In the JournalsPerspective

Tai chi viable option for patients declining cardiac rehabilitation

Tai chi may be a safe and effective alternative option for the improvement of physical activity among patients with CHD who decline enrollment in cardiac rehabilitation, according to data published in the Journal of the American Heart Association.

According to the study background, nearly one-quarter of patients who survive an acute coronary event will experience another CV event or are at risk for mortality in the next 5 years. Despite this, more than 60% of patients decline participation in cardiac rehabilitation after MI.

“We thought that tai chi might be a good option for these people because you can start very slowly and simply and, as their confidence increases, the pace and movements can be modified to increase intensity,” Elena Salmoirago-Blotcher, MD, PhD, assistant professor of medicine at the Warren Alpert School of Medicine at Brown University, said in a press release. “Tai chi exercise can reach low- to moderate-intensity levels. The emphasis on breathing and relaxation can also help with stress reduction and psychological distress.”

Salmoirago-Blotcher and colleagues randomly assigned 29 patients with CHD declining cardiac rehabilitation (mean age, 68 years; 27% women) into two groups. The LITE patient cohort had two sessions per week for 12 weeks and the PLUS cohort had three sessions per week for 12 weeks with an additional 12 weeks of maintenance classes.

The researchers measured physical activity, quality of life and weight at baseline and again 3, 6 and 9 months after baseline. At 3 months, patients were given a stress test to measure aerobic fitness.

Physical activity benefits

At 9 months, retention rates were 90% in the LITE cohort and 88% in the PLUS cohort.

Researchers found no adverse events related to the performance of tai chi and no cardiac adverse events.

Significant mean between-group differences in moderate- to vigorous-intensity physical activity in favor of the PLUS group were observed at 3 months (100.33 minutes per week; 95% CI, 15.7-184.95; P = .04) and 6 months (111.62 minutes per week; 95% CI, 26.17-197.07). Median moderate- to vigorous-intensity physical activity was also higher in the PLUS group vs. the LITE group at 9 months (P = .03), Salmoirago-Blotcher and colleagues wrote.

Mean percentage weight loss was higher in the PLUS group (2.86 kg) vs. the LITE group (–0.45 kg).

At 3 months, quality-of-life scores were better in the PLUS group vs. the LITE group (beta = –0.69; 95% CI, –1.34 to –0.04), but the difference was not statistically significant at 6 months or 9 months, according to the researchers.

There was no change in aerobic fitness in either group.

“On its own, tai chi wouldn’t obviously replace other components of traditional cardiac rehabilitation, such as education on risk factors, diet and adherence to needed medications,” Salmoirago-Botcher said in the release. “If proven effective in larger studies, it might be possible to offer it as an exercise option within a rehab center as a bridge to more strenuous exercise, or in a community setting with the educational components of rehab delivered outside of a medical setting.”

More research needed

According to an accompanying editorial by James P. Pirruccello, MD, from the cardiology division at Massachusetts General Hospital and Harvard Medical School, and colleagues, although tai chi as a replacement for cardiac rehabilitation may be feasible and acceptable for some patients, its ability to reduce CV morbidity and mortality in patients after a coronary event requires further research.

“Ongoing efforts to understand and address the barriers to [cardiac rehabilitation] through novel and, perhaps, alternative solutions will be important on the ‘road to increased participation’ in rehabilitative services after a coronary event, with the ultimate goal of reducing disparities in care and improving secondary cardiovascular prevention,” they wrote. – by Dave Quaile

Disclosures: One author reports he is founder and sole owner of the Tree of Life Tai Chi Center. The other authors and editorial writers report no relevant financial disclosures.

 

Tai chi may be a safe and effective alternative option for the improvement of physical activity among patients with CHD who decline enrollment in cardiac rehabilitation, according to data published in the Journal of the American Heart Association.

According to the study background, nearly one-quarter of patients who survive an acute coronary event will experience another CV event or are at risk for mortality in the next 5 years. Despite this, more than 60% of patients decline participation in cardiac rehabilitation after MI.

“We thought that tai chi might be a good option for these people because you can start very slowly and simply and, as their confidence increases, the pace and movements can be modified to increase intensity,” Elena Salmoirago-Blotcher, MD, PhD, assistant professor of medicine at the Warren Alpert School of Medicine at Brown University, said in a press release. “Tai chi exercise can reach low- to moderate-intensity levels. The emphasis on breathing and relaxation can also help with stress reduction and psychological distress.”

Salmoirago-Blotcher and colleagues randomly assigned 29 patients with CHD declining cardiac rehabilitation (mean age, 68 years; 27% women) into two groups. The LITE patient cohort had two sessions per week for 12 weeks and the PLUS cohort had three sessions per week for 12 weeks with an additional 12 weeks of maintenance classes.

The researchers measured physical activity, quality of life and weight at baseline and again 3, 6 and 9 months after baseline. At 3 months, patients were given a stress test to measure aerobic fitness.

Physical activity benefits

At 9 months, retention rates were 90% in the LITE cohort and 88% in the PLUS cohort.

