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Impact of Tai Chi Exercise on Balance Disorders: A Systematic Review

Article  in  American Journal of Audiology · May 2019

DOI: 10.1044/2018_AJA-18-0115

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 AJA
Review Article
Impact of Tai Chi Exercise on Balance
Disorders: A Systematic Review
Hsin-Wei Huang,a Nannette Nicholson,b and Sheila Thomasc
Purpose: Tai chi is receiving increasing research attention with
its benefit of improving flexibility and balance. The objective
of this review was to examine the evidence concerning the
impact of tai chi as a practical therapy for vestibular rehabilitation
on individuals with balance and vestibular disorders.
Method: A systematic review using 4 electronic databases
was conducted. Randomized clinical trials and quasi-
experimental studies were included.
P
eople with vestibular problems often experience
dizziness and trouble with balance, vision, or mo-
bility. Vestibular disorders are associated with dys-
function and deficit, unilateral or bilateral, in peripheral
(outside the brain; part of the inner ear) and/or central system
(McDonnell & Hillier, 2015). Examples of these disorders
include benign paroxysmal positional vertigo, vestibular
neuritis, labyrinthitis, Ménière’s disease, and acoustic neuroma/
vestibular schwannoma. Benign paroxysmal positional ver-
tigo, for instance, a sudden vertigo induced by a change
in head position (Hornibrook, 2011), is the most common
disorder of the vestibular system in the inner ear that in-
creases in prevalence with age (Lawson, Johnson, Bamiou,
& Newton, 2005). Patients who undergo canalith reposi-
tioning maneuvers may show dizziness, insufficient postural
stability control, and increased risk of falls (Bressi et al.,
2017; Di Girolamo et al., 1998). Moreover, vertiginous symp-
toms are often accompanied by elevated levels of anxiety and
emotional disturbance (Jacob, 1988). Dizziness is one of the
most common complaints among older adults (Furman, Raz,
& Whitney, 2010; Hanley, O’Dowd, & Considine, 2001).
a
Department of Audiology and Speech Pathology, University of
Arkansas for Medical Sciences/University of Arkansas at Little Rock
b
Department of Audiology, Nova Southeastern University,
Fort Lauderdale, FL
c
Department of Library Education and Reference Services, University
of Arkansas for Medical Sciences, Little Rock
Correspondence to Hsin-Wei Huang: hhuang2@uams.edu
Editor-in-Chief: Sumitrajit Dhar
Received July 13, 2018
Revision received December 3, 2018
Accepted December 10, 2018
https://doi.org/10.1044/2018_AJA-18-0115
American Journal of Audiology • 1–14 • Copyright © 2019 American Speech-Language-Hearing Association
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Results: Four studies met the inclusion criteria and were
included for data analysis. Results indicate positive effect
of tai chi practice on dynamic postural stability in balance
of its practitioners.
Conclusion: Tai chi may be a useful therapy as for vestibular
rehabilitation as it improves dynamic balance control
and flexibility of individuals with balance and vestibular
disorders.
Balance depends on proper function of vestibular, visual,
and somatosensory systems, as well as other factors: muscle
strength, joint mobility, and cognition (Ganança, 2015).
Balance impairment has a significant impact on health-
related quality of life of patients, especially on their emo-
tional and physical status (Gámiz & Lopez-Escamez, 2004;
Jacob, 1988; Lopez-Escamez, Gamiz, Fernandez-Perez,
Gomez-Fiñana, & Sanchez-Canet, 2003).
Falls are reportedly the leading cause of physical and
psychological trauma in population of age 65 years and
older (Centers for Disease Control and Prevention [CDC],
2006). The risk of falls not only increases with age but is
also linked with balance and vestibular dysfunction, which
has raised public health concerns (Scuffham, Chaplin, &
Legood, 2003). A number of researchers proposed that
balance control ability and flexibility are associated with
falls, especially in the elderly population (Chiacchiero,
Dresely, Silva, DeLosReyes, & Vorik, 2010; Li et al., 2016;
Tse & Bailey, 1992). Participation in balance or muscle-
strengthening exercises can reduce the fall rate of this pop-
ulation (CDC, 2006; Li et al., 2016; Tse & Bailey, 1992).
Tai chi, originally practiced as a martial art form by
the ancient Chinese (tai chi chuan), is an exercise derived
from the martial art form consisting of slow, continuous,
fluid movements for total self-development (Chang et al.,
2011; Kuramoto, 2006). Physically, it is a gentle exercise
appropriate for older adults; mentally, it is a study of con-
centration; spiritually, it is a practice of meditation (Galante,
1981). Tai chi is also a preventive and curative branch in
Chinese medicine (Kuramoto, 2006). Tai chi facilitates a
number of health benefits, which include balance control,
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
1
flexibility, blood pressure reduction, cardiovascular fitness,
pain reduction, and mood and self-esteem improvement
(Blake & Batson, 2009; Kuramoto, 2006; Lauche et al., 2016;
Sun et al., 2016; Wolf, Coogler, & Xu, 1997; Yeh, Wang,
Wayne, & Phillips, 2008).
Tai chi is receiving increasing research attention,
mainly because many studies have shown already that tai
chi is beneficial for improving flexibility and balance (Li
et al., 2005; Nguyen, Taw, & Wang, 2013; Tsang, Wong,
Fu, & Hui-Chan, 2004; Tse & Bailey, 1992; Wayne et al.,
2004; Wu, 2002; Zwick, Rochelle, Choksi, & Domowicz,
2000). Western science has recently been giving attention
