NIH Public Access Author Manuscript Act Dir Q Alzheimers Other Dement Patients. Author manuscript; available in PMC 2014 March 31.
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Published in final edited form as: Act Dir Q Alzheimers Other Dement Patients. 2010 ; 11(4): 8–17.
Teaching Tai Chi to elders with osteoarthritis pain and mild cognitive impairment Jason Y. Chang, PhD [Associate Professor], Department of Neurobiology and Developmental Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas Pao-Feng Tsai, RN, PhD [Associate Professor], College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas Sheery Woods [Assistant Community Fitness Program Coordinator], University Rehab Therapy and Fitness Center, Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Cornelia Beck, RN, PhD [Professor], Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas Paula K. Roberson, PhD [Professor and Chair], and Department of Biostatistics, Colleges of Medicine and Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas Karl Rosengren, PhD [Professor] Department of Psychology, Northwestern University, Evanston, Illinois
Abstract Objective—This article describes the authors’ experience and strategies in teaching Tai Chi, a gentle exercise derived from an ancient Chinese martial art, to mildly cognitively impaired elders to relieve osteoarthritic knee pain. The 12-form Sun-style Tai Chi, a set of Tai Chi forms endorsed by the American Arthritis Foundation, was used in the program. Teaching Tai Chi to elders with mild cognitive impairment requires particular strategies tailored to their physical and cognitive frailty. When effectively taught, Tai Chi can be a unique and cost-effective intervention for elders with knee pain caused by osteoarthritis.
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Introduction Tai Chi was expected to be good for arthritic knee pain because the weight-bearing aspects of Tai Chi gradually strengthen leg muscles, including the quadriceps,1 and this may help to re-establish normal mechanics around the knee joint.2 Improved stability of the knee joint should provide protection because it reduces excessive stress and strain on the lax joint capsule where nociceptors are located.2 This should also improve the general physical functioning of elders.3 Indeed, studies using the Sun-style 12-form Tai Chi have shown benefits in reducing pain and stiffness, improving balance and abdominal muscle strength,4 improving knee and ankle strength, and building up physical fitness.5 Despite documented evidence that exercise provides benefits to elders, many communitydwelling elders do not exercise, in part because of compromised physical strength and/or multiple medical conditions. Knee pain caused by osteoarthritis (OA) is one of the leading causes of disability among elders,6 and because of the pain, elders with knee OA may avoid physical activities that require the use of the lower extremities. This inactivity may weaken muscles making further physical activity difficult.7 Up to 15 percent of elders aged 65 years
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or older have cognitive impairment (CI),8 and the prevalence increases to approximately 50 percent among those aged 85 years or older.9 Elders with CI have additional obstacles preventing them from exercising. For example, they are forgetful and may not be able to remember the date/time of a scheduled exercise activity. Sedentary life style, low perceived chance of success, low perceived importance of the goal, and high perceived costs may prevent elders from initiating physical activity.10 Elders also tend to exhibit less selfefficacy for exercising than other age groups.11 When performed adequately, exercise can help to relieve OA knee pain and prevent further physical deconditioning.12,13 Therefore, it was important to design an exercise program suitable for elders with CI and OA of the knee. Much of the research testing the effectiveness of exercise programs tended to exclude elders with CI, but this exercise program used a Tai Chi program tailored to elders’ cognitive and physical frailty.
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Tai Chi, an exercise derived from an ancient Chinese martial art,14 involves slow, continuous movement of the upper and lower extremities in a sequential, fluid, dance-like manner. In addition to benefits for OA pain, the practice of Tai Chi has been found beneficial for patients with various chronic conditions.15,16 It can greatly increase the range of motion and flexibility, and it helps to improve cardiovascular function and balance control. According to a recent meta-analysis, Tai Chi is recommended as an alternative to aerobic exercise, particularly for sedentary adults ≥ 55 years old. Practicing Tai Chi regularly is effective in improving aerobic capacity, and the greatest gains are seen among those who were initially sedentary.17 Like other aerobic exercises, Tai Chi and other forms of body-mind exercise are also reported to have beneficial effects on cognition. A cross-sectional study found that elders who reported practicing body-mind exercises (mainly Tai Chi) and those who reported practicing other types of aerobic exercises (such as dancing, jogging, swimming, and playing tennis) demonstrated better memory and learning functions than those who did not exercise regularly. However, no differences in these functions were found between elders who did aerobic exercises and those who did body-mind exercises.18 A recent crosssectional study confirmed these results.19 Tai Chi also provides the additional benefits of social interaction among group members when practiced in a group setting. Thus, if a Tai Chi exercise program has built-in features to assist in learning and to encourage participation, elders with CI and OA of the knee should be able to participate.
