Tai chi for osteoarthritis_ a systematic review

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Tai chi for osteoarthritis_ a systematic review Powered By Docstoc
					Clin Rheumatol (2008) 27:211–218
DOI 10.1007/s10067-007-0700-4


Tai chi for osteoarthritis: a systematic review
Myeong Soo Lee & Max H. Pittler & Edzard Ernst

Received: 7 March 2007 / Revised: 27 June 2007 / Accepted: 29 June 2007 / Published online: 14 September 2007
# Clinical Rheumatology 2007

Abstract The aim of this study was to evaluate data from              that tai chi may be effective for pain control in patients with
controlled clinical trials testing the effectiveness of tai chi       knee OA. However, the evidence is not convincing for pain
for treating osteoarthritis. Systematic searches were con-            reduction or improvement of physical function. Future
ducted on MEDLINE, AMED, British Nursing Index,                       RCTs should assess larger patient samples for longer
CINAHL, EMBASE, PsycInfo, The Cochrane Library                        treatment periods and use appropriate controls.
2007, Issue 2, the UK National Research Register and, Korean medical databases, the Qigong              Keywords Osteoarthritis . Pain . Systematic review . Tai chi
and Energy database and Chinese medical databases (until
June 2007). Hand searches included conference proceed-
ings and our own files. There were no restrictions regarding          Introduction
the language of publication. All controlled trials of tai chi
for patients with osteoarthritis were considered for inclu-           Osteoarthritis (OA) is the most common joint disease. It is
sion. Methodological quality was assessed using the Jadad             associated with ageing and most often affects the joints of
score. Five randomised clinical trials (RCTs) and seven               the knees, hips, fingers and lower spine region. It is
non-randomised controlled clinical trials (CCTs) met all              estimated that about 10% of men and 18% of women aged
inclusion criteria. Five RCTs assessed the effectiveness of           more than 60 years have symptomatic OA [1]. Eighty
tai chi on pain of osteoarthritis (OA). Two RCTs suggested            percent of those with OA will have limitations in
significant pain reduction on visual analog scale or Western          movement, and 25% cannot perform major daily activities
Ontario and McMaster Universities Osteoarthritis Index                of life [1].
(WOMAC) compared to routine treatment and an attention                   Because there is no known cure for OA, the main
control program in knee OA. Three RCTs did not report                 therapeutic strategy is symptomatic. This includes analge-
significant pain reduction on multiple sites pain. Four RCTs          sics, nonsteroidal anti-inflammatory drugs (NSAIDS),
tested tai chi for physical functions. Two of these RCTs              COX-2 inhibitor, glucocorticoids, topical analgesics and
suggested improvement of physical function on activity of             cartilage protective agents (e.g., diacerin, glucosamin, and
daily living or WOMAC compared to routine treatment or                chondroitin) as well as exercise and surgery [2, 3]. Exercise
wait-list control, whilst two other RCTs failed to do so. In          is often recommended for management of OA [4–6], and
conclusion, there is some encouraging evidence suggesting             there is some evidence of effectiveness [7, 8]. Tai chi is a
                                                                      form of complementary therapy with similarities to aerobic
                                                                      exercise and includes relaxation, deep and regulated
M. S. Lee (*) : M. H. Pittler : E. Ernst                              breathing techniques and slow movement. It may offer
Complementary Medicine, Peninsula Medical School,                     physiological and psychological benefits for OA sufferers
Universities of Exeter & Plymouth,                                    [9]. It is claimed that tai chi is beneficial for arthritis by
25 Victoria Park Road,
                                                                      alleviating joint pain and increasing strength, flexibility and
Exeter EX2 4NT, UK
e-mail:                                          balance in older patients [10–13]. Given these reports, it
e-mail:                                             seems pertinent to evaluate the effectiveness of tai chi as a
212                                                                                               Clin Rheumatol (2008) 27:211–218

symptomatic treatment of OA. The aim of this paper was to           ing and withdrawals; the score ranges from a minimum of
systematically review and critically assess the clinical trial      zero to a maximum of five points. Taking into account that
evidence for the effectiveness of tai chi in patients with OA.      patients and therapists are impossible to blind to tai chi, one
                                                                    point was given for blinding if the outcome assessor was
                                                                    blinded. Discrepancies were resolved by discussion be-
Materials and methods                                               tween the two reviewers (MSL, MHP) and if needed, by
                                                                    seeking the opinion of the third reviewer (EE).
Data sources