to tai chi’s benefits as a form of preventive and rehabilita-
tive therapy, whereas the overall effectiveness has been well
documented in Chinese scientific literature. Tse and Bailey
(1992) conducted the first research in the West to evaluate
the influence that tai chi training has on postural control in
which they studied on the Chinese community of the greater
Boston area. They reported that tai chi practitioners per-
formed better on postural control tests than nonpractitioners,
suggesting a positive link between tai chi and postural con-
trol. In addition, they suggested that the performance could
have been affected by many other variables such as envi-
ronmental factors, activity history, interests, and occupa-
tion. Zeeuwe et al. (2006) designed the first randomized
clinical trial in Europe that examines tai chi chuan and fall
prevention. They evaluated the effect of tai chi chuan on
fall prevention and physical and psychological functions in
older Dutch adults. However, further information regarding
the efficacy of tai chi chuan and fall reduction is warranted.
Chan and Bartlett (2000) evaluated the methodological
rigor and conducted a meta-analysis using seven studies
published between 1992 and 1998. They concluded that
the research evidence supporting the practice of tai chi as
a way to improve balance and postural control is of moder-
ate quality. Furthermore, they noted that movements
within tai chi mimic the actions of daily life and that tai
chi helps to develop body awareness, knowledge of one’s
body in its surroundings, and body reaction to movement.
They proposed further investigation to determine the value
of tai chi in promoting health and wellness.
Tai chi as therapy has been studied in populations
such as traumatic head injury (Blake & Batson, 2009), chronic
neck pain (Lauche et al., 2016), fall prevention (Liu &
Frank, 2010; Logghe et al., 2010), and chronic medical
conditions (Wang, Collet, & Lau, 2004). Moreover, tai chi
has been utilized as a rehabilitative technique for stroke
patients (Au-Yeung, Hui-Chan, & Tang, 2009; Taylor-Piliae
et al., 2014), Parkinson’s disease (Hackney & Earhart, 2008;
Li et al., 2012, 2014), and arthritis (Fransen, Nairn,
Winstanley, Lam, & Edmonds, 2007; Song, Lee, Lam,
& Bae, 2003). Although tai chi is believed to have physi-
ological and psychological benefits, improving quality of
life (Wang et al., 2004), it is not widely recognized as an
intervention option for balance and vestibular disorders.
The purpose of this systematic review was to examine the
evidence regarding the potential use of tai chi as a practical
therapy for vestibular rehabilitation on individuals with
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balance and vestibular disorders. This review further
explores the benefits of practicing tai chi to improve mobil-
ity and balance, thereby reducing the risk of falls and
injuries.
Method
This systematic review was conducted at the Univer-
sity of Arkansas for Medical Sciences, with approval of
the institutional review board (Protocol 206614). This sys-
tematic review was conducted following guidelines pro-
vided in the Cochrane Handbook for Systematic Reviews
of Interventions (Higgins & Green, 2011). Search terms
were generated using the PICO framework first suggested
by Counsell in 1997. Counsell (1997) identified four impor-
tant components of a well-focused clinic question where
P stands for population, I stands for intervention/exposure,
C stands for comparison, and O stands for outcome mea-
sure. These components are used to generate search terms
and strategies for electronic databases (see Table 1). Specif-
ically, we wanted to know if individuals with balance or
vestibular disorders benefited from tai chi (with or without
a comparison group) according to clinical and/or behav-
ioral measures of dynamic balance and stability. Use of
the PICO terms facilitated the development of a systematic
search strategy used in relevant and available electronic
databases (see Appendix A).
A standard reporting tool recognized by most profes-
sions was used to illustrate the flow of activities during
the publication identification and selection process. This
tool is known as the Preferred Reporting Items for Sys-
tematic Reviews and Meta-Analysis (PRISMA; Moher,
Liberati, Tetzlaff, Altman, & Prisma Group, 2009). The
PRISMA depicts the total number of publications identi-
fied, the number of duplications, the number eliminated
during the screening process based on exclusion criteria,
the number included in the full-text critical appraisal, and
the number of publications included in the study.
The Joanna Briggs Institute (JBI) checklists were
used to screen studies for methodological rigor to deter-
mine quality for inclusion in our systematic review (Pearson,
Wiechula, Court, & Lockwood, 2005). The JBI checklists
have been developed individually for a wide variety of
study types (e.g., cohort, case control, quasi-experimental)
and are available on their website (JBI, n.d.).
The Grading of Recommendations, Assessment,
Development, and Evaluation (GRADE) scoring system
of four categories (Guyatt et al., 2008) was used for the
critical appraisal and rating of study strength and quality.
Although the GRADE was designed by Guyatt et al. in
2008, Goldet and Howick (2013) later developed a simpli-
fied approach regarding how to best use this instrument to
ascertain study strength and quality.
Data Sources
Publications were identified from the following Univer-
sity of Arkansas for Medical Sciences electronic databases:
Table 1. PICO framework.