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Although in general Tai Chi is an exercise that is elderly friendly, the Sun-style is especially suitable for elderly people with unsteady gait, weak muscles, and bodily pains. It is because this style uses a high stance and a step/follow-step technique, which is good for maintaining balance and reducing stress on the knee joints. The 12-form Sun-style Tai Chi developed by Dr. Lam20 is designed for patients with arthritis, the most common chronic condition in elders,21 and it has been adopted by the American Arthritis Foundation.
Purpose This article reports our teaching strategies for seniors with physical and cognitive frailty, as part of a larger study, which has been reported elsewhere.22 Elders participating in the study were recruited from senior residential facilities and senior activity centers in Little Rock metropolitan area, Arkansas. Most of the participants were between 70 and 90 years old. Strategies tailored to physical frailty Dealing with safety issues—The on-site instruction took place in an activity room of each facility. We typically had five to 10 elders in a Tai Chi class, for easy monitoring of
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their safety. Even though Tai Chi is commonly practiced outdoors, we chose to conduct the instruction indoors, because of the safer and stable environmental conditions which were not affected by weather. We made special efforts to reduce the risk of falling. There was always a chair next to each elder so that she/he could sit down whenever necessary. The chair also helped the elder to maintain balance when standing. Usually, a certified Tai Chi instructor and a research assistant (RA) teamed up for the Tai Chi class. The instructor/RA would stop an elder from performing Tai Chi if the elder showed an unsteady gait or risk of falling. Occasionally, two certified Tai Chi instructors teamed up to do the instruction. As one instructor conducted the teaching, the other monitored risk of falling, observed the Tai Chi forms practiced by the elders, and made suggestions to the group as appropriate.
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Selecting the appropriate session duration—Exercise time per session for Stage 1 (total 30 sessions) was 20 to 30 minutes. This was based on the suggestion from the American Geriatrics Society reported,23 stating that exercise for sedentary elders should start with low to moderate intensity for a minimum of 20 to 30 minutes per session at least three times a week. In stage 2 (total 30 sessions), we gradually increased the exercise per session to 35 to 40 minutes because by then the elders had built up some physical strength for exercise. We found that about halfway through each session (about 10 to 20 minutes), some elders were tired. Thus, during each session, participants took a five-minute rest halfway through the exercise, which allowed the elders to rest and drink water if needed. Building up elders’ physical and muscle strength gradually—Each Tai Chi class started with a set of five-minute warm-up exercises and ended with another set of fiveminute cool-down exercises to avoid injury. The warm-up and cool-down exercises included breathing and gentle stretching of joints in the upper limbs, lower limbs, and the trunk. We always asked the elders to do the exercise within their comfort zone. To build up their muscle strength, elders started Tai Chi practice in each session in a seated position, and then switched to a standing position. Over time, the instructor gradually increased the time that participants stood in each session, from 10 to 30 minutes. The instructor used a high-squat posture in sessions 1 through 30, and then used a lower squat posture in sessions 31 through 60. The elders were instructed to use a lower squat position if they chose to; however, this was not required.
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Practice in weight shifting and balance control—Conscious weight shifting and balance control are integral parts of Tai Chi practice. However, continuous and concurrent movement of the upper and lower limbs makes it difficult for elders to pay attention to weight shifting and balance control. Consequently, we devoted a portion of the time in each session (about five minutes) to practicing steps, ie, focusing on the control of lower limbs. We used the characteristic “step-follow step” movement of the feet in the Sun-style Tai Chi. For example, when the left foot moved one step forward, the right foot would follow by a half-step in the next move. This helped to avoid overextension of the body and maintain balance. We reminded the elders to take smaller steps if they felt unsteady. We found that once the elders could manage the steps and balance well, they performed the combined upper and lower limb movements with more confidence. Strategies tailored to cognitive frailty Length of program—On the basis of our prior experience, we expected that elders with CI would need at least 16 to 20 sessions to learn the 12 forms. Regular practice helps people to perfect their Tai Chi forms, and this has an important impact on the outcomes. In our pilot
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study,24 repetition helped the elders to gradually establish their “muscle memory” in performing Tai Chi. Based on these considerations, in our current program, Tai Chi instruction included two stages, as described earlier: stage 1 (30 sessions in the first 10 weeks) enabled them to learn the forms, and stage 2 (30 sessions in the second 10 weeks) enabled them to rehearse the forms. The current program lasted for a total of 60 sessions over 20 weeks, which is longer than the typical Tai Chi program (24 sessions over 12 weeks).4,25 Teaching method—The instructor started with form 1 in session 1 and gradually added new forms in later sessions as participants made progress. The instructor first used the “mirror image” teaching method. With this method, the instructor faced the participants and they “mirrored” the instructor’s movements to practice. This allowed the elders to see the instructor’s Tai Chi form and also to follow the instructions easily. At the same time, the instructor could have direct eye contact with participants and monitor their performance and safety.
