- CLINICAL STUDIES
Effects of Tai Chi Mind-Body Movement Therapy
on Functional Status and Exercise Capacity in
Patients with Chronic Heart Failure:
A Randomized Controlled Trial
Gloria Y. Yeh, MD, MPH, Malissa J. Wood, MD, Beverly H. Lorell, MD,
Lynne W. Stevenson, MD, David M. Eisenberg, MD, Peter M. Wayne, PhD,
Ary L. Goldberger, MD, Roger B. Davis, ScD, Russell S. Phillips, MD
PURPOSE: To examine the effects of a 12-week tai chi program
on quality of life and exercise capacity in patients with heart failure.
METHODS: Thirty patients with chronic stable heart failure
and left ventricular ejection fraction 40% (mean [. SD] age,
64 . 13 years; mean baseline ejection fraction, 23% . 7%;
median New York Heart Association class, 2 [range, 1 to 4])
were randomly assigned to receive usual care (n . 15), which
included pharmacologic therapy and dietary and exercise
counseling, or 12 weeks of tai chi training (n . 15) in addition
to usual care. Tai chi training consisted of a 1-hour class held
twice weekly. Primary outcomes included quality of life and
exercise capacity. Secondary outcomes included serum B-type
natriuretic peptide and plasma catecholamine levels. For 3
control patients with missing data items at 12 weeks, previous
values were carried forward.
RESULTS: At 12 weeks, patients in the tai chi group showed
improved quality-of-life scores (mean between-group difference
in change, –25 points, P . 0.001), increased distance
walked in 6 minutes (135 meters, P . 0.001), and decreased
serum B-type natriuretic peptide levels (–138 pg/mL, P . 0.03)
compared with patients in the control group. A trend towards
improvement was seen in peak oxygen uptake. No differences
were detected in catecholamine levels.
CONCLUSION: Tai chi may be a beneficial adjunctive treatment
that enhances quality of life and functional capacity in patients with
chronic heart failure who are already receiving standard medical
therapy. Am J Med. 2004;117:541–548. ©2004 by Elsevier Inc.
Theprevalence of chronic heart failure is increasing
as the population ages, and the disease is the most
common reason for hospitaladmission among
From the Division for Research and Education in Complementary and
Integrative Medical Therapies (GYY, DME, RSP), Harvard Medical
School, Boston, Massachusetts; Division of General Medicine and Primary
Care (GYY, RBD, RSP), Department of Medicine, and Cardiovascular
Division (BHL, ALG), Beth Israel Deaconess Medical Center,
Boston, Massachusetts; Division of Cardiology (MJW), Massachusetts
General Hospital, Boston, Massachusetts; Division of Cardiology
(LWS), Brigham and Women’s Hospital, Program for Heart Failure,
Boston, Massachusetts; and the New England School of Acupuncture
(PMW), Division for Research, Watertown, Massachusetts.
This study was supported by unrestricted educational grants from the
Bernard Osher Foundation and in part by the Beth Israel Deaconess
Medical Center General Clinical Research Center grant (RR 01032)
from the National Institutes of Health (NIH). Dr. Yeh was supported by
an NIH Institutional National Research Service Award for Training in
Alternative Medicine Research (AT00051). Dr. Phillips was supported
by a Mid-career Investigator Award from the NIH National Center for
Complementary and Alternative Medicine (AT00589). Dr. Goldberger
was supported by the NIH National Center for Research Resources
(RR13622), the National Institute on Aging (AG08812), and the G.
Harold and Leila Y. Mathers Charitable Foundation. Dr. Stevenson was
supported by the W. T. Young Foundation.
Requests for reprints should be addressed to Gloria Y. Yeh, MD,
MPH, Harvard Medical School Osher Institute, 401 Park Drive, Suite
22A, Boston, Massachusetts 02215, or gyeh@caregroup.harvard.edu.
Manuscript submitted November 6, 2003, and accepted in revised
form April 15, 2004.
© 2004 by Elsevier Inc.
All rights reserved.
Medicare patients. Approximately 5 million adults in the
United States are affected, with 550,000 new cases diagnosed
each year (1). Despite advances in pharmacologic
therapy, such as the use of angiotensin-converting enzyme
inhibitors and beta-blockers, patients with heart
failure experience progressively deteriorating function.