Electronic databases were searched from their respective            Results
inceptions through June 2007 using the following data-
bases: MEDLINE, AMED, British Nursing Index,                        The searches identified 181 potentially relevant studies, of
CINAHL, EMBASE, PsycInfo, the of                 which, 169 studies were excluded (Fig. 1). Among these,
National Institute of Health and National Research Register,        two randomised clinical trials (RCTs) were excluded
the Cochrane Library 2007, Issue 2, Korean databases                because they did not clarify the type of arthritis [15], whilst
(Korean Studies Information, DBPIA, Korea Institute of              the other reported different outcome measures for an
Science, Technology Information, Research Information               already published trial [16]. Twelve trials, five RCTs and
Center for Health Database and Korean Medline, Korea                seven non-randomised controlled clinical trials (CCTs) met
National Assembly Library), the Qigong and Energy                   the inclusion criteria and were reviewed (Table 1). One
Medicine Database (Qigong Institute, Melon Park, version            ongoing RCT which is conducted at Turfs New England
7.3) and Chinese medical databases (China Academic                  Medical Center, USA funded by NCCAM was located from
Journal, Century Journal Project, China Doctor/Master      at ( This is a
Dissertation Full text DB, China Proceedings Conference             three-armed, single-blind RCT over a 12-week treatment
Full text DB). The search terms used were taichi or tai adj         period assessing the effectiveness of tai chi for knee pain,
chi or tai chi chun or Korean or Chinese language terms for         stiffness and physical function and health related quality of
tai chi and osteoarthritis, degenerative arthritis, osteoarthri-    life in patients with knee osteoarthritis compared with a
tis, joint pain, knee pain, hip pain and arthritis. In addition,    stretching and wellness education program.
our own department files and relevant journals [Focus on
Alternative and Complementary Therapies (FACT) up to                Study quality
June 2007] were manually searched. Several tai chi
associations (n=10) and experts (n=4) were contacted and            All included RCTs described the methods of randomisation
asked to contribute any unpublished trials. In addition, the        [17–21]. Three of the five RCTs reported details on
references of all located articles and the proceedings of the       allocation concealment [17, 18, 21]. Sufficient details of
1st International Conference of Tai Chi for Health (Decem-          dropouts and withdrawals were described in 10 of the 12
ber 2006, Seoul, South Korea) were hand-searched for                included trials [17–26], except two studies which were
further relevant articles.                                          published as an abstracts only [27, 28].
                                                                       Two of three RCTs [18, 19, 21] that analysed a sample
Study selection                                                     size of ≥40 reported intergroup differences of pain on visual
                                                                    analog scale (VAS) or Western Ontario and McMaster
All prospective controlled clinical trials of tai chi for OA (not   Universities Osteoarthritis Index (WOMAC) in favour of
just chronic pain of the knee, hip and back etc.) were included.    tai chi compared with routine treatment and attention
Trials comparing tai chi with any type of control intervention      control [18, 21]. The three CCTs with analysed sample
were included. Any trials with tai chi as a part of a complex       sizes of ≥40 reported the superiority of tai chi on pain
intervention were excluded. No language restrictions were           reduction compared with no treatment, self-help manage-
imposed. Dissertations and abstracts were also included.            ment and aquatic exercise [22, 25, 26].
Hardcopies of all articles were obtained and read in full.
Data extraction and quality assessment
All articles were read by two independent reviewers (MSL,
MHP), and data from the articles were extracted according to        Five RCTs [17–21] assessed the effectiveness of tai chi on
pre-defined criteria. The Jadad score [14] was calculated by        pain of OA compared with usual physical activity [20],
assessing three criteria: description of randomisation, blind-      routine treatment [21], attention control program [18],
Clin Rheumatol (2008) 27:211–218                                                                                               213

Fig. 1 Flowchart of trial selec-
tion process. RCT Randomised
clinical trial                     Papers identified (n=181)

                                                                                   Excluded after scanning titles / abstract
                                                                                    • Not relevant (n=129)
                                                                                     • Not concerned with OA (n=23)

                                   Papers retrieved for further evaluation
                                   (n= 29)