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After elders were acquainted with the forms, the instructor practiced with elders with the “actual image,” while the RA monitored their safety. With this teaching method, the instructor stood in front of the group, facing in the same direction as participants, and the participants followed the instructor’s actual movements. The elders tended to move slowly because of their frail cognitive and physical conditions. Thus, the instructor moved slowly when teaching the forms so that the elders could follow the instruction without difficulty and without becoming confused. The instructor’s speech was gentle but loud enough so that elders with hearing problems could hear the instruction. Aid for dealing with memory problem—Because Tai Chi was originally derived from a Chinese martial art, providing the background information behind each Tai Chi form was used to make it interesting, to keep elders’ attention, and to help them to memorize the form. For example, we explained that the form “play the lute” can be used to pull the opponent’s hand (with one hand) and to attack the opponent’s elbow (with the other hand). “Brush knee” can be used to block the opponent’s kick (with one hand) and to push the opponent off balance (with the other hand). After the explanations, seniors understood the rationale for each form and could visualize the movement. We also provided handouts explaining and illustrating the forms to reinforce to elders what we talked about during the class.
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We found that a combination of visual and verbal cues during the instruction made the learning more interesting. The instructor generally used a script consisting of “Pick up the baby, give it to the mom … open the window …,” which linked all the forms together. Recital of the script, a mental exercise, helped the elders to remember the sequence. By session 24, the majority of elders had learned the complete set of Tai Chi forms. They might still have difficulty remembering the exact sequence of the forms, but they could usually follow the instructor to practice the forms. Emphasizing the importance of practice—We emphasized to elders that the benefits of Tai Chi come from practice, not from merely learning individual forms. Thus, we encouraged the elders to practice at home. We emphasized to them that it did not matter if they could not remember the whole sequence of forms. They could select a few forms that they liked and practice them repeatedly, because regular practice would increase their level of physical activity and should help with their OA pain and discomfort.
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Strategies to promote participation
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Seated Tai Chi—There were occasions when an elder would come to the class but did not have the strength to stand up for Tai Chi practice. We usually encouraged the elder to take part in the practice in a seated position. Just coming to the class, elders had to leave their home/apartment and walk to the classroom, which gave them a certain level of physical activity. The elders could then practice the forms using the upper limbs, and thus could still get some benefits from the exercise. A seated position also helped to prevent elders from falling. Instruction in person—We found that it was difficult to learn Tai Chi by watching an instructional DVD. It was especially difficult for cognitively, hearing, and/or visually impaired elders. We thus mainly used face-to-face Tai Chi instruction. The attention and communication from the personal contact were also very important for these sedentary elders, and the relationship with the instructor/staff helped to retain elders in the program. Using soft music—Practicing Tai Chi with music was a pleasant “moving meditation” experience for elders. Although there is no “Tai Chi-specific” music, we found that quiet, soft music with Chinese instruments gave elders an exotic and soothing learning environment.
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Sharing current Tai Chi research—It has been reported that positive health outcomes resulting from Tai Chi can facilitate practice.26 The instructor or our participants often brought a clip of a newspaper report on the potential benefits of Tai Chi and shared that with others in the class. For example, a recent report from the New York Times indicated that a study in Hong Kong found that Tai Chi improved standing balance for people with stroke.27 The instructor then obtained the original research paper from the university library and led a brief discussion with the elders during the break period in a Tai Chi session. The participants found this type of discussion refreshing and became even more enthusiastic about practicing Tai Chi.
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Recording Tai Chi performance—We recorded each participant’s Tai Chi performance and evaluated the accuracy. A total of four recordings were made during the 20-week course. The participant would first watch the instructor performing the 12-form Sun-style Tai Chi twice. She/he would then perform Tai Chi by following the instructor’s performance and verbal cues while the RA made a video recording. We sent the tapes to an independent laboratory for coding28 and used the results to help us determine whether the accuracy of Tai Chi performance affected other outcomes. Although this was not the intended purpose, we noticed that the elders found it interesting to be videotaped. They tried hard to perform the Tai Chi forms well when the video camera was rolling. Thus, occasional videotaping can be used as a tool to encourage participation and learning. Social interactions—Practiced in a group setting, this program offered an opportunity for pleasant social interactions among the elders. As some of them had lost their family members, having a Tai Chi class to attend routinely helped them to establish social connections with others. They enjoyed and needed this human contact. Holding social parties—Small parties were held at mid-term and at the end of the course. These gave us opportunities to discuss various issues regarding the Tai Chi class in a relaxed environment. At the parties, elders also liked to tell us about small events they had experienced. We would remember and then ask them later about those events. The social interactions during regular class sessions and at small parties made participants feel that they were “comrades” in our program. In this regard, it should be noted that the elders loved to be Act Dir Q Alzheimers Other Dement Patients. Author manuscript; available in PMC 2014 March 31.
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called by their names in the party or in the class. They felt cared for when we called them by name.