Reduced physical activity in patients with heart failure
leads to progressive deconditioning and exercise intolerance
(2). Trials have shown exercise to be associated with
improvements in exercise capacity, left ventricular hemodynamics,
and quality of life (2,3); attenuation of neurohormonal
activation and ventricular remodeling (4,5);
and decreased risk of hospitalization and death (6). These
studies, however, varied in the type of physical activity,
setting, duration, and intensity. Current American Heart
Association guidelines do not specify a standard exercise
prescription for patients with heart failure (2).
Tai chi is a mind-body movement therapy with origins
in traditional Chinese martial and healing arts. Although
widely practiced in Asia, particularly among the elderly,
its popularity is increasing in the United States. Reported
benefits include increased balance and decreased incidence
of falls (7–9), increased strength and flexibility
(8,10 –12), reduced pain and anxiety (13,14), improved
0002-9343/04/$–see front matter 541
doi:10.1016/j.amjmed.2004.04.016
Tai Chi Mind-Body Movement Therapy/Yeh et al
Table 1. Outline of the Tai Chi Intervention
Approximate Duration
Week Activities (min)
1 Introductory Session: Overview of Program
1. Tai chi principles, philosophies 15
2. Demonstration of tai chi form 10
3. Expectations of participants 10
4. Description of class format 5
5. Participation in warm-up exercises 30
2–5 Warm-up Exercises (Repeated during All Sessions)
1. Standing
a) “Drumming the body” 6
b) “Swinging to connect kidney and lungs” 3
c) “Washing the body with qi” 3
d) Standing meditation and breathing 3
2. Sitting
a) Neck/shoulder stretches 6
b) Arm/leg stretches 3
c) Sitting meditation and breathing 6
Total Warm-up time 30
Tai Chi Movements
1. “Raising the power” 5–10
2. “Withdraw and push” 5 per side
(Warm-up and Movements 1–2)
3. “Grasp sparrow’s tail” 5 per side
4. “Brush knee twist step” 5 per side
10–12 (Warm-up and Movements 1–4)
5. “Wave hands like clouds” 5–10
self-efficacy (15,16), and enhanced cardiopulmonary
function (10,11,17–20). Despite the lack of randomized
controlled trials, tai chi has become available in some
cardiac rehabilitation programs (21).
Tai chi incorporates both physical and meditative elements,
which makes it distinctly different from conventional
treadmill or bicycle workouts. It is relatively non-
strenuous and low impact, and is characterized by
postural alignment, weight shifting, and relaxed circular
movements. Tai chi has been estimated to equal about 2
to 4 metabolic equivalents, comparable with mild-moderate
aerobic exercise (22,23). Exercise trials have suggested
that lower intensity activity may be as beneficial as
exercise of higher intensity in heart failure patients (24).
Tai chi may thus be suitable for older or severely deconditioned
cardiac patients. Our objective was to investigate
whether tai chi is beneficial as an adjunctive treatment to
usual care for patients with chronic heart failure.
METHODS
Study Design
A total of 30 patients were recruited from advanced heart
failure clinics at Beth Israel Deaconess Medical Center
and Brigham and Women’s Hospital in Boston, Massa
chusetts. Clinicians approached eligible patients to discuss
enrollment in a study of “tai chi, a slow-moving and
meditative exercise.” Patients were assigned randomly to
receive either 12 weeks of tai chi training in addition to
their usual care, or to usual care alone, without a formal
supervised exercise protocol. Usual care included pharmacologic
therapy, dietary counseling, and general exercise
advice per American College of Cardiology/American
Heart Association guidelines (3). Patients receiving
usual care only were offered tai chi at the conclusion of
the study. We used permuted block randomization with
variable block size to generate treatment assignments. Assignments
were sealed in sequentially numbered, opaque
envelopes and opened by an unblinded investigator following
the patient’s baseline testing. All patients provided
written informed consent. Each institution’s human subjects
review board approved the protocol.
