The Effects of Tai Chi on Bone Mineral Density in
Postmenopausal Women: A Systematic Review

Peter M. Wayne, PhD, Douglas P. Kiel, David E. Krebs, PhD, Roger B. Davis, ScD,
Jacqueline Savetsky-German, MPH, MAOM, Maureen Connelly, MD, Julie E. Buring, ScD

ABSTRACT. Wayne PM, Kiel DP, Krebs DE, Davis RB, 2007 by the American Congress of Rehabilitation Medi- Savetsky-German J, Connelly M, Buring JE. The effects of Tai cine and the American Academy of Physical Medicine and Chi on bone mineral density in postmenopausal women: a sys- tematic review. Arch Phys Med Rehabil 2007;88:673-80.
Objective: To evaluate the evidence for Tai Chi as an inter-
vention to reduce rate of bone loss in postmenopausal women.
THE 2004 SURGEON GENERAL’S highlights that
among U.S. women, osteoporosis and osteopenia—2 con- Data Sources: Literature search using Medline, Science
ditions characterized by lower than average bone mineral den- Citation Index, Cochrane databases, China Biological Medi- sity (BMD)—are a serious and growing public health issue. In cine Database, and additional manual reference searches of 2002, the number of osteoporotic and osteopenic women over retrieved articles and personal libraries.
the age of 50 in the United States was estimated at 44 million.
Study Selection: Randomized controlled trials (RCTs), pro-
Because of baby-boomer driven anticipated changes in demo- spective cohort studies, and cross-sectional studies that in- graphics, this number is expected to increase substantially in cluded Tai Chi as an intervention, and had at least 1 outcome Tai Chi (also referred to as Tai Chi Chuan, Taijiquan) is a related to measurement of bone mineral density (BMD).
meditative, mind-body exercise that is growing in popularity in Data Extraction: Authors critically reviewed studies, eval-
the United States. Over the past century, millions of Chinese uated methodologic quality, and synthesized study results in a have practiced Tai Chi’s flowing, meditative movements to cultivate and maintain health and well-being. Because of its Data Synthesis: Six controlled studies were identified by
reputed health benefits, apparent safety, low cost, and growing our search. There were 2 RCTs, 2 nonrandomized prospective popularity, Tai Chi has become an increasingly recognized parallel cohort studies, and 2 cross-sectional studies. The 2 preventive and rehabilitative therapeutic tool by the conven- RCTs and 1 of the prospective cohort studies suggested that Tai tional medical community. Recent studies have begun to ad- Chi-naive women who participated in Tai Chi training exhib- dress the safety and efficacy of Tai Chi as a therapeutic inter- ited reduced rates of postmenopausal declines in BMD. Cross- vention for a variety of health concerns including: balance and sectional studies suggested that long-term Tai Chi practitioners had higher BMD than age-matched sedentary controls, and had slower rates of postmenopausal BMD decline. No adverse spiratory fitness and functional multiple effects related to Tai Chi were reported in any trial.
Conclusions: Conclusions on the impact of Tai Chi on BMD
are limited by the quantity and quality of research to date. This limited evidence suggests Tai Chi may be an effective, safe, review have recently been published. The 2004 and practical intervention for maintaining BMD in postmeno- Surgeon General’s report on osteoporosis specifically recom- pausal women. In combination with research that indicates Tai mends Tai Chi as a good exercise for fall and Tai Chi can positively impact other risk factors associated with low Chi is increasingly recommended to osteoporotic women as a safe BMD (eg, reduced fall frequency, increased musculoskeletal and effective exercise for bone density maintenance. Although strength), further methodologically sound research is warranted the fundamental principles of Tai Chi and some clinical re- to better evaluate the impact of Tai Chi practice on BMD and search suggest that it may help to maintain bone density in fracture risk in postmenopausal women.
postmenopausal women, to date there have been few attempts Key Words: Bone mineral density; Exercise; Osteopenia;
to systematically evaluate the evidence for this claim.
Osteoporosis; Rehabilitation; Tai Chi.
This review examines the use of Tai Chi as a potential inter- vention for postmenopausal women with low BMD. We begin byhighlighting the growing prevalence and public health impact ofosteoporosis and osteopenia, and the current standard of care forthese conditions. We then review the fundamental principles of From the New England School of Acupuncture, Watertown, MA (Wayne, Tai Chi that may make it beneficial for women with low BMD, Savetsky-German); Institute for Aging Research, Hebrew SeniorLife, Boston, MA(Kiel); MGH Institute of Health Professions, Massachusetts General Hospital, Boston, and critically review clinical studies that have evaluated the im- MA (Krebs); and Osher Institute, Harvard Medical School, Boston, MA (Wayne, pact of Tai Chi on BMD. We also summarize research on the impact of Tai Chi on other risk factors associated with osteopo- Supported by the National Center for Complementary and Alternative Medicine rosis and osteopenia. Last, we offer suggestions for future research (grant no. 5 U19 AT002022-02 and 7 R21 AT003503-02).
