Parkinsonism and Related Disorders 14 (2008) 589e594 www.elsevier.

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Review

Effectiveness of tai chi for Parkinsons disease: A critical review

Myeong Soo Lee a,*, Paul Lam b, Edzard Ernst a
a

Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter, Devon EX2 4NT, UK b University of New South Wales, Sydney, NSW, Australia

Received 16 November 2007; received in revised form 28 January 2008; accepted 1 February 2008

Abstract The objective of this review is to assess the effectiveness of tai chi as a treatment option for Parkinsons disease (PD). We have searched the literature using 21 databases from their inceptions to January 2008, without language restrictions. We included all types of clinical studies regardless of their design. Their methodological quality was assessed using the modied Jadad score. Of the seven studies included, one randomised clinical trial (RCT) found tai chi to be superior to conventional exercise in terms of the Unied PD Rating Scale (UPDRS) and prevention of falls. Another RCT found no effects of tai chi on locomotor ability compared with qigong. The third RCT failed to show effects of tai chi on the UPDRS and the PD Questionnaires compared with wait list control. The remaining studies were either non-randomised (n 1) or uncontrolled clinical trials (n 3). Collectively these data show that RCTs of the tai chi for PD are feasible but scarce. Most investigations suffer from methodological aws such as inadequate study design, poor reporting of results, small sample size, and publication without appropriate peer review process. In conclusion, the evidence is insufcient to suggest tai chi is an effective intervention for PD. Further research is required to investigate whether there are specic benets of tai chi for people with PD, such as its potential effect on balance and on the frequency of falls. 2008 Elsevier Ltd. All rights reserved.
Keywords: Tai chi; Complementary medicine; Parkinsons disease

Contents 1. 2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Data extraction, quality, and validity assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Study quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 590 590 590 590 590 590 592 592 592 593

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4.

* Corresponding author. Tel.: 44 (0)1392 439035; fax: 44 (0)1392 427562. E-mail addresses: myeong.lee@pms.ac.uk, drmslee@gmail.com (M.S. Lee). 1353-8020/$ - see front matter 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.parkreldis.2008.02.003

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M.S. Lee et al. / Parkinsonism and Related Disorders 14 (2008) 589e594 Table 1 The list of databases searched in the course of this review Title Medline Allied and Complementary Medicine Database (AMED) British Nursing Index PsycInfo Cumulative Index to Nursing & Allied Health Literature (CINAHL) EMBASE Scopus The Cochrane Library 2007 (Issue 4) Korean Studies Information (Korea) DBPIA (Korea) Korea Institute of Science and Technology Information (Korea) Research Information Center for Health Database (Korea) KoreaMed (Korea) National Assembly Library (Korea) China Academic Journal (China) Century Journal Project (China) China Doctor/Master Dissertation Full Text DB (China) China Proceedings Conference Full Text DB (China) Qigong and Energy Medicine Database (Version 7.4, Qigong Institute) Electronic Japan Science (Japan) Japan Science and Technology Information Aggregator (Japan)

1. Introduction The prevalence of Parkinsons disease (PD) is 0.5e1.0% among people aged 65e69 years, and rises to 1e3% among those aged 80 years and over [1]. Treatment involves not only appropriate drug therapy but also counseling, allied health intervention and, commonly, management of cognitive and psychiatric comorbidity. The chronic and debilitating symptoms of PD mean that patients often turn to complementary medicine for their alleviation [2e4]. Exercise and physiotherapy is often recommended for managing PD and there is some evidence of their effectiveness [5e10]. Regular movement has a measurable effect on the signs and symptoms of the disease as well as on its progression [11e15]. It has been claimed that physical activity can help protect dopamine-producing cell from early death [11]. Exercise limits motor impairments and helps to maintain brain dopamine levels. The cessation of exercising makes symptoms reappear and leads to a decrease of dopamine levels [12,13,15]. Tai chi is a form of complementary medicine with similarities to aerobic exercise. It combines deep breathing and relaxation with slow and gentle movements [16]. It has been reported that tai chi has benecial effects in reducing high blood pressure, and improving balance, muscle strength and fall prevention [17e22]. Considering these effects, possible mechanisms of tai chi include balancing the neurotransmitter in the motor cortex-basal gangliaemotor cortex feedback loop and ameliorating PD symptoms by bypassing the faulty this circuit [23]. Others have postulated that tai chi might induce plastic changes in the central nervous system responsible for balance control [24]. Tai chi is supported by the National Parkinson Foundation of the United States and other related societies in Canada [25e 27]. It is claimed that tai chi improves balance control, exibility, and muscular strength, and reduces the risk of falls in the elderly [19,20]. It therefore seems pertinent to evaluate the effectiveness of tai chi on PD. The objective of this systematic review was to summarize and critically assess the evidence for the effectiveness of tai chi in treating PD.
2. Methods 2.1. Data sources
Twenty-one electronic databases were searched from their inceptions up to January 2008 (Table 1). The search phrase used was (tai chi OR taiji OR shadow boxing) AND Parkinson disease. We also manually searched our own departmental les and relevant journals (FACT [Focus on Alternative and Complementary Therapies], up to December 2007). Further, the references in all located articles and the proceedings of the First International Conference of Tai Chi for Health (held in December 2006, Seoul, South Korea) were manually searched for further relevant articles.

