Balance for Life
Just when we knew where the floor was….. They moved it….
Tai Chi for falls prevention and rehabilitation
This subject has had a long and controversial history as it has been applied in broad brush strokes rather than targeting frail and pre-frail people as two significant groups. The most well known and quoted study is the Wolf study (1) which states general exercise reduce risks of falls by 10%. Specialised training reduces risks by 25%. Tai Chi reduces risks of falls by 47%(1)
The reason for writing this article is to discuss the research and my personal findings as a Tai Chi teacher working within health authorities and regular classes open to the general public. Through my company Balanced Approach, I have been presenting workshops for Physiotherapists, Occupational Therapists, Extend Teachers, PSI’s and care workers. This training has been organised by the PCT’s and Sports Councils.
My regular classes for the general public include people who have various interests from relaxation and gentle exercise, to a less aggressive martial art and spiritual development; we also get a number of referrals from GP’s and hospitals which can consist of patients with COPD, cardiac conditions, strokes, sports injuries etc.
We have people suffering from CFS (ME), MS, Parkinson’s; rheumatoid and osteoarthritis, people who are fully mobile, wheel-chair bound and everything in between. This mix gives a very good insight into Tai Chi’s effectiveness.
Some falls facts (taken from help the aged website)
· Falls make up over half of the admissions to A&E
· 14,000 died from fractures
· 50% fall again
· hip fractures cost NHS £1.7 billion
· after a fracture 50% no longer live independently
· over a third of people of 65 years fall each year
· General exercise reduce risks of falls by 10%. Specialised training reduces risks by 25%. Tai Chi reduces risks of falls by 47% (1)
How Tai Chi works – Therapeutic elements
- Continuous steady movement – performed slowly with awareness
- Small and large degrees of movement
- knee flexion and weight shifting
- straight and extended head and trunk – suspended from above. Do not watch the floor
- combined/coordinated rotational movement of head, trunk and extremities. Rotational movement builds greater stability than linear movement alone.
- centred movement – asymmetrical arm and leg movement about the waist.
- unilateral weight bearing and constant shifting
- improved circulation, suppleness and flexibility
- increased sense of connection to the ground
- checking/sensing the ground before moving into it
- strengthens muscles and balances tendons and ligaments
- abdominal breathing increases oxygenisation and relaxation
- increased special awareness – mind/body balance and connection
The Origins of Tai Chi
There are many different stories concerning its origins and creation. The most popular legend, which has little factual substantiation, is that of Zhang San Feng, a Daoist who, already having mastered Shaolin boxing, caught sight of a crane fighting a snake. Intrigued by the yielding, smooth evasion and darting counter-attacks of both creatures, he was inspired to develop a form of boxing, which would embody the natural philosophy of the Dao. Legend aside, in the middle of the eighteenth century a soft boxing was being taught in the village of Chenjiakou, in Henan province. This soft boxing was finally popularised by Yang Luchan (1780 - 1873), who, through diligent effort, learnt the Chen family boxing, and then went to Beijing, where he taught the art, in a modified form to the Manchu court. This YANGschool of boxing was destined to become the most popular form of Taijiquan (Tai Chi Ch’uan), with the help of Yang Cheng Fu (1883-1936), the most widely known descendent of Yang Luchan. It is characterised by large, smooth, flowing movements with an unbroken even tempo, avoiding strenuous over-exertion. Tai Chi became more accessible when Cheng Man-Ching(2) (1902-1975) a senior student of Yang Cheng Fu went to America from Taiwan and taught openly to all who were interested.
What is Tai Chi
Tai Chi is a sophisticated form of whole body Neuromuscular/skeletal movement re-education. With good use, the body moves easily - with balance and coordination; both mental and physical. Initially developed as a martial art, it has now become more widely practiced as an exercise for health and well-being. Its use of natural rotational, as well as linear movements, have placed this well above other falls training methods. Researchers attributed the dramatic improvement in balance to the fact that in the Tai Chi “form” participants continually used body rotational movements on a progressively diminishing base of support. Static balance exercises do not seem to improve balance in later life.
Fractures are more to do with function than falling(4)
Some hip fractures occur as a result of a direct injury when the patient hits the ground, but a high proportion occur as a result of stresses and strains set up by a sudden twisting when people are aged and suffer from osteoporosis. One textbook goes as far as to suggest that the majority of fractures of a brittle hip follow rotational forces induced by a stumble or a fall, and not from a direct injury as the patient hits the ground.
Dying from the feet up
Some cultures believe we die from the feet up and that our legs are your second heart. A physiological explanation for this would be that the constant weight changing during your Tai Chi practice generates a pumping action that improves circulation, lymph drainage and assists the heart. A psychological example might be that when you become immobile, you lose your zest for life.
Why do children and the elderly over-balance?