                                                                                     Excluded after full assessment (n=17)
                                                                                     • Not controlled trial (n=4)
                                                                                     •Duplicate publication in conference
                                                                                       proceeding (n=9)
                                                                                     • Not relevant (n=2)
                                                                                     •RCT not concerned with OA (n=1)
                                                                                     •RCT duplicate publication with difference
                                                                                       main outcome measures (n=1)

                                   Clinical trials included (n=12)
                                    • RCTs (n=5)
                                    • Non RCTs (n=7)

hydrotherapy and wait-list control [19] or Bingo recreation          reported positive effects of tai chi for pain on WOMAC
[17]. Two RCTs suggested significant pain reduction on               [23, 25], whilst one CCT failed to do so on VAS [24]. One
VAS [18] or WOMAC [21] compared to an attention                      CCT also compared tai chi with aquatic exercise [25],
control program or routine treatment in knee OA, respec-             which showed intergroup differences for pain on WOMAC
tively. Three RCTs did not report significant pain reduction         in favour of tai chi compared with aquatic exercise.
on the pain subscale of the arthritis impact measurement
scale (AIMS), WOMAC compared with usual physical                     Function
activity [20], hydrotherapy and waiting list [19] or Bingo
recreation [17] in multiple sites pain. The extent of                Four RCTs tested tai chi for physical function on WOMAC
heterogeneity of control treatment and OA sites prevented            or activity of daily living (ADL) [17–19, 21]. Two
a meaningful meta-analysis across these trials.                      suggested improvement of physical function on ADL or
   Compared with no treatment, three CCTs reported                   WOMAC scales compared to routine treatment [21] or
intergroup differences [22, 26, 27]. Three CCTs tested tai           waiting list control [19]. Compared to attention control [18]
chi for treating pain on WOMAC or VAS compared with a                or Bingo recreation [17], there were no such effects on
self-help management program [23–25]. Two CCTs                       WOMAC physical function or ADL, respectively. The
214                                                                                                                    Clin Rheumatol (2008) 27:211–218

Table 1 Summary of controlled clinical studies of tai chi for osteoarthritis

First author   Design, quality          Experimental          Control intervention   Main Outcomes       Intergroup              Author’s conclusion
(year)         scorea, allocation       intervention          (regimen)                                  differences
[ref]          concealment              (regimen)
               OA site
               Sample size
               (allocated /

Hartman        RCT, 3, n.r.             Tai Chi (60 min,      Usual physical         Pain (AIMS)         NS                      ‘Tai chi training can be a
 (2000)        Multiple joint            2 times weekly for    activity (n=16),      Arthritis self-     P<0.05                    safe and effective
 [20]           (hip, knee,              12 weeks,             routine care, total    efficacy                                     complementary therapy in
                ankles, foot)             n=19)                3 times group         Quality of life     Tension, P<0.005;         the medical management
               35/33                                           meeting, and           (AIMS)              satisfaction,            of lower extremity
                                                               telephone                                  P<0.001                  osteoarthritis’
                                                               discussion (every
                                                               2 weeks)

Song           RCT, 3, adequate         Tai Chi (60 min,      Routine treatment      Pain (WOMAC)        P<0.05                  ‘[...] tai chi exercise [...]
 (2003)        Knee                      3 times weekly for    (n=21)                Balance             P<0.005                   maybe beneficial for
 [21]          72/43                     12 weeks,                                   Physical function   P<0.01                    relieving their arthritic
                                         n=22)                                        (ADL)                                        related symptoms and
                                                                                                                                   improving balance [...]

Brismee        RCT, 4, adequate         Tai chi (40 min,      Attention control      Pain (VAS)          P<0.05                  ‘The group and home based
 (2007)         assessor blind           3 times weekly for    program (40 min,                                                    tai chi programme
 [18]          Knee                      6 weeks plus home-    3 weekly for          Physical function   NS                        provided significant knee
               41/41                     based tai chi for     6 weeks,               (WOMAC)                                      pain reduction and
                                         6 weeks, n=22)        n=19)                                                               physical function in the
                                                                                                                                   elderly with knee