PICO Description of detail

Participant (P) All patients of both sexes and all age groups with balance and vestibular disorders
Intervention (I) Use of tai chi as a practical therapy for vestibular rehabilitation on individuals with balance and vestibular
disorders
All styles of tai chi trainings were considered regardless of their forms, modifications (traditional or simplified),
and numbers of movements
Comparison (C) Following control groups were considered: patients who
(a) received no intervention
(b) conventional vestibular trainings
(c) rehabilitation including education, awareness, stress reduction, and exercises
Outcome (O) Clinical and/or behavioral measures to assess body and dynamic balance, dynamic gait function, neuromuscular
function, and trunk stability
Secondary outcome measures such as subjective evaluation of the symptom severity, relief of symptoms in
dizziness, level of confidence, and the impact of vestibular disorders in activities of daily living

Note. Adapted from Counsell (1997).

PubMed, CINAHL, PsycINFO, and Web of Science on
December 8, 2016, by an author with expertise in the devel-
opment of systematic search strategies (S. T.). Additional
publications were identified from the Google Scholar data-
base on January 31, 2017. Publication references were also
reviewed for potential study inclusion. Irrelevant publica-
tions were excluded by scanning their titles and abstracts.
Two sets of search terms were used in each database. Terms
related to tai chi such as tai chi or taiji were searched and
coupled with search terms related to balance and vestibular
disorders such as vertigo or dizziness or falls. Date limits
were not applied. The search terms and search strategy are
shown in Appendix A.
Inclusion/Exclusion Criteria
A priori inclusion criteria were extended from the
PICO question and organized by study design, type of
intervention, and outcome measures used. Inclusion was
limited to high-quality studies meeting strong methodologi-
cal rigor requirements. The studies included in this review
met the following criteria: (a) study design = randomized
controlled trials (RCTs) or quasi-experimental studies;
(b) intervention = tai chi; (c) outcome = clinical and/or be-
havioral measures of dynamic balance and stability. The
following criteria were considered for exclusion: (a) studies
not written in English; (b) reviews, letters, or comments
of original studies; and (c) incomplete data or data not
available. Duplicates were excluded. Inclusion was limited
to studies published in English.
Study Selection
Types of Studies
Studies included in this review were either RCTs
or quasi-experimental studies. Trials in which tai chi
as an intervention was performed for impairments other
than balance and vestibular disorders were excluded.
Case studies, case series, qualitative studies, reviews,
non–peer-reviewed publications, and uncontrolled studies
were also excluded.
Types of Participants
Studies were not limited by age or gender of partici-
pants. Participants with balance and vestibular disorders
were included.
Types of Interventions
Studies investigating the use of tai chi as a practi-
cal therapy for vestibular rehabilitation on individuals
with balance and vestibular disorders were included. In
this review, all styles of tai chi trainings were considered
regardless of their forms, modifications (traditional or
simplified), and numbers of movements.
Types of Controls
Studies with the following control groups were con-
sidered: participants who received (a) no intervention,
(b) conventional vestibular trainings, or (c) rehabilitation
including education, awareness, stress reduction, and
exercises.
Types of Outcome Measures
All studies included in this review used clinical and/
or behavioral measures to assess body and dynamic bal-
ance, dynamic gait function, neuromuscular function, and
trunk stability. Some of the studies also addressed second-
ary outcome measures such as subjective evaluation of
the symptom severity, relief of symptoms in dizziness, level
of confidence, and the impact of vestibular disorders in
activities of daily living.
Data Extraction and Quality Assessment
The reviewers (H. H. and N. N.) scanned the titles
and abstracts of all studies identified in the initial search
to locate any relevant RCTs and quasi-experimental stud-
ies. Hardcopies of all studies meeting the inclusion criteria
were obtained and read in full. Each study was read and