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Sharing with their peer and families—We encouraged the elders to show their families what they had learned in our class. We even helped them to practice a Tai Chi pose (eg, the form “single whip”) in case their grandchildren wanted to take a picture of them. This was designed to let their families know what their loved ones were involved in and show that they enjoyed the Tai Chi class. At the end of the course, each person received a DVD that contained their group and personal Tai Chi practice during the course to serve as a souvenir for them and a talking point with their peers and family. Suggestions and praises—To avoid embarrassment to individual elders, as a general rule, we addressed our suggestions for correct Tai Chi moves to the whole class unless a question was raised by an individual. After a practice session, elders liked to be praised for their efforts. This made them feel rewarded, which is consistent with a study showing that encouragement facilitates practice of Tai Chi by elders.26
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In summary, in our Tai Chi study conducted in several senior residential facilities and senior activity centers, most participants were 70 to 90 years old with mild CI and OA knee pain. The Tai Chi program that we provided was suitable for these elders because it was gentle and could be tailored to each individual’s physical and cognitive condition. Tai Chi could be practiced in a standing or in a seated position, any time, in a small area. Tai Chi was practiced indoors, as it was not affected by the weather and was relatively safe. Using teaching strategies tailored to participant’s physical and cognitive frailty, we found that the elders were able to perform at the pace and for the length of time designed. The Tai Chi group not only provided physical activity but also cognitive stimulation and social interaction for the elders, all of which are extremely important for elders to experience “successful aging.”29
Acknowledgments This work was supported by the National Institute of Nursing Research (R21NR010003 to P.T.) and the Alzheimer’s Arkansas (to P.T.). This work was also supported in part by the National Institute of Nursing Research (P20NR009006 to C.B. and P.K.R.). The authors thank Ms. Elizabeth Tornquist for editorial assistance.
References NIH-PA Author Manuscript
1. Qin L, Choy W, Leung K, et al. Beneficial effects of regular Tai Chi exercise on musculoskeletal system. J Bone Miner Metab. 2005; 23(2):186–190. [PubMed: 15750699] 2. Cheing GL, Hui-Chan CW, Chan KM. Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain? Clin Rehabil. 2002; 16(7):749–760. [PubMed: 12428824] 3. Fisher NM, Pendergast DR, Gresham GE, et al. Muscle rehabilitation: Its effect on muscular and functional performance of patients with knee osteoarthritis. Arch Phys Med Rehabil. 1991; 72(6): 367–374. [PubMed: 2059102] 4. Song R, Lee EO, Lam P, et al. Effects of Tai Chi exercise on pain, balance, muscle strength, and perceived difficulties in physical functioning in older women with osteoarthritis: A randomized clinical trial. J Rheumatol. 2003; 30(9):2039–2044. [PubMed: 12966613] 5. Choi JH, Moon JS, Song R. Effects of Sun-style Tai Chi exercise on physical fitness and fall prevention in fall-prone older adults. J Adv Nurs. 2005; 51(2):150–157. [PubMed: 15963186]
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6. Campbell AJ, Busby WJ, Robertson MC, et al. Disease, impairment, disability and social handicap: A community based study of people aged 70 years and over. Disabil Rehabil. 1994; 16(2):72–79. [PubMed: 8043887] 7. Steultjens MP, Dekker J, Bijlsma JW. Avoidance of activity and disability in patients with osteoarthritis of the knee: The mediating role of muscle strength. Arthritis Rheum. 2002; 46(7): 1784–1788. [PubMed: 12124862] 8. Pfeffer RI, Afifi AA, Chance JM. Prevalence of Alzheimer’s disease in a retirement community. Am J Epidemiol. 1987; 125(3):420–436. [PubMed: 3812449] 9. Hebert LE, Scherr PA, Bienias JL, et al. State-specific projections through 2025 of Alzheimer disease prevalence. Neurology. 2004; 62(9):1645. [PubMed: 15136705] 10. Phillips EM, Schneider JC, Mercer GR. Motivating elders to initiate and maintain exercise. Arch Phys Med Rehabil. 2004; 85(7, Suppl 3):S52–S57. quiz S58–S59. [PubMed: 15221728] 11. Conn VS. Older adults and exercise: Path analysis of self-efficacy related constructs. Nurs Res. 1998; 47(3):180–189. [PubMed: 9610652] 12. O’Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: A randomised controlled trial. Ann Rheum Dis. 1999; 58(1):15–19. [PubMed: 10343535] 13. Thomas KS, Muir KR, Doherty M, et al. Home based exercise programme for knee pain and knee osteoarthritis: Randomised controlled trial. BMJ. 2002; 325(7367):752. [PubMed: 12364304] 14. Lan C, Lai JS, Chen SY. Tai Chi Chuan: An ancient wisdom on exercise and health promotion. Sports Med. 2002; 32(4):217–224. [PubMed: 11929351] 15. Klein PJ, Adams WD. Comprehensive therapeutic benefits of Taiji: A critical review. Am J Phys Med Rehabil. 