Anxiety is a multi-faceted disorder that appears to be growing in prevalence. Since exacting definitions of the condition are hard to develop it is not known for certain whether anxiety is in fact, worse, or simply that the reporting of it is more common in an era when we are more cognizant of psychological maladies. The study in question by Hoffmann-Smith et al from 2009 describes well the potential toll anxiety can take on the social, emotional and economic functions of individuals and their resulting effect on society.
It also demonstrates the drawbacks of treatment through traditional medicine. Therefore, the careful study of alternative treatments such as Tai Chi (Qigong) is well-justified. This study by Hoffmann-Smith et al evaluated the psychological and physical effects of an intervention based on Tai Chi exercise. The authors conclude that the effect of Tai Chi on anxiety is promising but stop short of drawing direct causal links between the two. Despite its flaws, the study does highlight the potential for future research. Background The positive effects of exercise on well being are firmly established.
What benefits the body benefits the mind. Unfortunately many people have difficulty finding the time or interest to do it on a regular basis. This lack of exercise contributes to the anxieties of modern life. Many sink into a cycle where decreasing health causes increasing anxiety and vice-versa. Untreated or uncontrolled anxiety can have profoundly negative effects on the individual and on society. Quality of life may be compromised. In some cases “affected individuals may have a lower than normal life expectancy” (Zhang, 2008).
The social and financial costs of dealing with this widespread affliction warrant research into Tai Chi and other alternative methods for controlling it. Tai Chi, also called Qigong, is literally translated as meaning “supreme ultimate power”. It was developed centuries ago as part of the fitness regimen for martial arts. It is now part of traditional Chinese medicine. It still enjoys widespread usage in Asia and, increasingly, in the West. The reasons for doing Tai Chi range from spiritual enlightenment to simple exercise. Tai Chi, in its original form, is more than physical exercise.
The intent is to form mind-body-spirit connections and exploit the energy that exists within and around all persons. According to Hoffmann-Smith et al. “This mind-body exercise is a standard of medical care in many Asian countries” (2009). In the Western world Tai Chi is a popular aspect of the self-help trend of alternative medicine. A “mainstreaming” of Tai Chi has occurred in recent years as classes have become offered everywhere from Universities to local recreation centres. Study Purpose The goal of the study is to “explore the effects of Tai Chi on a clinical ambulatory population…
” (Hoffmann-Smith et al. , 2009). It can only be assumed that the vagueness of the study goal is by design. The authors are unwilling to put forward a strong hypothesis in any direction. Rather, the goals are observation and analysis without any particular bias at the outset. The study does not contain a substantial Literature Review because there is not a great deal of literature to choose from. More generic literature on anxiety is used to illustrate the problem. A few studies on Tai Chi are cited. Most surveys conclude that the research on alternative medicine, Tai Chi and anxiety are flawed.
Zhang writes that: The article acknowledges the lack of research and does not rely heavily on it in drawing its conclusions. Most of the research is applicable and up to date, with the possible exception of the slightly dated material on the effects of anxiety disorders. A more comprehensive review could have made for an even stronger case for research such as this as well as allowing for the development of applicable practises in the clinical setting. The article is referred to as a pilot study because the authors were unable to locate any directly similar research.
Methodology, Results and Discussion This intervention began with of an interview of 66 subjects, 19 of which ultimately completed the protocol. Subjects were interviewed using the Hamilton Anxiety Rating Scale. Psychiatrists conducted the interviews. The subjects were acquired from physicians’ offices and hospitals. Those having prior experience with Tai Chi and those with severe heart problems were not accepted. Consent was obtained and reviewed by an outside agency. A ten week session of Tai Chi was administered by qualified instructors who were also physicians. Classes were held twice weekly.
Subjects who were absent more than three times were dropped from the protocol. Graphics illustrating the 24 Tai Chi forms are well-constructed. A simple, but effective bar graph comparing starting and ending Ham-A scores is presented as well as a table that stratifies those results in more detail. All of the results are self-report. Independent measures of anxiety such as blood pressure and pulse rate are not included within this study, except as indicated by the subjects. The authors make their conclusions based on improvements in the Ham-A score from baseline levels.