Huang et al.: Tai Chi and Balance Disorders 3

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appraised independently by the two reviewers. Data from
the studies were extracted according to criteria defined
by the reviewers. Discrepancies were noted and discussed
between and resolved by consensus. Data were validated
using a data extraction form (see Appendix B) designed for
this study.
The JBI checklists were used to assess the methodo-
logical quality of the studies (Pearson et al., 2005). The
JBI checklists consisted of a list of 13 and nine questions
for RCTs and quasi-experimental studies, respectively. For
each question, “yes” indicated a low risk of bias, “no” in-
dicated a high risk of bias, and “unclear” indicated that
the risk of bias was uncertain. For the critical appraisal
and rating of study quality, the GRADE scoring system of
four categories was used (Goldet & Howick, 2013; Guyatt
et al., 2008). The final GRADE scores were assigned based
on the overall scores for each comparison: high (at least
4 points overall), moderate (3 points), low (2 points),
and very low (1 or less). If different GRADE scores were
assigned by the two independent reviewers (H. H. and
N. N.), characteristics of the study were discussed until
consensus was reached.
Data Analysis
Data were extracted and organized in summary ta-
bles. A summary table for study design, population, inter-
vention, comparison, outcome, and strength/quality rating
was developed. Data were further analyzed by develop-
ing a summary table to depict the intervention character-
istics and study findings. A meta-analysis could not be
performed due to the lack of homogeneity among study
designs, participants, intervention characteristics, and out-
come measures.
Results
Study Description
The study flow was mapped in Figure 1 using the
PRISMA flow diagram (Moher et al., 2009). Following
execution of the search strategy, the reviewers identified
a total of 1,614 publications for potential inclusion in the
systematic review. An initial review of titles and abstracts
resulted in identification of 45 relevant studies for full text
review. The remaining 1,569 publications were deemed
irrelevant or were duplicate studies and removed from
further consideration (see Figure 1). The reviewers read
45 studies in full and then excluded 41 of these studies.
Thirty-six were excluded because interventions other than
tai chi were used or disorders other than balance and
vestibular impairment were assessed. One study assessed
nonclinical and/or behavioral measures, such as quality
of life, and four were non–peer-reviewed studies or reviews.
Four studies met the criteria for methodological rigor and
were included in the systematic review.
Four studies (three RCTs and one quasi-experimental
study) were subjected to data extraction. Key features of
these studies are presented in Table 2. Three of the four
4 American Journal of Audiology • 1–14
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studies were from the United States, and one was from Po-
land. Two of the included studies adopted a two-armed
parallel group design, one employed a cross-over design,
and one used a quasi-experimental design with four partici-
pant groups.
The sample size ranged from 19 to 40 subjects ran-
domized to either vestibular rehabilitation or the control
intervention. Participants included in these studies were
over 55 years (middle-age and older adults) of age. The
study participants were drawn from both genders but were
predominantly females. The participant data regarding
balance and vestibular dysfunction were variable among
studies. Participants’ most common complaint was of im-
balance or postural instability with dizziness or vertigo. All
the included studies used modified tai chi movements and
postures. The movements and postures were selected and
adopted from traditional tai chi training selected accord-
ing to accuracy of multijoint trajectories, positioning, and
whole-body coordination. The number of treatment ses-
sions ranged from one to five times, lasting from 3 to
18 weeks (see Table 3).
Quality of Evidence
Table 4 presents a summary of the risk of bias within
four studies included in this review. One of the three RCTs
included allocation concealment, whereas the other two
reported poorly on the allocation sequence generation. Pa-
tients were blinded in only one of the RCTs, whereas pa-
tients were not blinded in another RCT and the other one
did not report clearly. None of the studies blinded the
outcome assessor, or this feature was poorly described. The
quasi-experimental study employed adequate methods to
clearly show reliability of data (Pearson et al., 2005).
The final GRADE scores are also shown in Table 4
(Goldet & Howick, 2013). One of the included studies was
rated high (4 points). One study was rated as moderate
(3 points) due to downgrading for lack of description of
follow-up and withdrawals. Two studies were rated as low
(2 points). One of the studies rated as low quality was an
RCT with incomplete reporting on blinding and allocation
process; the other was the quasi-experimental study, pro-
viding observational evidence.
Outcomes
The Timed Up and Go (Mathias, Nayak, & Isaacs,
1986; Podsiadlo & Richardson, 1991), Functional Reach
(Duncan, Weiner, Chandler, & Studenski, 1990), Single
Stance Time (Fregly & Graybiel, 1966; Fregly, Smith, &
Graybiel, 1973), and Tandem Stance Time tests (Graybiel
& Fregly, 1965) are clinical measures to examine functional
mobility during standing up, sitting down, walking, reach-
ing forward, standing on one leg, and tandem stance (Berg,
Wood-Dauphinee, Williams, & Maki, 1992). In the Gatts
and Woollacott (2006) study, results showed significant im-
provement ( p ≤ .0007) on all clinical/behavioral measures
in Tai Chi Group 1 and significant improvement on five of
Figure 1. Flow chart of the study selection.
the six measures (except for Stand on Left Leg, p ≤ .1641)
in Control Group 2b with the tai chi cross-over. The
electromyography results demonstrated significant reduc-
tion of the following outcome measures after tai chi train-
ing: (a) tabialis anterior onset time (Group 1 by 50.25 ms,
p ≤ .004; Group 2b by 17.36 ms, p ≤ .028) and (b) co-
contraction (Group 1 from 50% to 0%, p ≤ .016).
In the Lee, Jung, Abraham, Lei-Rivera, and Kim
(2012) experiment, the Activities-Specific Balance Confidence
Scale (ABC; Powell & Myers, 1995) and the Dynamic Gait
Index (DGI; Shumway-Cook & Woollacott, 1995) were
used to evaluate the utility of tai chi as an effective form
of vestibular rehabilitation. The results revealed significant
improvement (2.617, p ≤ .047) on ABC in Group 1 (nor-
mal vestibular testing) and significant improvement (3.87,
p ≤ .003) on DGI on Group 2 (abnormal vestibular testing).
However, there was no significant difference in Group 3
(central) and Group 4 (indeterminate).
Body balance was studied by using the 8 Foot Up
and Go Test (Rikli & Jones, 1999) and Computer Posturo-
graphy for the limits of stability in the Maciaszek and
Osinski (2012) study. The results showed significant
improvement in four parameters (8 Foot Up and Go:
ANOVA(H) = 8.32, p ≤ .003; forward deflection:
ANOVA(H) = 3.70, p ≤ .050; backward deflection:
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ANOVA(H) = 5.04, p ≤ .024; maximum sway area:
ANOVA(H) = 8.86, p ≤ .002) for subjects participating
in tai chi exercise over the control group.
Parameters assessed in the McGibbon et al. (2005)
study consisted of dynamic gait function (time–distance
function), lower extremity motor control (mechanical
energy expenditures [MEEs]), and trunk stability (kine-
matics). The results demonstrated that tai chi and vestib-
ular rehabilitation can improve gait function (gait speed:
p ≤ .009 in tai chi but p ≤ .060 in vestibular rehabilitation;
step length: p ≤ .010 in tai chi and p ≤ .045 in vestibular
rehabilitation; stance duration: p ≤ .055 in tai chi but p ≤ .044
in vestibular rehabilitation). Moreover, tai chi improved
lower extremity motor control more than vestibular rehabil-
itation (reduced relative hip concentric MEE: p ≤ .001,
adjusted α = .017; and increased relative ankle concentric
MEE: p ≤ .019, adjusted α = .025) by selective redistribu-
tion of joint energetics. The correlation revealed a stronger
gait and better trunk control.
Discussion
Falls are the leading cause of physical and psycho-
logical trauma in the elderly population, each year affecting
approximately 30% of people of age 65 years and above
Huang et al.: Tai Chi and Balance Disorders 5
 6
American Journal of Audiology • 1–14

Table 2. Summary of characteristics of tai chi for vestibular rehabilitation.