Fransen        RCT, 4, n.r., assessor   Tai chi (60 min,      (A) Hydrotherapy       Pain (WOMAC)        Tai chi vs A, NS;       ‘[...] hydrotherapy or tai chi
 (2007)        blind                     2 times weekly        (60 min, 2 times                           Tai chi vs B, NS         classes can provide large
 [19]          Hip or knee               for 12 weeks,         weekly                Physical function   Tai chi vs A, NS;         and sustained
               152/152                   n=56)                 for 12 weeks,          (WOMAC)             Tai chi vs B,            improvements in physical
                                                                n=55)                                     P<0.05                   function for many older,
                                                              (B) Waiting list       Quality of life     Physical:                 sedentary individuals with
                                                               (n=41)                 (SF-12)             Tai chi vs A, NS;        chronic hip or knee OA’
                                                                                                          Tai chi vs B, NS;
                                                                                                          Tai chi vs A, NS;
                                                                                                          Tai chi vs B, NS

Adler          RCT, 3, adequate         Tai chi (60 min,      Bingo (n=11)           Pain (WOMAC)        NS                      ‘The current study will
 (2007)        Hip or knee               once weekly for                             Physical function   NS                        serve as a feasibility study
 [17]          22/14                     10 weeks,                                    (ADL)                                        for future tai chi research’
                                         n=11)                                       Psychological       NS

Park (2004)    CCT, 1, n.r.             Tai chi (50 min,      No treatment           Pain (VAS)          P<0.01                  ‘Tai chi exercise program
 [26]          Hip or knee               3 times weekly for    (n=25)                Flexibility         NS                        can be an effective nursing
               48/45                     12 weeks, n=20)                             Balance             P<0.01                    intervention to [...] reduce
                                                                                                                                   pain in patients with

Baek           CCT, 1, n.r.             Tai chi (50 min,      No treatment           Pain (VAS)          P<0.0001                ‘Tai chi exercise program can
 (2005)        n.r.                      3 times weekly for    (n=25)                Flexibility         P<0.05                    be effective nursing
 [22]          76/52                     4 weeks and 5                               Physical function   P<0.05                    intervention for
                                         times weekly for                             (ADL)                                        osteoarthritis patient to
                                         14 weeks, n=27)                                                                           improve pain, flexibility
Clin Rheumatol (2008) 27:211–218                                                                                                                              215

Table 1 (continued)

First author    Design, quality      Experimental          Control intervention     Main Outcomes             Intergroup            Author’s conclusion
(year)          scorea, allocation   intervention          (regimen)                                          differences
[ref]           concealment          (regimen)
                OA site
                Sample size
                (allocated /

Yen (2003)      CCT, 0, n.r.         Tai Chi (50 min,      No treatment             Balance                   NS                    ‘Tai chi exercise program
 [28]b          n.r.                  3 times weekly for    (n=20)                  Flexibility               NS                      might have several positive
                46/17                 6 months,                                     Quality of life           NS                      impacts in health status
                                      n=26)                                          (SF-36)                                          among the osteoarthritis
                                                                                                                                      elderly patients’

Lee (2006)      CCT, 0, n.r.         Tai chi (60 min,      No treatment             Pain (n.r.)               P<0.05                ‘Tai chi led to a significantly
 [27]b          n.r.                  2 times weekly for    (n=n.r.)                Stiffness                 P<0.05                  greater reduction in pain,
                46/n.r.               12 weeks,                                     Balance                   P<0.05                  [...], stiffness [...]’

Lee (2006)      CCT, 1, n.r.         Tai chi (60 min,      (A) Aquatic exercise     Pain (WOMAC)              Tai chi vs A          ‘[...] tai chi exercise may be
 [25]           Knee                  2 times weekly for    (60 min, 2 times                                   (P<0.05);            more suitable than aquatic
                60/50                 8 weeks, n=18)        weekly for                                        Tai chi vs B          exercise for osteoarthritis
                                                            8 weeks,                                           (P<0.05)             exercise programs’
                                                            n=16)                   Balance                   Tai chi vs B
                                                           (B) Self-help                                       (P<0.05);
                                                            management                                         A vs B
                                                            program (120 min,                                  (P<0.05)
                                                            once weekly for         Physical function         Tai chi vs B
                                                            8 weeks, n=16)           (WOMAC)                   (P<0.05);
                                                                                                               A vs B

Lee (2004)      CCT, 1, n.r.         Tai chi (60 min,      Arthritis self-help      Pain (VAS)                NS                    ‘[...] tai chi exercise program
 [24]           n.r.                  once weekly for       management              Balance                   P<0.01                  can be utilized as a safe and
                46/28                 8 weeks, n=15)        program (8 weeks,       Flexibility               Angle of right          effective nursing program
                                                            n.r. n=13)                                         ankle dorsiflexion     to improving the risk
                                                                                                               (P<0.01)               factors for fall in the older
                                                                                                                                      adults with osteoarthritis’