Study Sample
Inclusion criteria comprised left ventricular ejection fraction
40% by echocardiography in the past year and
maintenance on a stable medical regimen, defined as no
major changes in pharmacologic therapy in the past 3
months. Exclusion criteria comprised unstable angina,
myocardial infarction, or cardiac surgery within the past
3 months; uncontrolled cardiac arrhythmias; major
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Table 2. Baseline Characteristics of the Study Sample
Tai Chi (n Control
Characteristic . 15) (n . 15) P Value
Mean . SD or Number (%)
Age (years) 66 . 12 61 . 14 0.67
Male sex 10 (67) 9 (60) 0.71
Race 0.28
Black 7 (47) 4 (27)
White 8 (53) 9 (60)
Asian 0 2 (13)
Baseline ejection fraction (%) 24 . 7 22 . 8 0.43
New York Heart Association class 2.2 . 1.0 2.2 . 0.6 0.19
I 4 (27) 1 (6.6)
II 6 (40) 9 (60)
III 3 (20) 5 (33)
IV 2 (13) 0
Medications
Angiotensin-converting enzyme inhibitor 13 (87) 14 (93) 0.54
Beta-blocker 14 (93) 13 (87) 0.54
Loop diuretic 13 (87) 15 (100) 0.48
Digoxin 11 (73) 8 (53) 0.45
Spironolactone 4 (27) 4 (27) 1.00
Cholesterol-lowering agent 5 (33) 6 (40) 0.70
Heart failure etiology 0.79
Idiopathic dilated 9 (60) 8 (53)
Ischemic 4 (27) 4 (27)
Alcohol-related 1 (7) 1 (7)
Hypertensive 0 1 (7)
Peripartum 1 (7) 0
Adriamycin-induced 0 1 (7)
Cardiovascular-related comorbid conditions
Coronary artery disease 4 (27) 7 (47) 0.45
Implanted cardiac device* 6 (40) 4 (27) 0.70
Arrhythmia 10 (67) 6 (40) 0.27
Valvular heart disease 7 (47) 3 (20) 0.25
Hypertension 11 (73) 9 (60) 0.70
Diabetes 3 (20) 5 (33) 0.68
* Automatic implanted cardiac defibrillator or pacemaker.
structural valvular disease; current participation in a conventional
cardiac rehabilitation program; lower extremity
amputation; cognitive dysfunction; and inability to
speak English.
Intervention
The intervention consisted of 1-hour group tai chi classes
held twice weekly for 12 weeks. A standard protocol of
meditative warm-up exercises followed by five simplified
tai chi movements (25) was developed by an experienced
tai chi instructor (PMW) (Table 1). Program development
was guided by similar interventions used in prior tai
chi trials involving elderly patients and those with limited
mobility (26). The five core movements, adapted from
Master Cheng Man-Ch’ing’s Yang-style short form, were
chosen for ease of comprehension and their ability to be
performed in cyclic repetition. Traditional warm-up ex
ercises included weight shifting, arm swinging, visualization
techniques, and gentle stretches of the neck, shoulders,
spine, arms, and legs. These exercises focus on
releasing tension in the physical body, incorporating
mindfulness and imagery into movement, increasing
awareness of breathing, and promoting overall relaxation
of body and mind. Chairs were provided for resting at any
time, and patients were allowed to progress at their own
pace. Each class was supervised by a physician (GYY,
MJW). In addition, there was a 35-minute instructional
videotape outlining the warm-up exercises and tai chi
movements presented in class. Patients were encouraged
to practice at home at least three times per week.
Main Outcome Measures
Quality of life. Quality of life was measured using the
Minnesota Living with Heart Failure Questionnaire (27).
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Tai Chi Mind-Body Movement Therapy/Yeh et al
Figure 1. Change in Minnesota Living with Heart Failure quality-of-life scores from baseline to 12 weeks. Means (. SD) are shown
in bold. At 12 weeks, patients in the tai chi group reported significantly better quality-of-life (lower scores) as compared with those
in the usual care group (P . 0.001).
This self-assessment instrument consists of 21 items covering
physical, psychological, and socioeconomic dimensions
of illness, and quantitates the disability related to
each item on a 6-point response scale. Scores range from
0 to 105, with a lower score denoting a more favorable
functional status. Prior studies have reported that a score
of 7 indicates some degree of impaired quality of life and
that an improvement of 5 points represents a clinically
meaningful change (2).
Exercise capacity. Patients performed a standardized
walk test that measures the distance walked at a comfortable
pace in 6 minutes. This test correlates with peak oxygen
uptake, and has been used to assess functional capacity
and predict survival in heart failure drug trials
(28). Although the assessor was not blinded to the intervention
group, the person administering the test read
standard scripted instructions to each patient, stood at
the same place along the corridor, and remained otherwise
silent for the 6-minute duration.