Population
GRADE Sample size (sex, Mean age Intervention (regimen) Control (regimen) Outcome
Study Design scoring male/female) years) (n = male/female) (n = male/female) measures

Gatts & Randomized Moderate 19 (2/17) 77.55 (TC) Simplified tai chi exercises (VT) Balance education, Clinical/behavioral:
Woollacott control (3 points) and repetition of 12 traditional awareness education, 1. Timed Up and Go
(2006) Control/ postures stress reduction, deep 2. Functional Reach
cross-over (90 min, 5 times weekly for breathing, and axial 3. Single Stance Time
3 weeks; n = 11 (1/10)) mobility exercise (90 min, 4. Tandem Stance Time
5 times weekly for Lab:
3 weeks; n = 8 (1/7)) Electromyography
1. tabialis anterior
2. medial gastrocnemius
Lee et al. Quasi- Low 37 (6/31) 72.30 (2, 3, 4) 16 Movements of Yang (1) 16 Movements of Yang 1. Activities-Specific
(2012) experimental (2 points) 1: Normal style with modification to suit style (45 min, 1 time Balance Scale
2: Vestibular each participant’s needs weekly for 8 weeks; 2. Dynamic Gait Index
Pre and post 3: Central (45 min, 1 time weekly for 8 weeks; n = 6)
4: Indeterminate n = 31)
Maciaszek & Randomized Low 40 69.70 (E) 5 sequences of movement (K) No tai chi intervention 1. 8 Foot Up and Go
Osinski control (2 points) chosen from the simplified (n = 20) 2. Computer Posturographic
(2012) 24 forms of tai chi System PE 90
(45 min, 2 times weekly for
18 weeks; n = 20)
McGibbon Randomized High 36 (16/20) 59.50 (TC) 5 movements of Yang-style (VR) eye–head coordination 1. Time–distance measure
et al. control (4 points) short form exercise, VOR training, for dynamic
(2005) (70 min, 1 time weekly for balance retraining exercise gait function
10 weeks; n = 19) (70 min, 1 time weekly 2. Mechanical energy
for 10 weeks; n = 17) expenditures for lower
extremity neuromuscular
control
3. Kinematics for trunk stability

Note. GRADE = Grading of Recommendations, Assessment, Development, and Evaluation; TC = tai chi; VT = vestibular training; E = experimental group with tai chi exercise;
K = control group; VR = vestibular rehabilitation; vestibulo-ocular reflex.

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Table 3. Summary of tai chi intervention.

Total
Study Style session Movement Rationales of selection

Gatts & Yang 90 min, 12 Postures:commencement, white stork Traditional tai chi training
Woollacott Simplified 5 times cools its wing, brush knee, play the Tai chi chuan: the 27 forms
(2006) weekly for guitar, repulse monkey, heel kick,
3 weeks toe kick, golden cockerel, fair lady
21 hr total works the shuttles, part the wild
horses’ mane, cloud hands, cross
hands
Lee et al. Yang 45 min, 16 Movements: Traditional Yang style
(2012) Modified 1 time bow stance, bow and arrow, first tai chi
weekly for movement, gathering, polishing the
8 weeks table top, gathering energy, punching,
6 hr total stepping, stoking the fire, pitching,
turning the wheel, embrace the moon,
crane spreads wings, swimming, rooster
stands on 1 leg, repulse monkey
Maciaszek & Wuduan 45 min, 5 Sequences: 24-Form tai chi chuan
Osinski tai chi 2 times commencement, part the wild horses’ Yang style
(2012) chuan weekly for mane, white stork cools its wing,
Simplified 18 weeks brush knee, strums the lute, repulse
27 hr total monkey, grasp the bird’s tail, cloud
hands, single whip, high pat on horse,
rooster stands on 1 leg, needle to the
bottom of the sea, cross hands
McGibbon Yang 70 min, 5 Movements: Cheng Man-Ching’s
et al. Simplified 1 time rising the power, withdraw and push, Yang-style short form
(2005) weekly for cloud hands, brush knee twist step,
10 weeks separate right and left legs
11 hr total