Cho (2007)      CCT, 1, n.r.         Tai chi (60 min,      Arthritis self-help      Pain (WOMAC)              P<0.05d               ‘The nursing interventions
 [23]           n.r.                  2 times weekly for    management              Stiffness                 NSd                     applied for osteoarthritis
                38/29                 6 weeks, n=12)        program (120 min,        (WOMAC)                                          patients [...] showed the
                                     Tai chi plus self-     once weekly for         Fatigue (Lickert scale)   P<0.005d                cost effectiveness of
                                      help managementc      6 weeks, n=13)                                                            symptoms management of
                                      (120 min, 2 times                                                                               this population.’
                                      weekly for
                                      6 weeks, n=13)

RCT Randomised clinical trial, CCT non-randomised clinical trial, n.r. not reported, NS no significant difference, VAS visual analogue scale,
WOMAC Western Ontario and McMaster Universities Osteoarthritis Index, ADL activities of daily Living, AIMS arthritis impact measurement
  Quality score: Jadad score (maximum 5 points)
  Abstract only
  Not relevant to this review
  Statistical significances were tested by the reviewers.

extent of heterogeneity (control treatment) prevented a                           intergroup differences between tai chi and self-help [25]. A
meaningful meta-analysis across these trials.                                     further CCT compared tai chi with no treatment and
   One three-armed CCT compared tai chi with aquatic                              suggested the effectiveness of tai chi on physical function
exercise and self-help management and reported significant                        assessed with ADL [22].
216                                                                                            Clin Rheumatol (2008) 27:211–218

Balance                                                             The effect sizes (ES) in terms of pain reduction were
                                                                 significant for tai chi compared with routine treatment (ES=
One RCT tested the effectiveness of tai chi on balance and       0.66) and attention control programs (ES=0.64). The effect
reported intergroup differences compared with routine            sizes of tai chi included in this review were greater than that
treatment [21].                                                  for previously reported treatments [3]. For example, the
   Three CCTs tested tai chi for balance compared with no        effect on pain in the present study was higher than the
treatment [26–28]. Two studies reported intergroup differ-       effects of NSAIDs (ES= 0.49), analgesics (ES = 0.11),
ences [26, 27], whilst the other failed to do so [28]. One       systemic corticosteroids (ES=0.11) and exercise (ES=0.35
CCT compared tai chi with self-help management and               to 0.52) according to type of exercise [3, 7]. Exercise
showed intergroup differences in favour of tai chi [24]. In a    combined with medication showed a higher ES (0.78) than
three-armed CCT [25], tai chi was found to improve               those of tai chi [3]. However, these results are difficult to
balance compared to self-help management.                        compare quantitatively due to the use of different assess-
                                                                 ment measures for evaluating pain and the use of different
Flexibility                                                      controls for evaluating the effect size. A direct comparison
                                                                 tai chi with standard treatments would be desirable.
Three CCTs compared tai chi with no treatment control for           Despite the relative lack of convincing evidence for tai
flexibility [22, 26, 28]. One study reported significant         chi, the mechanisms that could be involved suggest that it
intergroup differences [22], whilst two trials failed to do so   may have benefits. Tai chi is a form of physical exercise
[26, 28].                                                        which has effects on the cardiovascular and muscular
                                                                 systems, resulting in muscular adaptation and, ultimately,
Quality of life                                                  leads to increased muscle strength if performed regularly
                                                                 [9]. In addition to adaptation processes, these effects
Two RCTs assessed the effects of tai chi on quality of life      produce better cardiovascular function and may enhance
compared with routine treatment or hydrotherapy and              strength, balance and coordination. Furthermore, physical
waiting list control on AIMS [20] and SF-12 [19]. One            activity can improve joint stability and aid in reducing
RCT compared tai chi with routine care and reported              excess weight, effectively decreasing joint pain, increasing
favourable results for tai chi on the tension and satisfaction   function, and helpful for reducing OA disease process [2].
subscales of the arthritis impact measurement scale [20].        To date, there is insufficient data to suggest that the effects
Another RCT [19] did not find such effects on the SF-12          of tai chi are significantly different from those of
compared with hydrotherapy and waiting list controls.            conventional forms of exercise.
   One CCT failed to show a positive effect of tai chi on           When evaluating an intervention, one should assess its
quality of life with SF-36 compared with no treatment [28].      costs. No cost-effectiveness studies of tai chi for OA are
                                                                 available. The average direct cost of treating OA is
                                                                 approximately US $1,000–$2,600 per year per patient [29–
                                                                 31], and total annual costs are approximately US $5,700–
Discussion                                                       $9,880 [32, 33]. Tai chi experts estimate that 30–60
                                                                 sessions (1 h per class, two to three classes weekly for 4–
The overall findings of this systematic review suggest some      5 months) are required for treating OA. Each session would
effects in favour of tai chi for reducing pain associated with   cost up to $20. This would amount to total direct costs of
knee OA. However, the evidence is not convincing for pain        about $1,200. Thus, the direct costs for tai chi might turn
reduction or improvement of physical function. The number        out to be competitive, but reliable data are required.
of trials and total sample size are too small to draw any firm      This systematic review has several limitations. We
conclusions. One [18] of the included trials reported            cannot be absolutely certain that our searches located all
sporadic minor soreness and foot and knee pain at the first      relevant RCTs. Although strong efforts were made to
few days of intervention. None of the other reviewed trials      retrieve all RCTs on the subject, it is conceivable that some
reported any adverse events.                                     were not found. Restrictions of literature searches relating
   Among the 12 included studies, only five were rando-          to the language of publications and databases are problem-
mised [17–21]. Non-randomised trials are open to selection       atic. In this review, there were no restrictions in terms of
bias, which is likely to generate false positive results. In     publication language, and a large number of different
addition, one RCT [17] and one CCT [26] were unpub-              databases were searched. Selective publishing and selective
lished thesis, and two were a proceeding paper [27, 28],         reporting are other major causes for bias, which have to be
which have not gone through the process of formal peer           considered. It is conceivable that several negative RCTs
review.                                                          remained unpublished [34–37]. Further limitations include
Clin Rheumatol (2008) 27:211–218                                                                                                                 217