abstracts were included. Hard copies of all articles were obtained and read in full.

2.3. Data extraction, quality, and validity assessment

All articles were read by two independent reviewers (M.S.L. and P.L.), who extracted data from the articles according to predened criteria. The modied Jadad score [28,29] was calculated by assessing three criteria: description of randomisation, blinding, and withdrawals; with the score ranging from 0 to 5 points. Taking into account that it is impossible to blind patients and therapists to the use of tai chi, 1 point was given for blinding if the outcome assessor was blinded. Disagreements were resolved by discussion between the two reviewers (M.S.L. and P.L.), with the opinion of a third reviewer (E.E.) being sought if necessary. There was no disagreement between the two reviews about the Jadad scores.

3. Results Eleven articles were located, of which four were excluded for the reasons given in Table 2 [30e33]. The remaining seven studies comprised three randomised clinical trials (RCTs) [34e36], one non-randomised controlled clinical trial (CCT) [37], and three were uncontrolled clinical trials (UCTs) [38e 40]. Key data of the included studies are summarized in Table 3.
Table 2 Reports of excluded studies of tai chi for Parkinsons disease Author (year) Reason for exclusion Case series (n 2) Case series (n 2) Case series (n 4) Uncontrolled-qualitative study Direction of main outcome Positive Positive Neutral Positive

2.2. Study selection

All prospective clinical studies related to the effects of tai chi on PD were included. Trials in which tai chi formed part of a complex intervention were also included. No language restrictions were imposed. Dissertations and

Venglar (2005) [30] Kluding (2006) [31] MacLaggan (2000) [32] Klein (2006) [33]

Table 3 Summary of clinical studies of tai chi for Parkinsons disease First author (year) [ref] Design, sample size, quality score,a Hoehn and Yarh stages (range or mean, SD) RCT (parallel), 30, 2 (1 0 0 1 0), 1.5e3 Intervention (regimen) Control intervention (regimen) Main outcome measures Main results Authors conclusion

Marjama-Lyons (2002) [34]b

Tai chi (60 min, 2 times weekly for 12 weeks, n n.r.)

Their baseline exercise (no additional new exercise, n n.r.)

(1) (2) (3) (4)

UPDRS Fall frequency Limits of stability Global Assessment of Change Gait velocity Stride length % Stance % Double limb support Step duration

(1) P 0.026 (intergroup difference) (2) P 0.009 (intergroup difference) (3) NS (intergroup difference) (4) NS (intergroup difference) (1)e(5) NS

Tai chi is associated with improved motor function and a reduced frequency of falling in PD and should be considered for use in PD [.]

Hass (2006) [35]b RCT (parallel), 23, 1 (1 0 0 0 0), 2.2, SD 0.4

Tai chi (60 min, 2 times weekly for 16 weeks, n n.r.)

Qigong (60 min, 2 times weekly for 16 weeks, n n.r.)

(1) (2) (3) (4) (5)

[.] 16 weeks of tai chi training is not effective for inducing improved locomotor ability in patients with PD [.] Tai chi is [.] has no measurable effect on motor performance as measured by UPDRS, or TUG. [.] overall well-being appears unchanged, [.]. [.] tai chi improved physical and mental health [.] for the patients with PD

M.S. Lee et al. / Parkinsonism and Related Disorders 14 (2008) 589e594

Purchas and MacMahon (2007) [36]b

RCT (crossover), 20, 2 (1 0 1 0 0) n.r.