No commercial party having a direct financial interest in the results of the research that will improve our ability to evaluate the benefits of Tai Chi for supporting this article has or will confer a benefit upon the author(s) or upon any both prevention and treatment of low BMD.
organization with which the author(s) is/are associated.
Reprint requests to Peter M. Wayne, PhD, Harvard Medical School Osher Institute, Low BMD: Definitions and Prevalence
401 Park Dr, Ste 22A, Boston, MA 02215, e-mail: [email protected] Osteoporosis is a skeletal disorder characterized by compro- 0003-9993/07/8805-11004$32.00/0doi:10.1016/j.apmr.2007.02.012 mised bone strength that predisposes one to an increased risk of Arch Phys Med Rehabil Vol 88, May 2007
fracture. Bone strength primarily reflects the integration of Tai Chi and Its Rationale as a Treatment for Women
bone density and bone quality. Because bone density can be With Low BMD
easily measured, people are often classified as having osteopo- Tai Chi has its roots in the martial arts; yet for the past rosis or osteopenia based on the value of their BMD. Osteo- century millions of Chinese have practiced its flowing, medi- porosis is technically defined by the World Health Organiza- tative movements to cultivate and maintain health. Considered tion as a BMD T score of less than Ϫ2.5 (ie, 2.5 standard one of the treasures of Chinese medicine, Tai Chi is based on deviations [SDs] below a healthy, young white adult refer- the same basic principles that underlie acupuncture and Chi- whereas osteopenia is often used to characterize BMD nese herbal therapies. It employs detailed regimens of physical T scores between Ϫ1.0 and Ϫ2.5. Because bone tends to be movement, breathing techniques, and cognitive tools (both lost with aging, untreated osteopenic women are at risk of visualization and focused internal awareness) to strengthen the body, calm the mind, and “balance the flow of Qi” (life BMD is a strong risk factor for future bone fractures in asymp- A number of characteristics of Tai Chi practice that might tomatic postmenopausal It is estimated that 4 in 10 make it an effective therapy for maintaining bone density and white women 50 years or older in the United States will improving postural control have been explored in recent re- experience a hip, spine, or wrist fracture sometime during the These intended characteristics and their pur- remainder of their Models based on meta-analyses indi- ported effects include: (1) a constant shifting of weight from 1 cate a doubling of relative risk for fracture with each SD leg to the other, which facilitates improved lower-extremitystrength and/or mechanical load and dynamic standing balance; decline in A recent prospective of more than (2) an emphasis on maintaining a vertical posture with an 200,000 women over the age of 50 reported that relative to extended head and trunk position, which promotes a less flexed those with normative BMD, women with osteopenia and os- posture; (3) the use of different parts of the body taking turns teoporosis had 1.8-fold and 4.0-fold increases in fracture rates, playing the role of stabilizer and mover, which enables move- respectively. Although the relative risk of fracture was higher ments to be executed smoothly without compromising balance in osteoporotic women, because of the far greater number of and stability; (4) a continuous, slow, even tempo that facilitates osteopenic women (40% vs 7%), the absolute numbers of sensory awareness of the speed, force, trajectory, and execution fractures were much higher among osteopenic women, making of movements, as well as awareness of the external environ- osteopenia a potentially more widespread public health ment; (5) the symmetrical and diagonal arm movements of Tai Chi, which promote arm swing in gait and increase trunk Fractures associated with low bone density are a significant rotation around the waist; (6) moderate knee flexion, which cause of The downward spiral in health after lowers the body’s center of gravity; and (7) flowing circular osteoporosis-related hip fractures is associated with up to 20% and spiraling movements, which promote joint flexibility. Al- higher mortality rates in the year after a Recent though we are not aware of any studies that have been explic- from Sweden have shown increased mortality after itly designed to examine Tai Chi’s impact on mechanical load spine fractures as well as hip fractures. Medical costs associ- and BMD in postmenopausal women, a handful of studies have ated with managing hip and other fractures are high, and were shown that Tai Chi improves lower-extremity biomechanic estimated to be $13.8 billion in the United States in 1995, efficiency during activities of daily Such changes are likely to translate into increased mechanical load on key Despite the high prevalence of osteoporosis and osteopenia, regions of the skeleton including the femur, hip, and lowerspine.