Researchers found no adverse events related to the performance of tai chi and no cardiac adverse events.

Significant mean between-group differences in moderate- to vigorous-intensity physical activity in favor of the PLUS group were observed at 3 months (100.33 minutes per week; 95% CI, 15.7-184.95; P = .04) and 6 months (111.62 minutes per week; 95% CI, 26.17-197.07). Median moderate- to vigorous-intensity physical activity was also higher in the PLUS group vs. the LITE group at 9 months (P = .03), Salmoirago-Blotcher and colleagues wrote.

Mean percentage weight loss was higher in the PLUS group (2.86 kg) vs. the LITE group (–0.45 kg).

At 3 months, quality-of-life scores were better in the PLUS group vs. the LITE group (beta = –0.69; 95% CI, –1.34 to –0.04), but the difference was not statistically significant at 6 months or 9 months, according to the researchers.

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There was no change in aerobic fitness in either group.

“On its own, tai chi wouldn’t obviously replace other components of traditional cardiac rehabilitation, such as education on risk factors, diet and adherence to needed medications,” Salmoirago-Botcher said in the release. “If proven effective in larger studies, it might be possible to offer it as an exercise option within a rehab center as a bridge to more strenuous exercise, or in a community setting with the educational components of rehab delivered outside of a medical setting.”

More research needed

According to an accompanying editorial by James P. Pirruccello, MD, from the cardiology division at Massachusetts General Hospital and Harvard Medical School, and colleagues, although tai chi as a replacement for cardiac rehabilitation may be feasible and acceptable for some patients, its ability to reduce CV morbidity and mortality in patients after a coronary event requires further research.

“Ongoing efforts to understand and address the barriers to [cardiac rehabilitation] through novel and, perhaps, alternative solutions will be important on the ‘road to increased participation’ in rehabilitative services after a coronary event, with the ultimate goal of reducing disparities in care and improving secondary cardiovascular prevention,” they wrote. – by Dave Quaile

Disclosures: One author reports he is founder and sole owner of the Tree of Life Tai Chi Center. The other authors and editorial writers report no relevant financial disclosures.

 

    Perspective
    John P. Higgins

    John P. Higgins

    Tai chi, "the source, the beginning," is an ancient Chinese art practiced for improving health, longevity, focus, mood and defense training. Tai chi's principle lies in the yin and yang of how forces relate to its movements, allowing a force or motion to flow through the body, rather than stopping or resisting it. In this way, a positive and a negative may be complementary and internally beneficial. Another benefit of tai chi is that it can be practiced by young or old, improves strength, mood, balance and flexibility. It is this all-ages appeal that brings its relevance center stage to cardiac rehabilitation.

    Participation in cardiac rehabilitation is notoriously bad. Typically, 20% or fewer of patients with CHD enter cardiac rehabilitation as many fear exercise after their MI/surgery, or believe it is dangerous to them; and the majority of patients who start cardiac rehabilitation eventually drop out. 

    In this study, tai chi was used in 29 men and women who had recently suffered MI and who declined cardiac rehab in a randomized fashion. One group did hospital-supervised sessions of tai chi twice a week for 12 weeks, the other did it 3 times a week for 24 weeks. In addition, both groups received instructional DVDs so they could practice at home in between hospital sessions. Within 3 months, those doing tai chi more frequently were much more active, and at 6 months, more were riding bikes, going up and down stairs, and other activities that they had been afraid to try before. So, in this sense, the tai chi activity “flowed” into other activities of daily living and exercises in a beneficial way, and in many was “the source” of their growing confidence. And tai chi is customizable to the individual patient’s abilities, and can with some simple instructional video, be done safely at home or at the local park.

    The retention rate is impressive; at 9 months approximately 90% were still doing tai chi. This is remarkable given that the figure is < 50% with traditional cardiac rehabilitation.  More studies with larger and more diverse cardiac patients are welcomed to corroborate these findings, but this is an impressive start.

    Cardiac rehabilitation has often been referred to as “the forgotten intervention,” as most patients are not referred by their physicians or they just refuse or don’t attend. Most medical providers are indifferent to cardiac rehabilitation and its benefits. This is unfortunate, as cardiac rehabilitation is associated with reductions in morbidity and mortality which exceed those gained from statins, beta-blockers, ACE inhibitors/angiotensin receptor blockers, aldosterone antagonists, aspirin and P2Y12 receptor inhibitors combined. It is invaluable when it comes to medicine, relatively inexpensive, and lives up to the saying “exercise is medicine.” So, any method that we can boost attendance and compliance with cardiac rehabilitation should be encouraged because it will improve our patients’ functional capacity, confidence, balance, flexibility, mood and quality of life, and save their lives too. Tai chi may truly be “the source, the beginning” of a new healthy chapter for our cardiac patients in the future.

    • John P. Higgins, MD, MPhil, MBA, FACC, FACP, FAHA
    • Professor of Medicine Sports Cardiologist The McGovern Medical School at UTHealth, Houston

    Disclosures: Higgins reports no relevant financial disclosures.