Tai chi (60 min, n.r. for 12 Wait list (n 10) weeks, n 10)

(1) UPDRS (2) PDQ39 (3) TUG

(1)e(3) NS

Cheon (2006) [37]b

CCT, 16, 0 (0 0 0 0 0) 2e3

Tai chi (60e80 min, 3 (A) Combined exercise times weekly for 8 weeks, program (dancing, n 9) waking and elastic band exercise, 60e 80 min, 3 times weekly for 8 weeks n 7) (B) No treatment (n 7) Tai chi (n.r., n.r., 10 weeks, n 17) N/A

(1) (2) (3) (4) (5)

UPDRS SEADL Functional tness Depression (BDI) QoL (De Boers PDQoL)

(1) Tai chi vs B, P < 0.05 (2) Tai chi vs B, P < 0.05 (3) Tai chi or (A) vs. (B), strength or exibility, P < 0.05 (4) NS (5) Tai chi or (A) vs. (B), P < 0.05

Welsh (1997) [38]b

UCT, 17, 1 (0 0 1 0 0) n.r.

(1) PD QoL (2) Depression (BDI)

(1) NS [.] tai chi may have promise as an (2) Improved (not reported the adjunctive strategy for improving statistical values) depression and overall quality of life in individuals with PD. (1) P 0.002 (2) P 0.01 (3) P 0.01 (1) (2) (3) (4) (5) NS P < 0.05 P < 0.01 NS NS except emotional functioning (P < 0.05) [.] tai chi is an appropriate physical activity for older adults with PD [.] Tai chi chuan exercise shows a signicant improvement in [.] agility/ dynamic balance, aerobic endurance and emotional functioning of quality of life [.]

Li (2007) [39]

UCT, 17, Tai chi (90 min, 5 N/A 1 (0 0 1 0 0) 1e3 consecutive days, n 17) UCT, 7, 1 (0 0 1 0 0), 2.5, SD 0.3 Tai chi (45e60 min, 3 N/A times weekly for 8 weeks, n 7)

(1) 50-ft speed walk (2) TUG (3) Functional reach (1) (2) (3) (4) (5) UPDRS 6-min walk TUG Depression (BDI) QoL (PD QoL)

Sung (2006) [40]

n.r.: not reported; UPDRS: Unied Parkinsons Disease Rating Scale; SEADL: Schwab and England Activity of Daily Living; PD: Parkinsons disease; QoL: quality of life; BDI: Beck Depression Inventory; TUG: timed up and go; N/A: not available; NS: no statistical signicance. a Quality score: modied Jadad score (randomisation 1 point appropriate randomisation method 1 point describing withdrawals and dropouts 1 point assessor blinding 1 point patient blinding 1 point), maximum 5 points. b Published as abstract or proceeding.

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3.1. Study quality Of the three included RCTs, one RCT [34] was given 2 points for the use of randomisation and assessor blinding, one RCT [35] was given 1 point for the use of randomisation, and the third RCT [36] was given 2 points for the use of randomisation and for reporting dropouts and withdrawals. All UCTs scored 1 point since they reported withdrawals and dropouts [38e40], while the CCT scored 0 points since it failed to do so [37]. Only one trial [35] described details on allocation concealment. 3.2. Outcomes Marjama-Lyons et al. [34] investigated the effect of tai chi on motor function and falling in PD patients. Patients were randomised into two groups: one receiving tai chi and the other receiving baseline exercise. After 12 weeks, the score on the Unied PD Rating Scale (UPDRS) and the fall frequency were signicantly better in the tai chi group than in the control group, but there were no differences in the limit of stability and Global Assessment of Change. Hass et al. [35] assessed the effectiveness of tai chi on locomotor ability in 23 PD patients. Participants were randomised into two groups: one receiving tai chi and the other receiving qigong meditation. At the end of treatment period, the locomotor ability e including gait velocity and stride length e did not differ between the groups. Purchas and MacMahon [36] investigated the effect of tai chi on UPDRS, Parkinson Disease Questionnaires 39 (PDQ39), and timed up and go (TUG). Patients were randomised into two groups: one receiving tai chi and the other comprising wait list controls with a crossover design. After 12 weeks, there were no signicant intergroup differences in the UPDRS, PDQ39, or TUG. Cheon et al. [37] tested the effects of tai chi on PD. Participants were nonrandomly allocated into three parallel groups: tai chi, combined exercise program, or no treatment. After 8 weeks, the UPDRS, Schwab and England Activity of Daily Living, and quality of life scores were higher for tai chi than for no exercise, but there were no differences between tai chi and the combined exercise program. The three UCTs included in the present study assessed the effects of tai chi on PD. One trial showed that tai chi had positive effects on depression (although the detailed statistical data were not reported) but no effects on the quality of life [38]. Another UCT found that tai chi improved a 50-ft speed walk, TUG, and functional reach [39]. The third UCT showed that tai chi improved a 6-min walk and TUG, but had no effects on depression, quality of life, or UPDRS [40]. 4. Discussion Perhaps the most important nding of this systematic review is that there have been very few rigorous trials of the effects of tai chi on PD. This is surprising given that tai chi is an