and the substantial burden on the health care system, onlylimited progress has been made in developing effective, pre- ventive, and sustainable interventions aimed at reducing ratesof fractures associated with low BMD. For example, recent Clinical Trials Examining Tai Chi’s Effect on BMD in
suggest that although calcium with vitamin D sup-plementation in relatively healthy women without known os- Postmenopausal Women
teoporosis may result in modest improvement in hip bone To systematically review the evidence evaluating Tai Chi for density, it does not reduce the risk of hip fractures, and it may reducing rates of postmenopausal BMD loss, we conducted a increase the risk of kidney stones. Pharmacologic treatment to literature search using Medline, Science Citation Index, and “prevent” further bone loss and fractures in women with os- Cochrane Database of Randomized Controlled Trials. Search teopenia has been shown not to be a cost-effective strategy strategies for each of these databases included using the fol- lowing statements and key words: Tai Chi or Tai Chi Chuan orTaijiquan and bone or osteoporosis or menopause, and in- Current guidelines for the treatment of osteoporotic and cluded the period 1966 through April 2006. We also conducted osteopenic women generally include the recommendation of a separate literature search using China Biological Medicine regular There is currently no consensus regarding Database for Chinese-language randomized trials using the key the optimal types and regimens of exercise for treating low words Taijiquan, bone, and osteoporosis. Finally, we manually BMD, however, or for addressing other risk factors associated searched the bibliographies of retrieved articles and our per- with osteoporosis and osteopenia (eg, poor balance, decreased sonal libraries for additional relevant citations.
muscle strength, diminished agility). Moreover, among post- Because only a small number of the studies we retrieved menopausal women, compliance with conventional exercise were randomized controlled trials (RCTs), and because RCTs regimens is often low, due to health factors that may limit employing Tai Chi interventions are not amenable to double- certain types of exercise, lack of motivation, and inability to blinding, we chose not to use a more traditional instrument (eg, sustain long-term interest, among other The 2004 Jadad to evaluate study methodologic quality. Rather, Surgeon General’s on osteoporosis stresses the need for study quality was descriptively characterized with respect to new, creative, sustainable exercise programs for women at risk reporting of the following criteria: randomization (yes or no); details of randomization methods; clear inclusion and exclu- Arch Phys Med Rehabil Vol 88, May 2007
Table 1: Quality of Design and Methodologic Features of Studies Evaluating Tai Chi for Low BMD
Abbreviation: NA, not applicable.
Legend: ͌, design and methodology feature adequately reported; Ϫ, design and methodology feature not adequately reported.
sion criteria; blinding of outcomes assessors; description of ferences between Tai Chi and age-matched sedentary con- withdrawal and dropouts; sample size estimates and justifica- trols were observed in an earlier study conducted by the tion; use of appropriate statistical analyses; details of Tai Chi same research group in a similar This earlier intervention (eg, style, training schedule); and experience of Tai study also tracked changes in BMD over a 12-month period and found that rates of both trabecular and cortical BMD Our database searches of Medline, Science Citation Index, loss in the distal tibia (assessed using peripheral quantitative and Cochrane identified a total of 191 citations. Titles and computerized tomography [pQCT]) were approximately abstracts of these citations were manually reviewed and con- 50% lower in the Tai Chi group (Pϭ.044, Pϭ.031). The Tai sidered eligible only if they described a prospective or cross- Chi group also exhibited a nonsignificant trend toward lower sectional study that employed Tai Chi as an intervention, and BMD loss in the femur (measured with DXA). Another had at least 1 outcome related to measurement of BMD. A total cross-sectional study also reported greater spine and femur of 9 citations met these criteria. Six of these 9 citations were BMD among long-term female Tai Chi practitioners (nϭ18) limited to abstracts of proceedings from scientific meetings andwere thus excluded; the remaining 3 were included in this when compared with age- and sex-matched controls (nϭ22) review. Two additional eligible citations were identified using the China Biological Medicine Database for Chinese-language Second, Tai Chi-naive women who undergo Tai Chi train- randomized trials, and 1 was identified in the personal library ing exhibit reduced rates of postmenopausal BMD decline.
