed below.

Relevance of Tai Chi Studies to Date for Patients With

The vast majority of balance-related Tai Chi studies we have
cited focused on older and/or frail adults without a specific
diagnosis of vestibular disease. Only 4 studies59,60,67,73 specifically
mention fall history or balance problems among the
recruited participants. Only 1 study73 included younger subjects
with balance impairments, and it did not report specific
causes of impairments. Some proportion of the older adults
whose balance improved from participation in Tai Chi studies
we reviewed may have had undiagnosed vestibular dysfunction.
However, the evidence suggesting that older adults have
decreased vestibular function is limited and contradictory. Although
the number of cochleovestibular axons or cell bodies
may indeed decrease with age, aging patients are rarely diagnosed
with frank vestibulopathy. Perhaps this is because of the
plasticity of the CNS, but it could as well signify the extremely
small impact the vestibular system has on the slow, deliberate
movements typical of older persons. Only from the results of
future Tai Chi trials that explicitly enroll older patients with
and without vestibulopathy will we be able to evaluate the
benefits of Tai Chi for vestibulopathy versus general, presbyopic
balance, and postural impairments.

Design Limitations of Studies to Date and Considerations
for Future Tai Chi–Vestibulopathy Studies

Both the types of, and the great variability in, outcome
measures across studies published to date limit our ability to
evaluate the efficacy of Tai Chi for vestibulopathy, and for
balance impairment in general. Of the studies summarized in
table 1, 2 directly monitored fall frequency, 6 assessed static
balance tests (eg, single-leg standing time), 12 dynamic stability,
4 gait speed, 9 flexibility, 6 strength, 2 fear of falling, and
7 impacts on ADLs and QOL. This heterogeneity of outcome
measures makes it very difficult to make comparisons between
studies or to draw broader generalizations across all studies.
Further, few studies have made the coordinated measurements
of multiple outcome variables that enable one to analyze relationships
between outcomes. An exception is the work done by
Wolf et al.59,60,69 These studies included concomitant measures
of dynamic stability, strength, flexibility, fear of falling, QOL,
and ADLs. This broader, multivariate approach allowed for
modeling that revealed the somewhat unexpected result that

Tai Chi reduced the probability of falling through means other
than reductions in sway velocity, including modulating fear of
falling. In a recent review, Wu38 also noted the marked variability
in outcome measures used in Tai Chi studies, and its
impact on limiting generalizations. Paralleling a trend of poor
experimental designs in complementary and alternative medicine
research in general,74 many of the studies we reviewed
relied on designs that significantly limit inference. Of the 24
studies included in this review, only 10 were prospective
RCTs. Ten additional prospective studies either did not involve
randomization23,70,75,76 or simply did not include a control
group.24,71,73,77-79 The remaining trials were cross-sectional
studies.22,56,80,81 Additionally, sample sizes in the RCTs were
relatively small, ranging from 20 to 200 (mean, 71.7; median,
52.5), and were even smaller in non-RCT studies (mean, 30.1;
median, 21.0).

The duration of the Tai Chi interventions varied considerably
across studies. Prospective studies ranged from 8 weeks to
1 year, and cross-sectional studies included participants with
experience ranging from 1 to 35 years. There is no consensus
in the Tai Chi literature as to how long or intensively one needs
to practice to benefit from Tai Chi. Wu38 noted that, across both
prospective and cross-sectional studies, some balance-related
outcomes such as single-leg stance time with eyes closed were
greater in studies that involved participants with longer durations
of Tai Chi training. We also found significant variability
in the content of Tai Chi interventions. Studies relied on
grossly different styles of Tai Chi (eg, Yang vs Wu vs Tai Chi
Chih), and within a style also differed in the particular forms
they have used. For example, studies that relied on the Yang
style variously employed 108, 37, 24, and 9 movement forms,
or they extracted subsets of movements from these systems to
be practiced in novel sequences. Eight studies did not provide
information on the style of Tai Chi practiced,24,56,63,64,71,79,80
and 4 studies simply stated that they included Tai Chi–like
movements, giving little or no detail of the specific content
included in the intervention.33,65-67 Moreover, a number of
studies mentioned the inclusion of ancillary exercises that
preceded (warm-up) and/or followed (cool-down) practice of
Tai Chi forms, with little or no description of these exercises.
Given that little research is available to evaluate the potential
advantages and disadvantages of different Tai Chi styles and
forms, and of the additive or synergistic value of ancillary
exercises, direct comparisons between studies, and generalization
across studies should be made cautiously. Future Tai
Chi–vestibulopathy studies should be explicit about the content
of ancillary exercises and their relevance to the therapeutic