In addition, patients performed a symptom-limited
exercise test using a bicycle ramp protocol to determine
peak oxygen uptake. Testing was performed on an electronically
calibrated bicycle, with expired gas analysis under
continuous electrocardiographic monitoring. Blood
pressure was taken at 3-minute intervals. Respiratory gas
analysis was performed on a breath-by-breath basis using
a Sensormedic metabolic cart (Yorba Linda, California).
Peak values were averaged from the final 20 seconds of the
test. Tests were performed by blinded assessors. Peak oxygen
uptake has a strong linear correlation with cardiac
output and skeletal muscle blood flow, and has been used
as a criterion to predict when patients with chronic heart
failure should undergo cardiac transplantation (29).
Secondary Outcome Measures
Serum biomarkers. B-type natriuretic peptide samples
were analyzed on whole blood collected in ethylenediaminetetraacetic
acid using a fluorescence immunoassay
(Biosite Triage BNP Test; San Diego, California). Levels
Figure 2. Change in 6-minute walk distance from baseline to 12 weeks. Means (. SD) are shown in bold. At 12 weeks, patients in the
tai chi group performed significantly better as compared with those in the usual care group (P . 0.001). Imputation methods (last
value carried forward) were used for missing 12-week data, affecting 1 patient in the control group.
544 October 15, 2004 THE AMERICAN JOURNAL OF MEDICINE. Volume 117
Tai Chi Mind-Body Movement Therapy/Yeh et al
Table 3. Comparison of the Effects of Tai Chi versus Usual Care Only on Changes in Outcomes during the 12-Week Trial
Outcome Measure
Tai Chi (n . 15)
Baseline 12-Week
Control (n . 15)*
Baseline 12-Week
Between-Group
Difference in Change P Value
Mean . SD
Mean (95%
Confidence Interval)
Minnesota Living with Heart
Failure score†
43 . 21 26 . 23 44 . 20 52 . 25 25 (36 to 14) 0.001
6-minute walk (m)
Peak oxygen uptake
(mL/kg/min)
Serum B-type natriuretic
peptide† (pg/mL)
Plasma norepinephrine
(ng/mL)
327 . 106
10.5 . 3
329 . 377
1.3 . 0.7
412 . 116
11.4 . 3
281 . 365
1.9 . 2.3
340 . 117
11.1 . 6
285 . 340
1.2 . 0.8
289 . 165
10.4 . 6
375 . 429
1.4 . 0.7
135 (85 to 185)
1.6 (0.2 to 3)
138 (257 to 19)
0.35 (0.84 to 1.54)
0.001
0.08
0.03
0.77
* Imputation methods (last value carried forward) were used for missing 12-week data, affecting 1 patient in the control group for quality-of-life score
and serum B-type natriuretic peptide level, and 3 patients in the control group for peak oxygen uptake.
† Lower values indicate improvement. Thus, a negative between-group difference in change for quality-of-life score and B-type natriuretic peptide
level suggests improvement, while a positive value for the 6-minute walk test suggests improvement.
correlate positively with the degree of left ventricular dysfunction;
serum levels 100 pg/mL support a diagnosis
of symptomatic heart failure (30).
Catecholamine samples were drawn on ice in heparinized
tubes after 20 minutes of rest with an intravenous
catheter in place. After centrifugation, plasma was separated
and stored at –70°C. Analyses for norepinephrine
were performed using high-performance liquid chromatography/
electrochemical detection.
Continuous ambulatory electrocardiographic recording.
Patients underwent 24-hour ambulatory electrocardiographic
monitoring to assess the prevalence and
frequency of cardiac arrhythmias. Recordings were performed
using a Marquette Electronics series 8500 Holter
monitor (Milwaukee, Wisconsin), digitized at 128 Hz,
and annotated using a Marquette Electronics MARS 8000
Holter scanner. Annotations were verified manually and
edited by an experienced technician who was blinded to
treatment assignment.
Timing of Measurements
All measures were obtained at baseline and 12 weeks.
Measurements for the quality-of-life assessment,
6-minute walk test, and peptide levels were also obtained
at 6 weeks in the event that data at 12 weeks were unavailable.