the small sample sizes and the often suboptimal quality of                 13. Wang C, Collet JP, Lau J (2004) The effect of Tai Chi on health
the primary data. One should note, however, that design                        outcomes in patients with chronic conditions: a systematic review.
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features such as placebo or blinding are difficult to                      14. Jadad AR, Moore RA, Carroll D et al (1996) Assessing the quality
incorporate in studies of tai chi and that research funds                      of reports of randomized clinical trials: is blinding necessary?
are scarce. These are factors that evidently influence both                    Control Clin Trials 17:1–12
the quality and the quantity of research.                                  15. Adler P, Good M, Roberts B et al (2000) The effects of tai chi
                                                                               on older adults with chronic arthritis pain. J Nurs Scholars
   In conclusion, there is some encouraging evidence                           32:377
suggesting that tai chi may be effective for pain control in               16. Song R, Lee EO, Lam P et al (2007) Effects of a Sun-style tai chi
patients with knee OA. However, the evidence is not                            exercise on arthritic symptoms, motivation and the performance of
convincing for pain reduction or improvement of physical                       health behaviors in women with osteoarthritis. J Korea Acad Nurs
function. Future RCTs should assess larger patient samples                 17. Adler PA (2007) The effects of tai chi on pain and function
for longer treatment periods and use appropriate controls.                     in older adults with osteoarthritis. PhD dissertation. Frances
                                                                               Payne Bolton School of Nursing, Case Western Reserve
Acknowledgements M.S. Lee was supported by the SRC program                     University, Ohio
for KOSEF (R11-2005-014), Korea.                                           18. Brismee JM, Paige RL, Chyu MC et al (2007) Group and home-
                                                                               based tai chi in elderly subjects with knee osteoarthritis: a
                                                                               randomized controlled trial. Clin Rehabil 21:99–111
                                                                           19. Fransen M, Nairn L, Winstanley J et al (2007) Physical activity
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Description: Tai Chi movement is slow, but slow makes sense. Research shows that Tai Chi and jogging on the heart as well, but the former is less physical exertion, suitable for everyone - including patients - exercise. Tai Chi to concentrate during practice must adjust their mentality and put pressure.