They conclude that: “This pilot study confirms that psychological benefit may result from the alternative discipline of Tai Chi” (Hoffmann-Smith, et al 2009). Data collection methods were spelled out clearly, but there is some room for subtlety within the results. Those subtleties raise the potential for error. Any downward change in Ham-A scores is considered improvement no matter how small. One weakness in this approach is that, conceivably, Ham-A scores could differ from the norm on any given day. Since this is not a time study we do not know the long-term effects of the intervention.
The authors note that in a potential case of bias, subjects were reporting their results to the same doctor who taught their Tai Chi class. In other words they may have felt compelled to tell him what they thought he wanted to hear. Along those lines, the study results stunned even the authors of the study. “It was especially surprising to investigators that such dramatic improvements were made… ” (Hoffmann-Smith, et al. , 2009). For example, anxious mood scores improved by 84%. Tension improved by 79%. This may be an indication that Tai Chi is highly effective in treating anxiety, or it may be a clue that the study is highly flawed.
Tai Chi is not necessarily an activity that lends itself easily to formal evaluation. Other researchers have found that “The richness and complexity of Tai Chi poses challenges related to the traditional distinction between specific and nonspecific effects” (Wayne and Kaptchuk, 2008). Therefore, even when some degree of internal validity may be ensured, generalisability is often more difficult. The authors note challenges t o internal and external validity such the lack of variable control and the small sample size. They make recommendations for further study.
These recommendations include the use of more screening tools, larger sample sizes and the use of a control group. Ethical considerations for this study are minimal. Subjects must be carefully screened to ensure that doing the exercises will not cause injury. Subjects should know what the movements are before giving informed consent. Analysis and Conclusion The greatest challenge to the validity of this study was the smallness of the sample size. Only fourteen women and five men finished the ten week intervention. Their average age was in the low-50s.
It may be informative to have data from those who left the protocol for reasons other than being disqualified. A minimal amount of diversity among the group that finished limits the extent to which the results can be applied to varied groups. Still, the reports given by those who finished are encouraging. The results of this study are similar to other studies finding that “Tai Chi appears to be associated with improvements in psychological well-being including reduced stress, anxiety, depression, and mood disturbance, and increased self-esteem” (Wang, 2009).
In an era when personal and societal costs of traditional medicine are spiraling upward this could be an important finding. There may be tremendous potential for reducing overall anxiety levels and dependence on pharmaceuticals while increasing flexibility and options for clinicians in the field. That being said, the research is still in its infancy. The authors are aware of many of the drawbacks to existing research on alternative medicine, in general, and in Tai Chi specifically. A meta-analysis by Zhang found that: “Many previous studies of it [alternative medicine] were poorly designed and had observer bias” (2008).
While not disqualifying the need for research, this does point to the need for refining of study targets, methods and evaluation. Those attempting to measure the effects of Tai Chi solely by quantitative means may be missing the boat however. As Mayer puts it: “Whether Qigong [Tai Chi] alone can affect hypertension is not necessarily the most important question” (2007). More detailed, in-depth studies over time are needed to parse out subtle effects that might, in the long run, be of great benefit. Tai Chi in its original form is not just an exercise of the body but also of the mind and spirit.
The latter two elements are not dealt with specifically in this study. The intervention is primarily one of physical exercise. This begs the question: Could almost any form of exercise achieve similar results? Is there something special about Tai Chi? These questions are far from being answered. Until more detailed study is done it is difficult to parse out the particular effects of Tai Chi. It is something that could be tried in a clinical setting however, as long as the instructor is qualified and the patient is healthy enough. If the patient believes it is helping, then it probably is helping.
Tai Chi, by itself, is not likely to be a long-term solution to anxiety or its many co morbidities. This study showed promise but the generalisability of its results is extremely limited. The research design is sufficient to answer the question because the research question itself only calls for an investigation into the issue. The study can be refined, expanded and replicated. Future research should focus on long-term effects and try to include some “hard” medical data in addition to client and professional perspectives. Doing so will allow for greater integration into practice within various fields.
At this point, there is not enough research to indicate that Tai Chi should be used as a replacement for traditional anxiety treatments. There are situations, however, where Tai Chi may be able to maximize the effects of traditional treatments. Sources Benson, Herbert and Eileen Steward. (1991). The Wellness Book: The comprehensive guide to maintaining health and treating stress-related illness. Secaucus, New Jersey: Carol Pub. Group. Chang, Rei-Yeuh and Malcolm Koo, et al. (2008). “The Effect of Tai Chi Exercise on Autonomic Nervous Function of Patients with Coronary Artery Disease”.
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