Additional Data Collection
At baseline, we asked patients to rate their expectations of
the helpfulness of tai chi on a 10-point visual analog scale,
where 10 indicated the highest expectation. At each follow-
up visit, we collected data on current medications,
regular activity level, recent emergency department visits,
and recent hospitalizations. For patients in the intervention
group, we also monitored attendance at classes and
compliance with home tai chi practice. At two separate
sessions (at approximately 6 and 12 weeks), heart rate and
blood pressure were taken immediately before and after
the class, each after 2 minutes of restful sitting.
Statistical Analysis
All statistical analyses were performed on an intention-
to-treat basis. Baseline characteristics of patients were
compared using t tests for continuous variables and the
Fisher exact test for nominal variables. Two-sample Wilcoxon
rank sum tests that adjusted for baseline scores
were used to compare the distribution of changes after 12
weeks between treatment and control groups. Data on
blood pressure and heart rate before and after tai chi sessions
were analyzed using paired t tests. Metabolic stress
test and Holter data for 3 patients in the control group
were unavailable at 12 weeks: 1 patient was too debilitated
to perform the tests, another refused, and the third was
only available for telephone-follow-up. For this last patient,
we were also unable to gather 6-minute walk, natriuretic
peptide, and catecholamine measurements at 12
weeks. The last value was carried forward for analyses
missing these items. Analyses were performed using SAS
statistical software, version 8 (Cary, North Carolina). P
values 0.05 were considered significant.
RESULTS
Thirty patients were recruited and followed between January
2002 and March 2003 (Table 2). The mean (. SD)
age was 64 . 13 years; the mean baseline ejection fraction
was 23% . 7%; and the median New York Heart Association
class was 2 (range, 1 to 4). There were no significant
differences between groups in demographic characteris-
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Tai Chi Mind-Body Movement Therapy/Yeh et al
Figure 3. Change in peak oxygen uptake from baseline to 12 weeks. Means (. SD) are shown in bold. At 12 weeks, there was no
significant difference between the two groups (P . 0.08). Imputation methods (last value carried forward) were used for missing
12-week data, affecting 3 patients in the control group.
tics, clinical factors, and rates of cardiovascular-related
disease.
More than three quarters (77%) of patients reported
some regular physical activity at home, such as walking.
Similar proportions of patients in each group reported
exercising (intervention: 14/15; control: 12/14). The duration
of exercise ranged from 5 to 65 minutes, and the
frequency ranged from once a week to daily.
Both groups had similar expectations of the helpfulness
of tai chi at the beginning of the study (intervention:
6.5; control: 7.1; P . 0.4).
Changes in Outcome Measures from Baseline to
12 Weeks
Compared with controls, patients in the tai chi group
showed statistically significant improvement in quality-
of-life scores (Figure 1), 6-minute walk distances (Figure
2), and serum B-type natriuretic peptide levels (Table 3).
Changes in peak oxygen uptake were not significant, although
the intervention group showed an improvement
of almost 1 mL/kg/min, while the control group showed
deterioration of 0.7 mL/kg/min (Figure 3). There were no
significant trends seen in resting catecholamine levels.
Twenty-four– hour Holter monitoring revealed no
clinically important intraindividual differences in the incidence
of arrhythmia at baseline and 12 weeks. One patient
in the control group with a known history of intermittent
atrial fibrillation was in normal sinus rhythm at
baseline but in atrial fibrillation at 12 weeks.
Adverse Effects
No adverse events occurred during the tai chi sessions.
One patient in the intervention group and 4 in the control
group were hospitalized during the study period for exacerbation
of symptoms of heart failure. There were no
deaths during the 3-month study period in either group.
We did not detect any significant changes in mean blood
pressure (119/72 mm Hg vs. 117/72 mm Hg, P . 0.4) or
heart rate (75 beats per minute vs. 73 beats per minute, P
. 0.3) immediately before and after a tai chi session.
Patients in the intervention group attended 83% (20/
24) of class sessions, and 93% of patients (n . 14) reported
home tai chi practice for a mean duration of 86
minutes per week. All patients rated the tai chi sessions
highly (4 ona0to4 visual analog scale for enjoyment)
and expressed interest in additional instruction. Fourteen
planned to continue with tai chi on their own after the
study.
