Farah Aleisa, MD

Zhao J, Chau JPC, Chan AWK, Meng Q, Choi KC, Xiang X, Zhao Y, He R, Li Q. Tailored Sitting Tai Chi Program for Subacute Stroke Survivors: A Randomized Controlled Trial. Stroke. 2022.

Ancient Chinese medicine suggests that Chi is aligned with our body fluids and stability of the nervous system, and it delivers functional and healing resources to all parts of the body, including the brain. It believes in the resting alert status of the body to activate circulation and facilitate oxygenation to the organs and cells. Its main outcome is harmonizing the nervous system. There are many energy channels connecting organs, glands, and cells, which are equivalent to the chemical and nervous signals. One of the modern definitions of Chi is the functionality of the chemical interactions in different body systems through enzymes, hormones, and even neurotransmitters; the methodology of Chi depends on the mind focus, breathing exercise, and specific body movements that all collaborate to enhance the efficiency of the inner chemical activities.

Dr. Zhao and his team studied the efficacy of a tailored Tai Chi rehabilitation program among stroke survivors who suffered from residual disabilities post-stroke events. The best time for rehabilitation for stroke patients is the first few days, post-stroke event, and the highest rate of recovery is up to 6 months. Beyond the 6 months period, recovery is still possible but in a much slower rate. This is the first study designed as an assessor-blind randomized controlled trial looking for the benefits of tailored Tai Chi exercises in the subacute stroke population. It enrolled patients from April 2020 to August 2020. Four separate inpatient neurology units of two tertiary A-level traditional Chinese medicine (TCM) hospitals in Kunming, China, included stroke survivors aged over 18 years, with a clinical diagnosis of ischemic stroke, with history of first-ever stroke, in the subacute stage of stroke, who can sit independently with or without cushions, use and raise at least one arm while sitting, and who are able to communicate. Few exclusion criteria were applied, like severe stroke with NIH stroke scale >16, cognitive impairment, hearing or visual disabilities, and pregnant women. Participants were randomized on a 1:1 ratio to the intervention or control groups with a block size of 8 stratified by NIHSS score (< 6 or ≥ 6) by an independent statistician according to a computer-generated randomization sequence.

There were five series of sitting Tai Chi exercises for stroke survivors with physical impairments, each with a target of strengthening the muscles for upper limb function and balance while taking into consideration survivors’ physical limitations. The series consisted of a 10-form sitting Tai Chi adapted from the 10-form Yang-style Wheelchair Tai Chi, which was offered for stroke survivors with minor weakness. Demonstration videos were recorded by the Tai Chi master. The applicability and clarity of the videos were approved by an expert and a user panel. Caregivers were involved to ensure the safety of stroke participants and to encourage them to participate and adhere to the tailored plan, ensuring continuity at home, which is similar to the rehabilitation protocol. 

Figure. Examples of movements of each series.
Figure. Examples of movements of each series.

Data were collected at baseline (T0), 1 week (T1), 8 weeks (T2), 12 weeks (T3), and 16 weeks (T4) after the commencement of the intervention by 4 trained RNs (inter-rater agreement of each instrument: 81.8%-95.5%). A sociodemographic and clinical data sheet was used to record the corresponding information. The primary outcomes were upper limb function (Fugl-Meyer Assessment Upper Extremity [FMA-UE] & Wolf Motor Function Test [WMFT]), balance control (Berg Balance Scale [BBS]), sitting balance control (Trunk Impairment Scale [TIS]), and depressive symptoms (Geriatric Depression Scale Short Form [GDS-SF]). Secondary outcomes included shoulder range of motion (ROM) (shoulder joint goniometer), shoulder pain (ShoulderQ), activities of daily living (ADL) (Modified Barthel Index [MBI]), and quality of life (QoL) (Stroke Specific Quality of Life Scale [SSQOL]).

A total of 160 participants with 800 observations for each outcome variable were measured at the five data collection time points. Stroke participants’ mean age was 62.98 years (SD: 12.85), and most of them had hemiparesis post-stroke event 75.6%, on average, 1.5 months duration prior to the beginning of the study, the median stroke severity was mild (NIHSS: 4), no significant differences in the outcomes and the number of dropouts were identified among those who continued the intervention at home compared to those in rehabilitation hospitals (p > 0.05), no adverse events were reported. The results revealed significant improvements in upper limb function in the performance time and functional ability domains of WMFT, balance control including sitting balance control, range of shoulder extension, shoulder external and internal rotation, depressive symptoms, as well in ADL’s (T2, T3, & T4), and QoL in the intervention group compared to the control group (all p-values < 0.05). The overall dropout rate was 16.3% (intervention 13.8%, control 18.8%), attendance to 80% of 208 the sessions (29 sessions) was considered adherent, among the 69 stroke participants who 209 completed the study, the compliance rate was 78.8%, a total of 43 (53.8%) stroke participants reported that they continued to practice sitting Tai Chi regularly during the post-intervention follow-up period.

This study has few limitations. Two hospitals were involved; the representativeness of the research participants may, therefore, be limited. Also, 89.6% of the potential participants were excluded due to the exclusion criteria. The main reason was safety considerations; particularly, patients with more severe deficits and more motor impairment may still benefit from a similar program. In addition, the stroke participants had performed 11 weeks of self-practice, which may have affected the internal validity of the intervention.

The study is the first RCT tailored sitting Tai Chi for stroke participants with different levels of physical impairment. The results were supporting the usefulness of a tailored sitting Tai Chi program, which doesn’t require many resources. We can look at it as a cost-effective rehabilitation tool for stroke survivors, integrating patients and their caregivers to facilitate early stroke recovery.