2004; 83(9):735–745. [PubMed: 15314540] 16. Wang C, Collet JP, Lau J. The effect of Tai Chi on health outcomes in patients with chronic conditions: A systematic review. Arch Intern Med. 2004; 164(5):493–501. [PubMed: 15006825] 17. Taylor-Piliae RE. The effectiveness of Tai Chi exercise in improving aerobic capacity: An updated meta-analysis. Med Sport Sci. 2008; 52:40–53. [PubMed: 18487885] 18. Chan AS, Ho YC, Cheung MC, et al. Association between mind-body and cardiovascular exercises and memory in older adults. J Am Geriatr Soc. 2005; 53(10):1754–1760. [PubMed: 16181176] 19. Lam LC, Tam CW, Lui VW, et al. Modality of physical exercise and cognitive function in Hong Kong older Chinese community. Int J Geriatr Psychiatry. 2009; 24(1):48–53. [PubMed: 18615844] 20. Arthritis Foundation. [Accessed December 9, 2010] Tai Chi program. Available at http:// www.arthritis.org/events/getinvolved/ProgramsServices/TaiChi.asp 21. CDC. Public health and aging: Projected prevalence of self-reported arthritis or chronic joint symptoms among persons aged > 65 years—United States, 2005–2030. MMWR Morb Mortal Wkly Rep. 2003; 52(21):489–491. [PubMed: 12809109] 22. Tsai PF, Chang JY, Chowdhury N, et al. Enrolling older adults with cognitive impairment in research: lessons from a study of Tai Chi for osteoarthritis knee pain. Res Gerontol Nurs Oct. 2009; 2(4):228–234. 23. American Geriatrics Society Panel on Exercise and Osteoarthritis: Exercise prescription for older adults with osteoarthritis pain: Consensus practice recommendations. A supplement to the AGS Clinical Practice Guidelines on the management of chronic pain in older adults. J Am Geriatr Soc. 2001; 49(6):808–823. [PubMed: 11480416] 24. Tsai P, Beck C, Chang JY, et al. The effect of tai chi on knee osteoarthritis pain in cognitively impaired elders: Pilot study. Geriatr Nurs. 2009; 30(2):132–139. [PubMed: 19345855] 25. Hartman CA, Manos TM, Winter C, et al. Effects of Tai Chi training on function and quality of life indicators in older adults with osteoarthritis. J Am Geriatr Soc. 2000; 48(12):1553–1559. [PubMed: 11129742] 26. Chen KM, Snyder M, Krichbaum K. Facilitators and barriers to elders’ practice of t’ai chi. A mindbody, low-intensity exercise. J Holist Nurs. 2001; 19(3):238–255. [PubMed: 11847870] 27. Au-Yeung SS, Hui-Chan CW, Tang JC. Short-form Tai Chi improves standing balance of people with chronic stroke. Neurorehabil Neural Repair. 2009; 23(5):515–522. [PubMed: 19129308]
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28. Rosengren KS, Christou E, Yang Y, et al. Quantification of taiji learning in older adults. J Am Geriatr Soc. 2003; 51(8):1186–1187. [PubMed: 12890093] 29. Karp A, Paillard-Borg S, Wang HX, et al. Mental, physical and social components in leisure activities equally contribute to decrease dementia risk. Dement Geriatr Cogn Disord. 2006; 21(2): 65–73. [PubMed: 16319455]
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Published in final edited form as: Act Dir Q Alzheimers Other Dement Patients. 2010 ; 11(4): 8–17.
Teaching Tai Chi to elders with osteoarthritis pain and mild cognitive impairment Jason Y. Chang, PhD [Associate Professor], Department of Neurobiology and Developmental Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas Pao-Feng Tsai, RN, PhD [Associate Professor], College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas Sheery Woods [Assistant Community Fitness Program Coordinator], University Rehab Therapy and Fitness Center, Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Cornelia Beck, RN, PhD [Professor], Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas Paula K. Roberson, PhD [Professor and Chair], and Department of Biostatistics, Colleges of Medicine and Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas Karl Rosengren, PhD [Professor] Department of Psychology, Northwestern University, Evanston, Illinois
Abstract Objective—This article describes the authors’ experience and strategies in teaching Tai Chi, a gentle exercise derived from an ancient Chinese martial art, to mildly cognitively impaired elders to relieve osteoarthritic knee pain. The 12-form Sun-style Tai Chi, a set of Tai Chi forms endorsed by the American Arthritis Foundation, was used in the program. Teaching Tai Chi to elders with mild cognitive impairment requires particular strategies tailored to their physical and cognitive frailty. When effectively taught, Tai Chi can be a unique and cost-effective intervention for elders with knee pain caused by osteoarthritis.