(CDC, 2006). Research suggests that participation in bal-
ance or muscle strengthening exercises can reduce the fall
rate of this population (Bergamaschi, Ferrari, Gallamini,
& Scoppa, 2011; CDC, 2006; Li et al., 2016). Tai chi is a
long-established martial art form that has been recognized
as an exercise, especially for elderly people (Chang et al.,
2011; Kuramoto, 2006; Tse & Bailey, 1992; Wolf et al.,
1996; Wolf, Coogler, et al., 1997). The literature demon-
strates that tai chi offers numerous cardiopulmonary,
musculoskeletal, and postural benefits to its practitioners
(Kuramoto, 2006; Tse & Bailey, 1992; Wolf, Coogler, et al.,
1997). Many studies have revealed that performance on
balance outcome measures can be improved by practicing
tai chi (Kuramoto, 2006; Liu & Frank, 2010; Verhagen,
Immink, van der Meulen, & Bierma-Zeinstra, 2004; Wu,
2002). Furthermore, tai chi has been utilized as a rehabilita-
tive technique for stroke patients (Au-Yeung et al., 2009;
Taylor-Piliae et al., 2014), Parkinson’s disease (Hackney &
Earhart, 2008; Li et al., 2012, 2014), and arthritis (Fransen
et al., 2007; Song et al., 2003).
Collectively, the results of the existing studies suggest
that tai chi can be a practical complementary therapy
for vestibular rehabilitation as it is beneficial to individ-
uals with symptoms, complaints, or a diagnosis of balance
and vestibular impairment. Tai chi is a helpful practice
that can be used to improve flexibility and balance control
(Li et al., 2005; Nguyen et al., 2013; Tsang et al., 2004;
Wayne et al., 2004; Wu, 2002; Zwick et al., 2000). However,
in this systematic review, the lack of homogeneity in terms
of outcome measures, styles, duration, and frequency of
the tai chi intervention among studies selected made it dif-
ficult to establish the best protocol, other ideal parameters,
or time of intervention to optimize health outcomes.
Two of the three RCTs were found to be of moder-
ate to low quality according to the GRADE scoring system
due to lack of clear reporting of allocation concealment or
blinding of participants. None of the three RCTs blinded
the outcomes assessors or therapists, or if blinding was
used, it was poorly described. Lack of blinding increases
the risk of biased results; thus, the strength of the evi-
dence coming from these studies decreased. Although
the quasi-experimental study employed adequate methods
to show clearly the reliability, it was found to be of low
quality according to the GRADE scoring. This rating
scale downgrades the research design because it was not
an RCT and only provided observational evidence. In
addition, the sample size (ranged from 19 to 40 subjects)
may not have been sufficient to establish the validity of
the results found due to the variability in assessments and
interventions.
Although all studies selected (three RCTs and one
quasi-experimental study) reported positive significant
findings on dynamic balance and improved gait and pos-
tural performance, different parameters were used to as-
sess body balance function. In the Gatts and Woollacott
(2006) study, functional mobility was examined using

Huang et al.: Tai Chi and Balance Disorders 7

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Table 4. Critical appraisal and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) scoring of included
randomized controlled trials (RCTs).

Gatts &
Woollacott Lee et al. Maciaszek & McGibbon
Study (2006) (2012) Osinski (2012) et al. (2005)

Randomized controlled trails

1. Was true randomization used for assignment of participants to Y Y Y
treatment group?
2. Was allocation to treatment group concealed? U U Y
3. Were treatment groups similar at the baseline? Y Y Y
4. Were participants blind to treatment assignment? N U Y
5. Were those delivering treatment blind to treatment assignment? N N Y
6. Were outcomes assessors blind to treatment assignment? U N U
7. Were treatment groups treated identically other than the intervention Y Y Y
of interest?
8. Was follow-up complete, and if not, were differences between groups Y Y Y
in terms of their follow-up adequately described and analyzed?
9. Were participants analyzed in the groups to which they were randomized? Y Y Y
10. Were outcomes measured in the same way for treatment groups? Y Y Y
11. Were outcomes measured in a reliable way? Y Y Y
12. Was appropriate statistical analysis used? Y Y Y
13. Was the trial design appropriate, and any deviations from the standard Y U Y
RCT design accounted for in the conduct and analysis of the trial?
Quasi-experimental study
1. Is it clear in the study what is the “cause” and what is the “effect” Y
(i.e., there is no confusion about which variable comes first)?
2. Were the participants included in any comparisons similar? Y
3. Were the participants included in any comparisons receiving similar Y
treatment/care, other than the exposure or intervention of interest?
4. Was there a control group? Y
5. Were there multiple measurements of the outcome both pre and post Y
the intervention/exposure?
6. Was follow-up complete, and if not, were differences between groups Y
n terms of their follow-up adequately described and analyzed?
7. Were the outcomes of participants included in any comparisons measured Y
in the same way?
8. Were outcomes measured in a reliable way? Y
9. Was appropriate statistical analysis used? Y
GRADE scoring M (3) L (2) L (2) H (4)

Note. Questions of quality assessment are based on the Joanna Briggs Institute critical appraisal checklist. Y = yes; N = no; U = unclear;
H = high; M = moderate; L = low.