Have you ever stopped and watched either? Children have two main reasons, one which applies when very young: When born the head is larger than the body to aid delivery and the body takes a time to catch up therefore making a child initially top heavy which allows them to easily be outside their field of balance. Secondly, and this one applied to the elderly or those recovering from strokes etc. as well -THEY OFTEN DON’T LOOK OR FEEL WHERE THEY ARE GOING. After watching many elderly frail with walking-frames, literally bulldozing their way through rooms, tripping over carpets, snagging themselves on chairs, banging into other people.
I feel that this a representation of their need to be independent, not ask for help, show that they can still manage alone. This stalwart trait is very understandable, but can leave them at great risk of unsure footing, loss of balance and ultimately falls.
Another aspects is how we walk; we fall forward and hope our legs keep up unhindered. This is equivalent to dropping a plate full of dinner then pushing a table underneath to catch it, hoping it will get there in time. In Tai Chi we learn to not commit body weight until we know the leg is definitely their first; this way we avoid trips and develop a strong stable base. Research in to planter pressure during Tai Chi practice(6) highlights the effects of tai chi’s approach to positioning and function. A natural bi-product of Tai Chi movement is strengthening of the vastus medialis obliquus (VMO). The VMO muscle is not effectively used during normal walking or running; in fact runners quite often suffer from knee pain due to weakness of the VMO. Research comparing normal walking with Tai Chi(7) showed a greater degree of muscle activation.
Children breathe with the abdomen before they are taught to ‘hold in their stomach and stand tall’. We later learn that breathing with our chest alone reduces the depth of the breath thereby increasing the need for more breaths. Consider how you feel when anxious or tight chested if you have asthma you will easily see the detrimental effect chest breathing has. By breathing with your abdomen your will draw down your diaphragm and learn to use more of your lung capacity. This improves oxygenisation to the blood, calms the mind/body and lowers the centre of gravity.
Function of Dorsiflexors and heal strike
The dorsiflexors are what allow you to work your car pedals or tap your foot to music. When they weaken it becomes hard to lift your foot without the toes dropping. This causes the foot to drag when walking and increases the risk of falls. Tai Chi teaches you to place your heel down first and to clearly define your steps. Poor definition is classified as poor heel strike and gives the impression the person is attempting to climb stairs as they lift their leg higher than would normally be necessary. The heel/toe exercise is designed to help but eventually the use of high ankle supportive footwear or ankle bracing may be needed. A bi-product of this is that the calf muscles shorten due to imbalance of use, which leads to the person leaning forwards and thereby increasing the risk of imbalance due to over-toppling..
One of the clear benefits of Tai Chi is improved spatial awareness (Kinaesthetic awareness). The steady, clearly defined movements, the walking exercises and concept of ‘aligning with gravity’, all add to an improved awareness of being. Exercises are designed to increase awareness of your range of balance and the need to move within that range. You learn to listen to your body and appreciate/understand what affects your balance. You learn to be aware of the ground beneath your feet…..
Learn to do less and understand body connection
A key phrase I use in my own classes is ‘learn to do less’. We think we need to do much more than we actually do to achieve the result we want. Consider your car: when driven hard it burns more fuel wares out sooner and doesn’t necessarily get you there any sooner; your body is no different. Through correct body connection you will move more efficiently, generate a greater result from less effort and have more energy to spare for when it is really needed. When you get up in the morning, you start with a certain amount of energy (2 slices of toast) and as you go through the day this is used up. Would it not be wonderful if by the end of the working day you had some energy left for yourself? Segmenting the body as we move causes a great deal of wastage and strain, so look how the body is constructed and feel the connections: hips to shoulders, knees to elbows, hands to feet. When you are weighted in your front leg is you ankle, knee and hip aligned? Is your shoulder aligned with your hip? Can you feel your weight falling through your body easily and uninterrupted? Does your whole foot feel connected to and pressing the ground?
Fallen arches, diminishing nerve response, nerve damage from stroke and ensuing numbness etc all affect your feeling of connection, but slow steady practice will improve your awareness and understanding of body balance. This is proprioceptive feedback in action
Why stand when we can sit and rest…?
Sitting allows muscles to rest but can, in time also weaken them. Sitting exercises are acceptable for those who cannot stand, but are not meant to replace standing practice. Sitting does not work the specific muscles and ligaments that control your balance. Sitting can diminish your feeling of connection to the ground. These types of exercises can be taken as part of a whole program but shouldlead to standing and moving practice where possible. In turn static standing exercises do not work your range of balance. Tai Chi’s rotational movements working on single weighted stances increase your range of balance.
The importance of correctly sitting and standing
Have you ever stood up quickly and gone light headed? A sudden drop in your blood pressure, which affects your balance centres, causes this. Now if you were already weakened from old age, poor blood pressure, stroke, illness etc, can you see how easy it would be to fall and possibly injure yourself? It is essential that correct methods of standing and sitting be taught. These should be steady and use each joint in a scissor action to ensure correct body movement is considered. By leaning too far forwards when standing or sitting, it is easy to topple forwards and over balance; by leaning too far back it is easy to fall into or over the chair and land with a thud which can jar and cause quite serious damage. Alexander technique(3) says “stand from the top up and sit from the bottom down”. This ensures correct use of the spine.