NIH-PA Author Manuscript
Introduction Tai Chi was expected to be good for arthritic knee pain because the weight-bearing aspects of Tai Chi gradually strengthen leg muscles, including the quadriceps,1 and this may help to re-establish normal mechanics around the knee joint.2 Improved stability of the knee joint should provide protection because it reduces excessive stress and strain on the lax joint capsule where nociceptors are located.2 This should also improve the general physical functioning of elders.3 Indeed, studies using the Sun-style 12-form Tai Chi have shown benefits in reducing pain and stiffness, improving balance and abdominal muscle strength,4 improving knee and ankle strength, and building up physical fitness.5 Despite documented evidence that exercise provides benefits to elders, many communitydwelling elders do not exercise, in part because of compromised physical strength and/or multiple medical conditions. Knee pain caused by osteoarthritis (OA) is one of the leading causes of disability among elders,6 and because of the pain, elders with knee OA may avoid physical activities that require the use of the lower extremities. This inactivity may weaken muscles making further physical activity difficult.7 Up to 15 percent of elders aged 65 years
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or older have cognitive impairment (CI),8 and the prevalence increases to approximately 50 percent among those aged 85 years or older.9 Elders with CI have additional obstacles preventing them from exercising. For example, they are forgetful and may not be able to remember the date/time of a scheduled exercise activity. Sedentary life style, low perceived chance of success, low perceived importance of the goal, and high perceived costs may prevent elders from initiating physical activity.10 Elders also tend to exhibit less selfefficacy for exercising than other age groups.11 When performed adequately, exercise can help to relieve OA knee pain and prevent further physical deconditioning.12,13 Therefore, it was important to design an exercise program suitable for elders with CI and OA of the knee. Much of the research testing the effectiveness of exercise programs tended to exclude elders with CI, but this exercise program used a Tai Chi program tailored to elders’ cognitive and physical frailty.
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Tai Chi, an exercise derived from an ancient Chinese martial art,14 involves slow, continuous movement of the upper and lower extremities in a sequential, fluid, dance-like manner. In addition to benefits for OA pain, the practice of Tai Chi has been found beneficial for patients with various chronic conditions.15,16 It can greatly increase the range of motion and flexibility, and it helps to improve cardiovascular function and balance control. According to a recent meta-analysis, Tai Chi is recommended as an alternative to aerobic exercise, particularly for sedentary adults ≥ 55 years old. Practicing Tai Chi regularly is effective in improving aerobic capacity, and the greatest gains are seen among those who were initially sedentary.17 Like other aerobic exercises, Tai Chi and other forms of body-mind exercise are also reported to have beneficial effects on cognition. A cross-sectional study found that elders who reported practicing body-mind exercises (mainly Tai Chi) and those who reported practicing other types of aerobic exercises (such as dancing, jogging, swimming, and playing tennis) demonstrated better memory and learning functions than those who did not exercise regularly. However, no differences in these functions were found between elders who did aerobic exercises and those who did body-mind exercises.18 A recent crosssectional study confirmed these results.19 Tai Chi also provides the additional benefits of social interaction among group members when practiced in a group setting. Thus, if a Tai Chi exercise program has built-in features to assist in learning and to encourage participation, elders with CI and OA of the knee should be able to participate.
NIH-PA Author Manuscript
Although in general Tai Chi is an exercise that is elderly friendly, the Sun-style is especially suitable for elderly people with unsteady gait, weak muscles, and bodily pains. It is because this style uses a high stance and a step/follow-step technique, which is good for maintaining balance and reducing stress on the knee joints. The 12-form Sun-style Tai Chi developed by Dr. Lam20 is designed for patients with arthritis, the most common chronic condition in elders,21 and it has been adopted by the American Arthritis Foundation.
Purpose This article reports our teaching strategies for seniors with physical and cognitive frailty, as part of a larger study, which has been reported elsewhere.22 Elders participating in the study were recruited from senior residential facilities and senior activity centers in Little Rock metropolitan area, Arkansas. Most of the participants were between 70 and 90 years old. Strategies tailored to physical frailty Dealing with safety issues—The on-site instruction took place in an activity room of each facility. We typically had five to 10 elders in a Tai Chi class, for easy monitoring of
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their safety. Even though Tai Chi is commonly practiced outdoors, we chose to conduct the instruction indoors, because of the safer and stable environmental conditions which were not affected by weather. We made special efforts to reduce the risk of falling. There was always a chair next to each elder so that she/he could sit down whenever necessary. The chair also helped the elder to maintain balance when standing. Usually, a certified Tai Chi instructor and a research assistant (RA) teamed up for the Tai Chi class. The instructor/RA would stop an elder from performing Tai Chi if the elder showed an unsteady gait or risk of falling. Occasionally, two certified Tai Chi instructors teamed up to do the instruction. As one instructor conducted the teaching, the other monitored risk of falling, observed the Tai Chi forms practiced by the elders, and made suggestions to the group as appropriate.