clinical/behavioral and electromyography measures. In the
Lee et al. (2012) experiment, the ABC and the DGI were
used to evaluate the utility of tai chi as an effective form
of vestibular rehabilitation. Body balance was studied by
using the 8 Foot Up and Go Test and Computer Posturo-
graphy for the limits of stability in the Maciaszek and
Osinski (2012) study. Dynamic gait function, MEEs, and
trunk kinematics were the parameters used in the McGibbon
et al. (2005) study. Moreover, uncertain vestibular dysfunc-
tion limited the comparison; only the quasi-experimental
study (Lee et al., 2012) demonstrated group-specific re-
sponses of change attributed to tai chi therapy (Group 1:
normal vestibular; Group 2: abnormal vestibular; Group 3:
central; Group 4: indeterminate).
The duration and frequency of the exercise protocols
were variable among the studies (ranged from 6 to 27 hr
in total). As demonstrated in this review, the Yang style is
the most common style used for tai chi training. Numbers of
tai chi forms vary from short (five forms) to long (108 forms).
Some authors suggest that individuals with balance/
vestibular dysfunction and reduced memory ability may be
better to start with short forms (Liu & Frank, 2010). Which
form should be selected depends on the individual tai chi
practitioner’s ability to perform particular body move-
ments, which may vary extensively between forms and im-
pact the practitioners’ ability to receive benefit from tai chi
(Liu & Frank, 2010). As Liu and Frank (2010) suggested,
shorter duration (< 12 weeks) may be better for more func-
tionally independent individuals, but it usually requires
increased frequency and session length. On the contrary,
long duration with less frequency may provide supportive
effect on those who have a balance/vestibular deficit (Wolf
et al., 1996). Several studies proposed that the selection
of tai chi exercise parameters could have an impact on the
outcome measures after tai chi training (Liu & Frank, 2010;
Wolf et al., 1996). Additional research is needed to deter-
mine the influence of practice frequency and intensity on
balance and/or vestibular outcomes.

8 American Journal of Audiology • 1–14

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 This review has several limitations. First of all, we
limited our search to publications written in English due
to difficulties in retrieving articles from databases in differ-
ent languages, such as Chinese and Japanese. Although
adherence to systematic review strategies as a method in
this review was observed, selective publishing and report-
ing may pose a potential publication bias. Results would
have been more inclusive if we had been able to include
studies written in other languages; this would have required
additional language skills of our team members. Moreover,
although we made a great effort to retrieve all the RCTs
on the subject, we cannot be certain that our search located
all the relevant trials. Further limitations include the pau-
city, homogeneity, and the frequently suboptimal methodo-
logical quality of primary data. These factors influence
both quality and quantity of the research studies reviewed
and limit the conclusions that we can make in the basis of
this systematic review. Despite the limitations and varia-
tions between studies, according to the results of this inves-
tigation, tai chi shows to be effective in improving balance
control as well as gait and postural performance. These
results will help guide clinical decisions regarding the use of
tai chi as a complementary means of rehabilitation treat-
ment such as repositioning procedures for patients to cope
with discomfort. Further scientific investigation is needed
in the future.
Conclusion
Although tai chi is receiving growing attention, there
were a surprisingly limited number of high-quality studies
regarding the benefits of tai chi as a rehabilitative strategy
to reduce fall risk for inclusion in this study. Therefore,
this systematic review elucidates the need for further inves-
tigation of tai chi as an intervention for balance/vestibular
disorders using a high-quality research design. Results of
this study demonstrated that tai chi improves dynamic bal-
ance control and flexibility of individuals with balance and
vestibular disorders. However, the number, size, and qual-
ity of the RCTs are not sufficient at this time to draw deci-
sive conclusions regarding dosage and effectiveness as an
intervention. Additional well-designed clinical trials are
needed to substantiate the effects of tai chi as a vestibular
rehabilitation option for certain disorders, especially ves-
tibular dysfunction, as well as the optimal treatment dura-
tion necessary to avoid recurrence of symptoms.
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Appendix A ( p. 1 of 2)
Search Strategies 12/08/2016

PubMed sent in .txt format

Recent queries
Search Add to builder Query Items found Time

#5 Add Search (#2 AND #3) 433 12:06:43

#4 Add Search (#1 AND #3) 387 12:04:49
#3 Add Search (vestibular diseases[mesh] OR vertigo[mesh] OR 254931 11:59:52
proprioception[mesh] OR accidental falls[mesh]
OR balance[tiab] OR dizziness[tiab] OR vertigo[tiab]
OR vestibular[tiab])
#2 Add Search (tai ji[mesh] OR “tai chi”[tiab] OR taiji[tiab] OR 1320 11:58:32
taijiquan[tiab] OR “t’ai chi”[tiab])
#1 Add Search (acupuncture therapy[mesh] OR acupuncture[tiab] 25266 11:57:28
OR meridians[tiab])

Huang et al.: Tai Chi and Balance Disorders 11

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Appendix A ( p. 2 of 2)
Search Strategies 12/08/2016

CINAHL sent in RIS format

Search ID# Search terms Search options Last run via Results

S5 S2 AND S3 Limiters - Exclude MEDLINE records Interface - EBSCOhost Research Databases 79

Search modes - Boolean/Phrase Search Screen - Advanced Search
Database - CINAHL Complete
S4 S1 AND S3 Limiters - Exclude MEDLINE records Interface - EBSCOhost Research Databases 272
Search modes - Boolean/Phrase Search Screen - Advanced Search
Database - CINAHL Complete
S3 vestibular OR balance Search modes - Boolean/Phrase Interface - EBSCOhost Research Databases 58,857
OR vertigo OR dizzy Search Screen - Advanced Search
OR dizziness Database - CINAHL Complete
OR proprioception
OR “accidental falls”
S2 acupuncture OR meridians Search modes - Boolean/Phrase Interface - EBSCOhost Research Databases 13,166
Search Screen - Advanced Search
Database - CINAHL Complete
S1 “tai chi” OR “tai ji” OR Search modes - Boolean/Phrase Interface - EBSCOhost Research Databases 1,624
taiji OR taijiquan Search Screen - Advanced Search
Database - CINAHL Complete

