The first draft

This section will discuss the first draft of the class exercises for the TCAS programme before amendments were made following the collaboration with the Tai Chi instructor (see

Appendix 3). The following discussion includes each individual exercise for both the classes and home practice, along with the justification for its inclusion. Additionally, justification for duration and intensity shall also be given attention.

The first draft of the TCAS programme was split into six parts:

1) Beginning meditation 2) Joint-loosening exercises 3) Leg-strengthening exercises

4) Tai Chi stepping (walking like a cat) 5) The Tai Chi movements

6) Closing meditation

1. Beginning meditation (sitting)

According to ancient tradition, mindfulness is important; meditation practice in the form of mindfulness-led breathing can improve psychological capacities and cognitive performance (Lee, 2018). Lee (2018) suggests that mindfulness-led breathing with accordant body postures of Tai Chi may affect the emotions in a positive way, reducing fear and inducing a relaxed state. According to one Tai Chi instructor, ‘one exhales more strongly when one is angry, whereas when one is calm, exhalation and inhalation are equal’ Yang (2010).

Participants involved in the TCAS programme may need to control their breathing pattern because of worry and stress associated with life changes following stroke. In a study exploring the effect of Tai Chi on preventing falls in the general elderly, it was suggested that by meditating at the beginning of the class, obtrusive thoughts, fears or anxieties which may distract the practitioner from focusing on Tai Chi movements, are avoided (Bartimole & Fristad, 2017).

Meditation leads to a deep awareness of the present moment through calming the mind, resulting in positive physical and emotional effects (Wright, 2007), including improving confidence, quality of life and motivation (Posadzki & Jacques, 2009). Meditation through mindful breathing exercises may help to reduce reactivity to repetitive thoughts and is used as a stress-management approach (Feldman, Greeson & Senville, 2010). According to Tappan (2002), who conducted a study on rehabilitation for balance and attention

impairment in people with an intracranial bleed, a lack of awareness of the present moment may lead to loss of balance. It is not known if Tai Chi studies involving stroke survivors utilised meditation as part of their intervention, though four studies included what the authors called a ‘warm up’ (Kim et al., 2015; Pan et al., 2017; Taylor-Piliae at al., 2014a;

Wang et al., 2010). By including meditation at the beginning of the TCAS programme, stroke survivors may be able to control their breathing and thus acquire a calm mind without any distractive thoughts which could lead to a loss of balance whilst practising Tai Chi.

2. Joint-loosening exercises

Many Tai Chi instructors recommend relaxing the joints as part of a warm-up before practising Tai Chi (Galante, 1980). Wu (2012) found that 15 minutes of repeated dynamic ankle joint exercise with weight-loading in whilst stationary may reduce ankle spasticity and improve walking ability. Loosening certain joints, such as the ankles, wrists, head, neck, shoulders and elbows exercises will, therefore, be included in the TCAS programme before practising Tai Chi.

3. Leg-strengthening exercises

Before starting any Tai Chi exercise, including stepping, practitioners should adopt a safe stance to avoid loss of balance. Wu (2012) suggested in a paper about the biomechanical characteristics of stepping in older Tai Chi practitioners, that by keeping the head forward as opposed to looking down to see where the feet are going, maintains balance. Wu (2012) further suggests that by keeping the head upright and gaze straight ahead, any mental distraction will be minimised, which is important because mental distractions have been found to have a direct impact on postural stability and balance on healthy older adults (Wu, 2012).

A semi-squat position is encouraged whilst performing the continuous, curved and spiral body movements that are characteristic of Tai Chi; during this semi-squat position, body weight is evenly distributed between the fore-foot and the rear-foot, and a large medial-lateral displacement of the foot centre of pressure (Lan, Chen, Lai & Wong, 2013). Older participants may not be able to maintain a semi-squat position, so Lan et al. (2013)

recommend a higher posture should participants have muscle weakness (Lan et al., 2013).

For those who may benefit from more advanced rooting exercises, single-leg rooting (bearing weight on one leg whilst raising the foot lightly off the floor) may be used as an advanced strengthening exercise. Single-leg dynamic balance exercise may improve

dynamic stability rapidly. Single-leg rooting was, therefore, included in the first draft of the TCAS programme included.

4. Tai Chi stepping (walking like a cat)

Tai Chi may be beneficial in improving stepping in stroke survivors; it has been shown that those who practise Tai Chi long-term step better than non-Tai Chi practitioners (Wu, 2012).

The author suggested this was because Tai Chi practitioners demonstrated a faster stepping time due to the shorter preparation time to lift the stepping leg. Wu (2012) continues by suggesting that a faster stepping time is biomechanically and functionally important to reduce falls upon postural disturbance. Pavlol, Owings, Foley & Grabiner (2001) who examined the mechanics leading to a fall from an induced trip in older adults, agree with

Wu (2012), suggesting further that delayed stepping was significantly associated with falls during walking.

It has been suggested in a study by Hausdorff, Edelberg, Mitchell, Goldberger and Wei, (1997) that step time, step length and step width are associated with falls in the general elderly. Tai Chi (and specifically Tai Chi stepping) is an exercise which may control step time, length, and width due to its light agile movements. According to Gatts and Woollacott (2007), who analysed how Tai Chi may improve balance in impaired older people, the only way a fall can be avoided is by placing the foot down safely. Further, after examining the characteristics of foot movements in Tai Chi, it was found that continuously shifting the centre of gravity challenges the practitioner’s balancing ability whilst the foot is firmly on the ground (Chau & Mao, 2006.) It has been shown that on placing the heel on the floor, healthy older people have a flatter foot position, thus reducing the risk of falls (Gatts &

Woollacott, 2007.) In Tai Chi stepping in the TCAS study, weight is shifted from one leg to another, then lifting the empty leg to step and when placing the foot down, the heel touches the floor first.

5. Tai Chi movements

Stroke survivors with hemiplegia experience difficulties with balance, because the paretic arm experiences a feeling of heaviness, causing the stroke survivor to lean to the affected side. Seated practice of the arm movements will help gain some spatial awareness and maintain balance when incorporating them into the Tai Chi stepping. Therefore, whilst seated, participants are encouraged to familiarise themselves with the Tai Chi movements by looking at the body part being exercised so that they are mindful of what that body part is doing in relation to the rest of the body. Once they have mastered one movement, they may move onto the next one, which is more challenging. Upper limb movements will be introduced only when participants have gained mastery in stepping without arm

movements. This is because by introducing arm movements, balance is challenged even further. As participants progress in stepping and moving the upper limbs whilst maintaining the centre of gravity the lower limb muscles become stronger because the muscles are being activated (Chau & Mao, 2006). Following ‘preparation’, there are eight Tai Chi

movements included in the TCAS which are described in Table 8, along with justification for their inclusion.

6. Closing meditation (seated)

The Tai Chi class ends with meditation. As discussed previously, meditation aims to calm the mind. At the end of the class, meditation aims to rest the body before returning to daily activities because stroke survivors are likely to be fatigued.

Table 8 Justification for including Tai Chi movements in the first draft of TCAS classes Movement Description Justification Reference Preparation The practitioner

Beginning Also known as ‘heaven and earth’, this scissors. As the foot is firmly rooted on the ground, the arms uncross so that the right hand is facing up at chest level. The left hand is facing down.

Wheel With knees slightly bent, the centre of

Cloud Hands Start as in ‘holding a ball’. Step with the

lower hand can rise. the floor and weight is shifted to the right

Brush Knee The right foot faces forward, in ‘bow the side and the right hand is raised in front of the chest, with the

3.4.2. The amended Tai Chi programme following consultation with the Tai Chi