One methodologically sound RCT of postmenopausal The 6 eligible studies identified by our search are summa- women observed that those randomized to 12 months of regular Tai Chi training (nϭ67) exhibited 3.6-fold (trabec- prospective parallel cohort and 2 were static cross- ular) to 2.3-fold (cortical) reductions in rates of BMD de- sectional Tai Chi practitioners were com- cline in the distal tibia as measured with pQCT (PϽ.005), as pared with age-matched sedentary controls in 5 compared with a no-exercise control group (nϭ65). No 1 compared Tai Chi with rope skipping and vigorous martial significant differences between groups were reported for and 1 compared Tai Chi with acupuncture and Chinese BMD of the spine or femur as measured with A herbal The duration of the Tai Chi intervention in second, less methodologically sound observed that the 3 prospective studies with naive practitioners ranged from DXA measures of BMD at the lumbar spine significantly 8 to 12 months. Five of the 6 studies were conducted in China increased (1.81%) after 10 months of Tai Chi whereas sedentary controls decreased (1.83%). Another intervention The methodologic quality of most studies was poor, as arm in this study—Tai Chi pushing hands (a 2-person inter- summarized in Of the 2 RCTs, only 1 provided ade- active exercise that involves a continuous issuing and re- quate details of randomization methods, inclusion and exclu- ceiving of gentle pushes)— exhibited even greater increases sion criteria, dropout rates, and justification for sample sizes.
in lumbar BMD (3.4%). This study also reported significant None of the 6 studies indicated that outcome assessors wereblinded, none included any information on the experience of BMD increases of the same magnitude in the distal ulna and Tai Chi instructors, and for all the non-RCT studies, dropout radius. Finally, another methodologically weak, nonrandom- rates, sample size justifications, and characteristics of the Tai ized study reported that 4 months of Tai Chi training re- Chi intervention were poorly described.
sulted in a 7.3% increase in bone density (skeletal location Results across the 6 studies summarized in suggest not indicated) as measured with broadband ultrasound at- the following: First, long-term postmenopausal Tai Chi tenuation This study also reported that serum practitioners have higher BMD than age-matched sedentary osteocalcin, a biomarker for bone formation, increased sig- controls, and have slower rates of bone loss. In 1 cross- nificantly in the Tai Chi group. No BMD or osteocalcin data sectional study of postmenopausal women, Qin et aused for the control group were provided.
dual-energy x-ray absorptiometry (DXA) to compare BMD Third, 1 nonrandomized cross-over provided quali- of 48 long-term Tai Chi practitioners with 51 age-matched tative data suggesting that Tai Chi improves perimenopausal sedentary controls. Subjects in the Tai Chi group had sig- symptoms including hot flashes and abdominal distention.
nificantly higher BMD in the lumbar spine (7.1%), the Finally, Tai Chi appears to be safe for peri- and postmeno- greater trochanter (7.2%), and Ward’s area (7.1%) of the pausal women. No significant adverse effects were reported in proximal femur (PϽ.05). Similar magnitudes of BMD dif- Arch Phys Med Rehabil Vol 88, May 2007
Table 2: Summary of Studies Evaluating Impact of Tai Chi on BMD in Peri- and Postmenopausal Women
quad strength and balancein Tai Chi vs control Abbreviation: TCM, traditional Chinese medicine.
being able to quantify true volumetric density as well as par-tition the 2 types of bone, trabecular and cortical, which may Limitations of Reviewed Studies Evaluating Tai Chi’s
respond differently to exercise. Moreover, it has the potential to Impact on BMD
have higher In the study by Chan et themagnitude of both cortical and trabecular BMD loss in the tibia Although the 6 studies summarized in suggest Tai decreased by approximately 1% in response to Tai Chi. In Chi may improve BMD of postmenopausal women, these re- contrast, a recent conventional exercise study that employed sults should be considered inconclusive and interpreted with QCT to monitor BMD dynamics observed that a 2-year inter- vention combining high- and low-impact training exhibited First, the majority of these studies have design and method- markedly greater impact on cortical versus trabecular BMD of ologic limitations. Only 2 of the 6 studies were randomized the spine (Ϸ3 % vs 1%, Again, direct compar- trials. Although cross-sectional studies enable investigations of ison between studies is limited by the different locations that long-term effects of Tai Chi, absence of randomization and BMD was assessed. Nevertheless, because cortical and trabec- longitudinal monitoring introduces great potential for bias.
ular BMD are known to contribute differently to the mechan- Sample sizes across all studies were small, with an average of ical strength of bone, future Tai Chi studies should consider 31 participants in Tai Chi and control groups. Additionally, using QCT to better understand the impact of this weight- information on Tai Chi interventions, eligibility criteria, blind- bearing exercise on bone morphology and quality, and the ing methods, and qualification of instructors were not available relationship between BMD compartmentalization and fracture or poorly described (see Finally, because of both the risk. Even though cost is greater and radiation dosage is higher diversity of approaches used to characterize BMD (ie, DXA, with QCT (radiation dosage is comparable to the background pQCT, BUA) and the diversity of skeletal sites at which BMD radiation dose obtained over the course of a year), it is justi- was assessed, comparisons and synthesis across studies is dif- fiable to use this technology when testing new therapies be- ficult. Moreover, some of the specific methods used to charac- cause it is essential to understand how potential improvements terize BMD, such as BUA, are known to have very low precision; the 1 study employing BUA that reported a 7.3%increase in bone density after only 4 months of Tai Chi most Tai Chi May Also Impact Other Risk Factors Associated
likely reflects a measurement artifact.