DISCUSSION
We found that tai chi enhanced the quality of life and
functional capacity in patients with chronic heart failure
who were already undergoing standard cardiac care.
These patients demonstrated improvements in 6-minute
walk distances and quality-of-life scores compared with
patients who did not practice tai chi. In addition, patients
who practiced tai chi had reduced B-type natriuretic peptide
levels, suggesting an improvement in cardiac filling
pressures.
In patients with comparable disease severity, similar
changes in exercise tolerance have been seen with conventional
training. Trials involving step aerobics, treadmill
or bicycle exercise, or arm or rowing ergometers have
reported increases of 10% to 20% in the 6-minute walk
test and of 12% to 31% in peak oxygen uptake (4,6,31–
34). We found a comparable increase of about 25% in the
6-minute walk test among patients in the tai chi group.
Results of quality-of-life measures in conventional exercise
trials have been mixed (6,32,35–37). We, however,
observed a large difference in Minnesota Living with
Heart Failure scores between the intervention and control
groups. Similar to our findings, conventional exercise
546 October 15, 2004 THE AMERICAN JOURNAL OF MEDICINE. Volume 117
Tai Chi Mind-Body Movement Therapy/Yeh et al
trials have failed to show consistent changes in resting
norepinephrine and epinephrine levels (32,38). To our
knowledge, longitudinal effects of conventional exercise
on serum B-type natriuretic peptide levels have not been
studied previously (39).
Our findings support prior research on tai chi and cardiovascular
disease. One prospective, noncontrolled trial
of 5 patients reported improvements in quality of life,
6-minute walk test distance, and symptoms after a 12week
intervention (21). Other controlled trials reported
improvements in blood pressure in patients after myocardial
infarction (19) and increases in peak oxygen uptake
and work rate following coronary bypass surgery
(18). Observational studies have suggested increased
exercise endurance and cardiac output, and decreased peripheral
vascular resistance and adrenergic tone
(10,11,17,40 – 42).
Tai chi appears to be a safe alternative to conventional
exercise training. No adverse events have been reported
previously, and we observed none in this study. Overall,
the adverse event rate in conventional exercise trials is
low. However, cases of worsened heart failure, arrhythmias,
and hypotension have been reported, and minor
musculoskeletal injuries are common (2). In contrast, tai
chi encourages patients to move fluidly with less strain,
and may be beneficial for patients with musculoskeletal
conditions, such as osteoarthritis or rheumatoid arthritis
(13,43).
It is unclear what component of tai chi is responsible
for the observed benefits. Physical activity can have important
effects, yet tai chi is a lower intensity activity than
those previously studied. Some studies have reported
benefits of meditation and relaxation techniques in patients
with heart failure (44-46). Further understanding
of these components, individually and in combination,
may help to define the mechanisms of tai chi.
Our study has several limitations. First, the inability to
blind patients to treatment assignment and unblinded
assessment of the 6-minute walk test may have influenced
results. In addition, with only 30 patients, the study had
limited power to detect differences in peak oxygen uptake.
Although we were unable to adjust for social interaction,
any effects on mood or perceived quality of life
would have been unlikely to account for the magnitude of
change reported in exercise capacity.
In conclusion, this study provides information on
meditative exercise among patients with heart failure.
Given the benefits we observed, large-scale investigations
are warranted and should include blinded assessments
and a comparison group that adjusts for group social effect.
Other endpoints might include left ventricular hemodynamics,
autonomic tone, serum biomarkers of cardiac
and immune function, and survival. Further studies
might also define the population most likely to benefit
from this type of intervention and assess whether the ob
served benefits can be sustained or increased. Finally,
comparisons with conventional treadmill or bicycle ergometer
exercise should help define the role of tai chi in
the management of patients with heart failure.
ACKNOWLEDGMENT
We would like to express our gratitude to all the patients, physicians,
nurses, laboratory staff, and tai chi instructors, and everyone
involved in this study. The support and participation of
all were invaluable.
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548 October 15, 2004 THE AMERICAN JOURNAL OF MEDICINE. Volume 117
Brother Bernard Seif, SMC, EdD, DNM
420 Frantz Road - Salesian Monastery (Not 414, which is an internet error)
Brodheadsville, PA 18322-7722
United States / e-mail: monk@epix.net
Harvard Medical School Osher Institute