The key to everything in Tai Chi can be summed up in the concept of living in the here and now, of being aware and paying attention to the moment. It is in the attention to detail, of listening to our bodies, that we develop a greater understanding.
The mental aspects of falls
As Tai Chi is a holistic system i.e. it treats mind and body as an integrated system, we learn to not only see what we do but FEEL it. Tai Chi is often referred to as meditation in movement. A high percentage of falls occur because people believe they are becoming frail and therefore the fall is inevitable. I also train people in NLP(5) and frequently discuss ‘self-talk’ and how we can convince ourselves of anything. Practicing a system of exercise that is not age limiting and includes a relaxed positive mental image is a must. This is where Tai Chi comes in to its own….. As well as learning to balance physically, students learn to balance mentally. As you can see from the figures at the beginning of this article, 50% of fallers fall again; this is due to a combination of weakness and attitude. We think of phobias such as spiders, needles, heights etc but tend to forget that the fear of falling is also a phobia that can grow out of proportion and become life limiting. Our aim should be to reframe peoples thinking and help them relax and gain confidence again. If taught correctly, Tai Chi will do this, but the development of NLP has made the process much quicker. I personally use Tai Chi as the core of the rehab/prevention program but also include aspects of Alexander Technique, NLP and hypnotherapy. The more tools in the toolbox the greater our options.
Why is Tai Chi so appealing to the medical field
There are many forms of exercise and rehabilitation but as far as I am aware Tai Chi is the only one with no contra-indications. It has been used for the best part of 20 years in UK hospitals for cardiac rehab solely because of this fact. There is extensive research into the beneficial effects of Tai Chi for: Cancer patients, Parkinson’s, knee osteoarthritis, sympathetic nervous system activity, fibromyalgia, cardiac conditions, COPD, plus further research still underway into its effects on depression, ADD, ME(CFS) and much much more. Jed Rowe (retired Senior Geriatrician for South Birmingham PCT) once said to me that we would need to develop an urbanised version of Tai Chi to increase its accessibility to the general public. I prefer to believe that if articles like this are published, plus the high visibility of Tai Chi on TV and the press keeps increasing, eventually it will be as ‘everyday’ as a walk in the park.
As the medical profession continues to accept it as a low cost effective alternative to drugs and complicated rehab systems, the awareness of the general public will increase also. There are already PCT’s around the country that offer Tai Chi on prescription; it can actually be safer than regular gym work that is already currently available on prescription and again is not age limiting.
Please note – not all Tai Chi teachers understand or have an interest in the positive benefits of Tai Chi as a method of falls prevention training; A few around the country, like myself, have chosen to research more deeply and develop a specific understanding and approach. If you would like to discuss Tai Chi and NLP in more detail, please contact Mark Peters at Balanced Approach via the website www.balancedapproach.co.uk or call 0121 251 6172
- Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T: Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques.
J Am Geriatr Soc 1996, 44:489-497
- Cheng Man-Ching moved to Taiwan in 1949 and established a career as a traditional Chinese medicine physician and teacher of his new T'ai Chi Ch'uan form, as well as practicing painting, poetry, and calligraphy. He published Cheng's 13 Chapters of Taiji Boxing in 1950 which has been translated into English two different times. He started the Shih Chung T'ai Chi Association in Taipei, He served as one of the painting teachers of Soong Mei-ling, Madame Chiang Kai-shek, whom he taught to paint lotuses; and as personal physician to Chiang Ka-shek in Taiwan and perhaps earlier. He and his family moved to the US in 1964
- The Alexander Technique was first developed in the 1890s by an Australian named Frederick Matthias Alexander. It is a system for effectively understanding muscular-skeletal function and alignment.
- Dr Thomas Stuttaford in The Times on 29th January 1998 following Queen Elisabeth the Queen Mother’s fall and hip fracture.
- What is NLP: Neuro-Linguistic Programming (NLP) studies the structure of how humans think and experience the world. From this we can create the opportunity for change. The map is not the territory is an excellent example; you map (or how you see something) is not the same as another persons map of any given thing. For more details see http://www.balancedapproach.co.uk/nlp_benefits.htm
- Plantar pressure distribution during Tai Chi exercise. Arch Phys Med Rehabil. 2006 Jun;87(6):814-20. Department of Sports Science and Physical Education, Chinese University of Hong Kong, Shatin, NT, Hong Kong.
- Muscle activation profiles about the knee during Tai-Chi stepping movement compared to the normal gait step. J Electromyogr Kinesiol. 2006 May 22. Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA.
The key to everything in Tai Chi can be summed up in the Zen concept of living in the here and now, of being aware and paying attention to the moment. It is in the attention to detail, of listening to our bodies. This helps us to help others and keep us all on the road to recovery.