Finally, few studies provide any detailed information on the
experience or qualifications of Tai Chi instructors, and only 1
study63 of the 10 RCTs reported using more than 1 Tai Chi
instructor. Because Tai Chi interventions can include many
qualitative components, including imagery, philosophy, encouragement,
and even the apparent embodiment of Tai Chi
principles, it is likely that individual personalities play a key
role in the success or failure of an intervention. A sample size
of only 1 instructor essentially creates the problem of pseudoreplication—
the effects of the instructor cannot be separated
from the effects of the intervention. Future studies should
include multiple instructors in both Tai Chi and control groups
to account for, and possibly characterize the relationship between,
instructor traits such as experience and personality, and
the success of an intervention.

Arch Phys Med Rehabil Vol 85, January 2004


Elements of Tai Chi That May Improve Vestibulopathy

Despite the lack of empirical evidence from Tai Chi studies
conducted with vestibulopathy patients, it is useful to speculate
on the mechanisms by which Tai Chi might improve function
in vestibulopathy patients, because this speculation may help
design future studies. A key component of vestibular rehabilitation
is improving VOR in persons who have gaze instability.
In VOR training, relatively rapid eye movement exercises are
emphasized. In contrast, Tai Chi emphasizes maintaining a
relaxed, nonfocused gaze during practice of many styles of Tai
Chi. Thus, improvements in dynamic postural stability related
to Tai Chi are not likely to be facilitated by improved VOR–
mediated gaze stability. However, only future Tai Chi–vestibulopathy
trials that monitor eye-head stability during Tai Chi
practice and characterize VOR function before and after Tai
Chi interventions will be able to test this hypothesis.

In contrast, the Tai Chi–related improvements reported in
musculoskeletal strength,22,23,59,62,77 flexibility,23,62,64,66,77 limb
control and kinesthetic sense,62,75,76 and single-stance
times56,65,70,73,75,81 may provide mechanisms that bypass the
rapid, demand-oriented, typical function of the VOR, emphasizing
proprioceptive and CNS adaptations. Improved strength,
flexibility, and single-stance times, for example, have been
correlated with improved dynamic postural stability and reduced

Interestingly, in studies where dynamic measures of balance
were directly assessed, results have been contradictory. For
example, some studies suggest Tai Chi reduces measures of
sway,78,80 whereas others suggest that postural stability during
dynamic testing is not improved.60,79 Wolf et al60 suggested
that Tai Chi might gain its success by preventing falls by
training older trainees to sway with the perturbation rather than
to resist it by limiting sway. Forrest79 hypothesized that Tai Chi
leads to greater use of elasticity of the peripheral structures,
suggesting that Tai Chi may be affecting biomechanics and
neuromuscular control in fundamentally different ways than
other vestibular rehabilitation interventions.

Tai Chi’s emphasis on mental concentration may provide
another mechanism by which it can improve postural control.
Tai Chi encourages practitioners to be very focused and concentrate
when practicing, and by doing so they exclude other
distractions and stressors, and improve their awareness of their
body and its movements.35,55,60 A growing body of evidence
suggests that attentional control may be an important factor in
posture and gait.82 For example, older adults challenged with
cognitive demands take longer to recover from postural perturbations
than those without simultaneous cognitive demands.
82 Moreover, these effects are greatest for older persons
with balance impairments.83 One possible mechanism by which
Tai Chi could improve vestibulopathy is through focused attention.
This notion could be tested in a Tai Chi–vestibulopathy
study that included a dual-task paradigm.