Second, the studies in include women with a range of With Low BMD
baseline BMD scores, ranging from normative to severely Independent of changes in BMD, Tai Chi may be of benefit to osteoporotic. Results of conventional exercise studies suggest women with low bone density because of its positive effect on that the responsiveness of BMD to exercise may vary with postural balance and fall risk. Systematic which developmental stage and degree of BMD loss include numerous randomized trials, suggest that Tai Chi practice This makes it difficult to evaluate the potential benefits of Tai can directly reduce risk of and/or positively impact factors Chi for women that differ in their magnitude of fracture risk associated with postural control including fear of (eg, normative BMD vs osteopenic vs osteoporotic).
Third, all but 1 of the 6 studies in were conducted in China and included only Asian women. It is well established daily Drawing on these data, a cost-benefit analysis that the prevalence of osteopenia and osteoporosis, and patterns concluded that Tai Chi could significantly reduce costs asso- of postmenopausal BMD loss vary in a predictable manner ciated with fall-related hip Noteworthy across these with respect to race and ethnicity—for example, African Amer- studies is that the majority have focused on older people, icans have the lowest, Hispanics intermediate, and whites and including and adults, and as in the trials Asians the highest prevalence of Consequently, reviewed above, few adverse effects have been reported. This results of these studies are of only limited use in predicting the suggests that the findings are relevant to postmenopausal responses of racially diverse populations of women.
women, and that Tai Chi can be safely practiced well into laterstages of life.
The Impact of Tai Chi Versus Conventional Exercise on
Only 1 of the studies included in this systematic review BMD in Postmenopausal Women
reported data on fracture rates. During their 12-month prospec-tive RCT, observed 1 fracture in the Tai Chi group The results of the most methodologically credible RCT we compared with 3 in the control group. Because this study was reviewed suggests that 12 months of Tai Chi training for Tai not designed and powered to compare fracture rates, and be- Chi-naive practitioners resulted in a clinically and statistically cause so few fractures were observed, this data should not be significant reduction in the magnitude of tibial BMD loss of overinterpreted. Surprisingly, none of the cross-sectional Tai approximately 1.0%, as measured with QCT. The magnitude of Chi studies we reviewed included information on prevalence of this retardation in bone loss is similar to that reported in a falls or fractures. Future long-term prospective and cross- meta-analysis characterizing the effects of walking exercise on sectional studies evaluating Tai Chi for bone health should also reductions in rate of BMD loss in postmenopausal women’s include data on prevalence of fractures.
BMD (1.31% and 0.92% retardation in bone loss for hip andspine, respectively, assessed using This comparison,however, must be made cautiously, because BMD estimates CONCLUSIONS
were made at different anatomic sites and using different Conclusions on the efficacy of Tai Chi for reducing rates of instrumentation. Moreover, it is difficult to measure “exercise BMD loss in postmenopausal women are limited by the small dosage” across varied types of exercise and studies. Because no number and generally low quality of studies to date. Acknowl- studies have directly compared Tai Chi with walking, there is edging these limitations, the totality of the available evidence no exact comparability in terms of exercise, intensity, and suggests Tai Chi may be an effective, safe, and practical intervention for maintaining BMD is postmenopausal women.
The use of QCT to assess BMD in Tai Chi studies is One methodologically sound prospective RCT suggests Tai In contrast to DXA, QCT has the advantage of Chi reduces rates of tibial BMD loss, 2 sound cross-sectional Arch Phys Med Rehabil Vol 88, May 2007
studies suggest long-term Tai Chi practitioners have higher 9. McGibbon C, Krebs D, Wolf S, Wayne P, Scarborough D, Parker lumbar and femur BMD than age-matched sedentary controls.
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Arch Phys Med Rehabil Vol 88, May 2007


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Bianco - Nero Vademecum per vivere al meglio l’esperienza Cos’è il Kenya? Lingua: Kiswahili, inglese e altre 42 lingue etniche Presidenti: Kenyatta, Moi e Kibaki (dal 2001) Mortalità infantile (primo anno di vita): 77 bambini morti su 1.000 nati Mortalità infantile (primi cinque anni di vita): 120 bambini morti su 1.000 nati Debito estero pro-capite: 205 €

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