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Selecting the appropriate session duration—Exercise time per session for Stage 1 (total 30 sessions) was 20 to 30 minutes. This was based on the suggestion from the American Geriatrics Society reported,23 stating that exercise for sedentary elders should start with low to moderate intensity for a minimum of 20 to 30 minutes per session at least three times a week. In stage 2 (total 30 sessions), we gradually increased the exercise per session to 35 to 40 minutes because by then the elders had built up some physical strength for exercise. We found that about halfway through each session (about 10 to 20 minutes), some elders were tired. Thus, during each session, participants took a five-minute rest halfway through the exercise, which allowed the elders to rest and drink water if needed. Building up elders’ physical and muscle strength gradually—Each Tai Chi class started with a set of five-minute warm-up exercises and ended with another set of fiveminute cool-down exercises to avoid injury. The warm-up and cool-down exercises included breathing and gentle stretching of joints in the upper limbs, lower limbs, and the trunk. We always asked the elders to do the exercise within their comfort zone. To build up their muscle strength, elders started Tai Chi practice in each session in a seated position, and then switched to a standing position. Over time, the instructor gradually increased the time that participants stood in each session, from 10 to 30 minutes. The instructor used a high-squat posture in sessions 1 through 30, and then used a lower squat posture in sessions 31 through 60. The elders were instructed to use a lower squat position if they chose to; however, this was not required.
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Practice in weight shifting and balance control—Conscious weight shifting and balance control are integral parts of Tai Chi practice. However, continuous and concurrent movement of the upper and lower limbs makes it difficult for elders to pay attention to weight shifting and balance control. Consequently, we devoted a portion of the time in each session (about five minutes) to practicing steps, ie, focusing on the control of lower limbs. We used the characteristic “step-follow step” movement of the feet in the Sun-style Tai Chi. For example, when the left foot moved one step forward, the right foot would follow by a half-step in the next move. This helped to avoid overextension of the body and maintain balance. We reminded the elders to take smaller steps if they felt unsteady. We found that once the elders could manage the steps and balance well, they performed the combined upper and lower limb movements with more confidence. Strategies tailored to cognitive frailty Length of program—On the basis of our prior experience, we expected that elders with CI would need at least 16 to 20 sessions to learn the 12 forms. Regular practice helps people to perfect their Tai Chi forms, and this has an important impact on the outcomes. In our pilot
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study,24 repetition helped the elders to gradually establish their “muscle memory” in performing Tai Chi. Based on these considerations, in our current program, Tai Chi instruction included two stages, as described earlier: stage 1 (30 sessions in the first 10 weeks) enabled them to learn the forms, and stage 2 (30 sessions in the second 10 weeks) enabled them to rehearse the forms. The current program lasted for a total of 60 sessions over 20 weeks, which is longer than the typical Tai Chi program (24 sessions over 12 weeks).4,25 Teaching method—The instructor started with form 1 in session 1 and gradually added new forms in later sessions as participants made progress. The instructor first used the “mirror image” teaching method. With this method, the instructor faced the participants and they “mirrored” the instructor’s movements to practice. This allowed the elders to see the instructor’s Tai Chi form and also to follow the instructions easily. At the same time, the instructor could have direct eye contact with participants and monitor their performance and safety.
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After elders were acquainted with the forms, the instructor practiced with elders with the “actual image,” while the RA monitored their safety. With this teaching method, the instructor stood in front of the group, facing in the same direction as participants, and the participants followed the instructor’s actual movements. The elders tended to move slowly because of their frail cognitive and physical conditions. Thus, the instructor moved slowly when teaching the forms so that the elders could follow the instruction without difficulty and without becoming confused. The instructor’s speech was gentle but loud enough so that elders with hearing problems could hear the instruction. Aid for dealing with memory problem—Because Tai Chi was originally derived from a Chinese martial art, providing the background information behind each Tai Chi form was used to make it interesting, to keep elders’ attention, and to help them to memorize the form. For example, we explained that the form “play the lute” can be used to pull the opponent’s hand (with one hand) and to attack the opponent’s elbow (with the other hand). “Brush knee” can be used to block the opponent’s kick (with one hand) and to push the opponent off balance (with the other hand). After the explanations, seniors understood the rationale for each form and could visualize the movement. We also provided handouts explaining and illustrating the forms to reinforce to elders what we talked about during the class.
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We found that a combination of visual and verbal cues during the instruction made the learning more interesting. The instructor generally used a script consisting of “Pick up the baby, give it to the mom … open the window …,” which linked all the forms together. Recital of the script, a mental exercise, helped the elders to remember the sequence. By session 24, the majority of elders had learned the complete set of Tai Chi forms. They might still have difficulty remembering the exact sequence of the forms, but they could usually follow the instructor to practice the forms. Emphasizing the importance of practice—We emphasized to elders that the benefits of Tai Chi come from practice, not from merely learning individual forms. Thus, we encouraged the elders to practice at home. We emphasized to them that it did not matter if they could not remember the whole sequence of forms. They could select a few forms that they liked and practice them repeatedly, because regular practice would increase their level of physical activity and should help with their OA pain and discomfort.