ofcially recommended method for treating the symptoms of PD. Most of the studies reviewed here were burdened with serious methodological aws. Of the seven studies analyzed in this review, ve studies (three RCTs [34e36], one CCT [37], and one UCT [38]) were published only as abstracts, and hence they had not been formally peer reviewed (and they also lacked essential details). Furthermore, one RCT [35] compared tai chi to qigong without including an adequate control group (e.g., placebo) or demonstrating the effectiveness of the treatment. Three of the seven studies in this review were UCTs [38e 40], which are open to bias that often leads to false-positive results. One reason for using tai chi for treating PD is that it is claimed to be effective at improving exibility and balance as well as reducing the frequency of falls [19,20]. Clearly these claims need to be tested in parkinsonian populations. One RCT [34] suggested that the fall frequency was lower for tai chi than for a baseline exercise control. However, another RCT [35] found that tai chi had no effect on locomotor ability, and another RCT [36] found that motor performance did not differ between tai chi and no treatment. One CCT [17] found that the symptoms of PD were signicantly improved by tai chi compared to control, but not compared to a combined exercise program. These results could merely reect the presence of nonspecic effects. The UCTs [38e40] suggested that tai chi improved functional tness but not UPDRS score or depression. Unfortunately, such data are highly susceptible to bias, and hence they provide little useful information on the value of tai chi as a therapeutic intervention for PD. Assuming that tai chi was benecial for treating PD, possible mechanisms of action may be of interest. These include normalizing neurotransmitter levels such as dopamine [32]. Others have postulated that regular tai chi improves balance and reduce the likelihood of falls by improving muscle exibility and trunk rotation [32]. Furthermore, tai chi may help promoting attentional resources in the basal gangalia by its meditative effects altering the recticular formation output [32]. Daily repetitive practice of tai chi may also promote development of new neural pathways, new motor programs, allow faster reactions when responding to postural challenges [32]. Future RCTs of tai chi for PD should adhere to accepted standards of trial methodology. In particular, trials should have sufciently large samples, ideally based on formal power calculations which, in turn, should be based on data from appropriate pilot studies. They should be long-term with sufcient treatment frequency, describe all aspects of their methodology in full detail to ensure reproducibility, use validated primary outcome measures, and employ adequate statistical tests. Outcome measures should include functional benet, quality of life, potential effects on balance and frequency of falls. The number of participants who withdrew from the study and their reason for doing so must be reported. Even if future research proves tai chi to be therapeutically valuable one would require further evidence on whether it has signicant advantages over conventional physical exercise.

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A clinical study is only truly useful if the intervention used can be replicated, and hence the type of tai chi employed is important. There are signicant differences between the numerous forms of tai chi, and so a clear description of the tai chi intervention should be provided together with a description of the level of expertise of the instructors. Limitations of our systematic review (and indeed systematic reviews in general) pertain to the potential incompleteness of the evidence reviewed. We aimed to identify all studies on the topic. The distorting effects of publication bias and location bias on systematic reviews and meta-analyses are well documented [41e44]. In the present review there were no restrictions on the review publication language, and a large number of different databases were searched. We are therefore condent that our search strategy located all relevant data on the subject. Further limitations include the paucity and the often suboptimal quality of the primary data. However, it should be noted that design features such as using placebos and blinding are difcult to incorporate in studies of tai chi, and that research funds for tai chi are scarce. These are factors that evidently inuence both the quality and quantity of research. In conclusion, the evidence is insufcient to suggest tai chi is an effective modality for treating PD. Further research is required to investigate whether there are specic benets of tai chi for people with PD, such as its potential effect on balance and on the frequency of falls. References
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