PscyINFO sent in RIS format

Search ID# Search terms Search options Last run via Results

S5 S2 AND S3 Search modes - Boolean/Phrase Interface - EBSCOhost Research Databases 47

Search Screen - Advanced Search
Database - PsycINFO
S4 S1 AND S3 Search modes - Boolean/Phrase Interface - EBSCOhost Research Databases 126
Search Screen - Advanced Search
Database - PsycINFO
S3 vestibular OR balance Search modes - Boolean/Phrase Interface - EBSCOhost Research Databases 53,734
OR vertigo OR dizzy Search Screen - Advanced Search
OR dizziness OR Database - PsycINFO
proprioception OR
“accidental falls”
S2 acupuncture OR meridians Search modes - Boolean/Phrase Interface - EBSCOhost Research Databases 2,929
Search Screen - Advanced Search
Database - PsycINFO
S1 “tai chi” OR “tai ji” OR taiji Search modes - Boolean/Phrase Interface - EBSCOhost Research Databases 517
OR taijiquan Search Screen - Advanced Search
Database - PsycINFO

Web of Science

Set Results

#5 471 #3 AND #2
Indexes = SCI-EXPANDED, SSCI Timespan = All years
#4 796 #3 AND #1
Indexes = SCI-EXPANDED, SSCI Timespan = All years
#3 728,089 TOPIC: (vestibular OR vertigo OR balance OR dizzy OR dizziness
OR falls OR falling OR proprioception)
Indexes = SCI-EXPANDED, SSCI Timespan = All years
#2 19,462 TOPIC: (acupuncture OR meridians)
Indexes = SCI-EXPANDED, SSCI Timespan = All years
#1 1,914 TOPIC: (“tai chi” OR “tai ji” OR taiji OR taijiquan OR “t’ai chi”)
Indexes = SCI-EXPANDED, SSCI Timespan = All years

Sent in three files in BibTex format.

12 American Journal of Audiology • 1–14

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Appendix B ( p. 1 of 2)
Study Review Form

Study title: ___________________________________________________________

Database: __________________Study Number______Reviewer_________________

(1) Study Screen Details

Screening Decision Screening Conclusion

Study Passes Screens ☐ Yes ☐ No Eligible for Review ☐ Yes ☐ No

(2) Study Design Details

GRADE Scores: ☐ High (at least 4) ☐ Moderate (3) ☐ Low (2) ☐ Very Low (1 or less)

Study Design: ☐ Randomized control trial ☐ One group pretest posttest design

☐ Pretest posttest design with a control group ☐ Posttest design ☐ Mixed Research

☐ Qualitative ☐ Other ________________________________________________

(3) Study Characteristics

Study Population ☐ Younger Population (< 65yo) ☐ Older Population (≥ 65yo)

Demographics Sample size_______ (M_______ F_______)

Mean Age_________

Vestibular Assessment ☐ VNG/ENG ☐ Rotary Chair ☐ MRI ☐ N/A

☐ Other: ________________________________________

Intervention Tai Chi

Duration________________________________________
Style___________________________________________
# of Movements__________________________________
☐ Modification: __________________________________
☐ Other: ________________________________________

Primary Outcome ☐ Static/Dynamic Balance ☐ Improved Mobility

☐ Improved Frequency and Severity of dizziness and vertigo
☐ Improved Gait and Postural Performance
☐ Other: ________________________________________

Secondary Outcome ☐ Gaze Stabilization ☐ Satisfaction ☐ Relaxation ☐ Calmness

☐ N/A
☐ Other: _______________________________________

Primary Outcome Measure ☐ Activities-Specific Balance Confidence Scale (ABC)

☐ Dynamic Gait Index (DGI) ☐ Clinical Exam
☐ Electromyography (EMG) ☐ Berg Balance Scale (BBS)
☐ Other: ______________________________________

Huang et al.: Tai Chi and Balance Disorders 13

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Appendix B ( p. 2 of 2)
Study Review Form

GRADE Scoring System

Type of evidence
Initial score based on type of +4RCTs/ SR of RCTs, +/− other types of evidence
evidence +2Observational evidence (e.g., cohort, case-control)
Quality
Based on Blinding and allocation process
Follow-up and withdrawals
Sparse data
Other methodological concerns (e.g., incomplete reporting, subjective outcomes)
Score 0 No problems
−1Problem with 1 element
−2Problem with 2 elements
−3Problem with 3 or more elements
Consistency
Based on Degree of consistency of effect between or within studies
Score +1Evidence of dose response across or within studies (or inconsistency across studies is explained by a dose
response); also 1 point added if adjustment for confounders would have increased the effect size
0 All/most studies show similar results
−1Lack of agreement between studies (e.g., statistical heterogeneity between RCTs, conflicting results)
Directness
Based on The generalizability of population and outcomes from each study to our population of interest
Score 0 Population and outcomes broadly generalizable
−1Problem with 1 element
−2Problem with 2 or more elements
Effect size
Based on The reported OR/RR/HR for comparison
Score 0 Not all effect sizes > 2 or < 0.5 and significant; or if OR/RR/HR not significant
+1Effect size > 2 or < 0.5 for all studies/meta-analyses included in comparison and significant
+2Effect size > 5 or < 0.2 for all studies/meta-analyses included in comparison and significant

14 American Journal of Audiology • 1–14

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