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Strategies to promote participation
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Seated Tai Chi—There were occasions when an elder would come to the class but did not have the strength to stand up for Tai Chi practice. We usually encouraged the elder to take part in the practice in a seated position. Just coming to the class, elders had to leave their home/apartment and walk to the classroom, which gave them a certain level of physical activity. The elders could then practice the forms using the upper limbs, and thus could still get some benefits from the exercise. A seated position also helped to prevent elders from falling. Instruction in person—We found that it was difficult to learn Tai Chi by watching an instructional DVD. It was especially difficult for cognitively, hearing, and/or visually impaired elders. We thus mainly used face-to-face Tai Chi instruction. The attention and communication from the personal contact were also very important for these sedentary elders, and the relationship with the instructor/staff helped to retain elders in the program. Using soft music—Practicing Tai Chi with music was a pleasant “moving meditation” experience for elders. Although there is no “Tai Chi-specific” music, we found that quiet, soft music with Chinese instruments gave elders an exotic and soothing learning environment.
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Sharing current Tai Chi research—It has been reported that positive health outcomes resulting from Tai Chi can facilitate practice.26 The instructor or our participants often brought a clip of a newspaper report on the potential benefits of Tai Chi and shared that with others in the class. For example, a recent report from the New York Times indicated that a study in Hong Kong found that Tai Chi improved standing balance for people with stroke.27 The instructor then obtained the original research paper from the university library and led a brief discussion with the elders during the break period in a Tai Chi session. The participants found this type of discussion refreshing and became even more enthusiastic about practicing Tai Chi.
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Recording Tai Chi performance—We recorded each participant’s Tai Chi performance and evaluated the accuracy. A total of four recordings were made during the 20-week course. The participant would first watch the instructor performing the 12-form Sun-style Tai Chi twice. She/he would then perform Tai Chi by following the instructor’s performance and verbal cues while the RA made a video recording. We sent the tapes to an independent laboratory for coding28 and used the results to help us determine whether the accuracy of Tai Chi performance affected other outcomes. Although this was not the intended purpose, we noticed that the elders found it interesting to be videotaped. They tried hard to perform the Tai Chi forms well when the video camera was rolling. Thus, occasional videotaping can be used as a tool to encourage participation and learning. Social interactions—Practiced in a group setting, this program offered an opportunity for pleasant social interactions among the elders. As some of them had lost their family members, having a Tai Chi class to attend routinely helped them to establish social connections with others. They enjoyed and needed this human contact. Holding social parties—Small parties were held at mid-term and at the end of the course. These gave us opportunities to discuss various issues regarding the Tai Chi class in a relaxed environment. At the parties, elders also liked to tell us about small events they had experienced. We would remember and then ask them later about those events. The social interactions during regular class sessions and at small parties made participants feel that they were “comrades” in our program. In this regard, it should be noted that the elders loved to be Act Dir Q Alzheimers Other Dement Patients. Author manuscript; available in PMC 2014 March 31.
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called by their names in the party or in the class. They felt cared for when we called them by name.
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Sharing with their peer and families—We encouraged the elders to show their families what they had learned in our class. We even helped them to practice a Tai Chi pose (eg, the form “single whip”) in case their grandchildren wanted to take a picture of them. This was designed to let their families know what their loved ones were involved in and show that they enjoyed the Tai Chi class. At the end of the course, each person received a DVD that contained their group and personal Tai Chi practice during the course to serve as a souvenir for them and a talking point with their peers and family. Suggestions and praises—To avoid embarrassment to individual elders, as a general rule, we addressed our suggestions for correct Tai Chi moves to the whole class unless a question was raised by an individual. After a practice session, elders liked to be praised for their efforts. This made them feel rewarded, which is consistent with a study showing that encouragement facilitates practice of Tai Chi by elders.26
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In summary, in our Tai Chi study conducted in several senior residential facilities and senior activity centers, most participants were 70 to 90 years old with mild CI and OA knee pain. The Tai Chi program that we provided was suitable for these elders because it was gentle and could be tailored to each individual’s physical and cognitive condition. Tai Chi could be practiced in a standing or in a seated position, any time, in a small area. Tai Chi was practiced indoors, as it was not affected by the weather and was relatively safe. Using teaching strategies tailored to participant’s physical and cognitive frailty, we found that the elders were able to perform at the pace and for the length of time designed. The Tai Chi group not only provided physical activity but also cognitive stimulation and social interaction for the elders, all of which are extremely important for elders to experience “successful aging.”29
Acknowledgments This work was supported by the National Institute of Nursing Research (R21NR010003 to P.T.) and the Alzheimer’s Arkansas (to P.T.). This work was also supported in part by the National Institute of Nursing Research (P20NR009006 to C.B. and P.K.R.). The authors thank Ms. Elizabeth Tornquist for editorial assistance.
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