Another mechanism by which Tai Chi may improve vestibulopathy
patients’ postural control is through improved overall
mood, optimism, and expectancy. Long-term chronic health
problems and limited ADLs, such as those associated with
vestibulopathy, may lead to poor psychologic profile, with
further negative feedback on function.40 Among transitionally
frail older adults, Kressing et al84 found an association between
fear of falling and depression. Results from many studies
suggest that physical exercise promotes emotional health and
psychologic well-being.85-88 In this review, we summarized 8
studies that reported positive psychologic responses to participating
in a Tai Chi intervention; 6 of the 8 studies also

characterized outcomes related to postural control. Only 1
study reported fear of falling59,60 and one the Dizziness Handicap
Inventory,73 which includes some psychologic and ADL
questions related to balance; in both cases, Tai Chi improved
survey scores. Only 1 of the 8 studies60 showed quantitative
relationships between psychologic behavior and balance-related

The rapidly expanding field of mind-body medicine has
clearly shown that the mind and the health of the physical body
are integrally interconnected.89-91 Our thoughts and beliefs may
influence a broad range of health-related phenomena including
immune function,92 cardiovascular disease,93 pain management,
and life expectancy with cancer.94 There is evidence
suggesting that some of the positive emotional gains resulting
from exercise may not result directly from an increase in
physical fitness, but may be because of the psychologic gains
from the expectancy or experience of trying to get fit, or
believing that one is fit.88,95-97 In 2 studies by Jin,31,32 in which
Tai Chi was found to reduce anxiety and improve various
components of mood, improved psychologic well-being was
thought to be partially accounted for by subject’s high expectations
about gains from Tai Chi. More broadly, Kaptchuck98
has proposed that therapies involving complementary and alternative
medicine rituals, beliefs, imagery, and alternative
conceptions of meanings of self and health may provide “enhanced”
placebo effects, beyond the magnitude of placebo
effects normally associated with mainstream therapies. This
may especially apply to Tai Chi, which incorporates unique
metaphors of vital energy, nature’s restorative power, and the
potency of mind-body interaction. Such constructs have the
potential to modify significantly a subject’s beliefs and expectations,
which, in turn, may contribute to a robust nonspecific
effect and healing in general.

Although the Tai Chi studies we reviewed suggest that Tai
Chi may improve psychologic well-being, and that these outcomes
occur concurrently with improved postural control, the
data are limited and provide little evidence of what the causal
links are between psychologic well-being and improved balance,
and whether these relationships would also be true for
vestibulopathy subjects. Nevertheless, the “mind” component
of this mind-body exercise may play an important role in
postural control of vestibulopathy patients, and exploring this
possibility poses an exciting area for future research.


At present, few data support the contention that Tai Chi
specifically targets the impairments, functional limitations, disability,
and QOL associated with peripheral vestibulopathy.
There are, however, compelling reasons to further investigate
Tai Chi for vestibulopathy, in part because Tai Chi appears to
be useful for various nonvestibulopathy etiologic balance disorders.
Especially needed are studies that integrate measures of
balance relevant to ADLs with other psychologic and cognitive
measures; these might help identify specific mechanisms
whereby Tai Chi can remedy balance disorders. Certainly, Tai
Chi is safe and has few side effects: Tai Chi provides a
moderate aerobic, low impact dynamic postural control challenge,
so even the least fit individuals can participate. Indeed,
few adverse effects have been reported despite Tai Chi applications
across numerous and diverse settings, patient diagnoses,
and comorbidities. More rigorous research is required,
including RCTs comparing Tai Chi and vestibular rehabilitation
among people with vestibulopathy, before a firm, defensible
answer is in hand.

Arch Phys Med Rehabil Vol 85, January 2004



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