ORIGINAL ARTICLE

The effects of Tai-Chi in conjunction with thera-band resistance

exercise on functional fitness and muscle strength among
community-based older people
Shu-Fen Lin, Huei-Chuan Sung, Tzai-Li Li, Tsung-Cheng Hsieh, Hsiao-Chin Lan, Shoa-Jen Perng and
Graeme D. Smith

Aims and objectives. The aim of this study was to investigate the effects of TaiChi in conjunction with thera-band resistance exercise on functional fitness and
muscle strength in community-based older people.
Background. Tai-Chi is known to improve functional fitness in older people. TaiChi is usually performed with free hands without resistance training and usually
focuses on training lower limbs. To date, no study has examined the use of TaiChi in conjunction with thera-band resistance exercise in this population.
Design. Cluster randomised trial design.
Methods. Older people at six senior day care centres in Taiwan were assigned to
thera-band resistance exercise or control group using a cluster randomisation.
The thera-band resistance exercise group (n = 48) received sixty minute theraband resistance exercise twice weekly for a period of 16 weeks. The control
group (n = 47) underwent routine activities in the day care centre, receiving no
Tai-Chi or resistance exercise.
Results. After receiving the thera-band resistance exercise, intervention participants displayed a significant increase in muscle strength of upper and lower
extremities. Significant improvements were recorded on most measures of the
Senior Fitness Test, with the exception of the chair-stand and back-scratch test.
Conclusion. Thera-band resistance exercise has the potential to improve functional fitness and muscle strength in community-based older people.
Relevance to clinical practice. Thera-band resistance exercise potentially offers a
safe and appropriate form of physical activity that nursing staff can easily incorporate into the daily routine of older people in day care centres, potentially
improving functional performance and muscle strength.

Authors: Shu-Fen Lin, RN, MSN, PhD Candidate, Institute of

Medical Sciences, Tzu Chi University, Hualien; Lecturer, Department of Nursing, Tzu Chi College of Technology, Hualien, Taiwan; Huei-Chuan Sung, RN, PhD, Associate professor,
Department of Nursing, Tzu Chi College of Technology & Institute
of Medical Sciences, Tzu Chi University; Director, Taiwanese Center for Evidence-based Health Care, Hualien, Taiwan; Tzai-Li Li,
PhD, Professor, Department of Sport Promotion, National Taiwan
Sport University, Taoyuan, Taiwan; Tsung-Cheng Hsieh, PhD,
Assistant professor, Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan; Hsiao-Chin Lan, EdD, Professor, Depart-

2015 John Wiley & Sons Ltd

Journal of Clinical Nursing, 24, 13571366, doi: 10.1111/jocn.12751

What does this paper contribute

to the wider global clinical
community?

The study provides scientific evi-

dence of the effects of Tai-Chi in

conjunction with thera-band resistance exercise in improving functional fitness and muscle strength
among community-based older
people.
Tai-Chi with thera-band resistance exercise is a safe, inexpensive and suitable activity and can
be incorporated into routine programmes in community health
promotion or day care centres
for older people to improve muscle strength and functional fitness.
Tai-Chi with thera-band resistance exercise provides an attractive and potentially effective
approach to improve physical
function for older people and
may further improve their daily
function and level of independence.

ment of Tourism & Hospitality, Kainan University, Taoyuan,

Taiwan; Shoa-Jen Perng, RN, PhD, Associate professor, Department of Nursing, Tzu Chi College of Technology, Hualien, Taiwan; Graeme D. Smith, BA, PhD, RGN, Professor, School of
Nursing, Edinburgh Napier University, Edinburgh, UK
Correspondence: Huei-Chuan Sung, Associate professor, Department of Nursing, Tzu Chi College of Technology & Institute of
Medical Sciences, Tzu Chi University, No. 880, section 2, ChienKou Road, Hualien, 970 Hualien, Taiwan. Telephone: +886 385
72158 ext. 2435.
E-mail: sunghc@mail.tcu.edu.tw

1357

S-F Lin et al.

Key words: functional fitness, muscle strength, older adult, resistance exercise,
Tai-Chi, thera-band
Accepted for publication: 14 November 2014

Introduction
Globally, the number of people living beyond the age of
sixty years is increasing (World Health Organization 2012).
Taiwan is no exception, currently the percentage of older
people has increased to 11
2% of overall population and it
is predicted to reach 14% by 2018 (National Development
Council 2014). One of the main health-related concerns of
this ageing population relates to the decline in physical
functions, and old age is associated with progressive declining health and mobility difficulties (Marsh et al. 2009).
From a physiological perspective, loss of muscle mass and
reduced muscle function have been identified as primary
factors that can lead to disability and loss of independence
in older people (Imagama et al. 2011, Peterson & Gordon
2011). Therefore, adopting effective interventions to manage frailty in older adults to improve physical health is crucial (Theou et al. 2011). Decreased physical activity has
been linked to diminishing physical function and this is
often further compounded by the natural ageing process,
and regular exercise is considered as an important and
effective way to promote functional fitness among older
people (Nelson et al. 2007).
Tai-Chi and thera-band exercise are low-to-moderate
intensity exercises that are suitable for older people. TaiChi is usually performed with free hands without resistance
training and mostly focus on training lower extremities,
whereas thera-band exercise places emphasis on resistance
training. Enhancement of the muscle strength of lower
extremities and upper extremities can increase functional
capacity (Holviala et al. 2006). To date, no study has
examined the combination of these approaches in relation
to physical functions in older people. This study is designed
to examine and evaluate the effects of a 16-week groupbased Tai-Chi in conjunction with thera-band resistance
(TCTR) exercise on functional fitness and muscle strength
in community-based older people.

Background
The American College of Sports Medicine (ACSM) suggested that a combination of aerobic exercise, muscle
strengthening exercises and flexibility exercise is more effec-

1358

tive than either form of training on its own in older people

(ACSM et al. 2009). Several types of exercises have been
suggested for older people, including Tai-Chi and theraband resistance exercise.
Tai-Chi is one type of aerobic exercise that has been
shown to be suitable for older people, patients with chronic
diseases and hypertension (Lo et al. 2012). Tai-Chi originates from China as a martial art, integrating physical, psychosocial, spiritual and behavioural elements to promote
mindbody interactions (Wang 2011). The mindbody
approach has also been linked to enhanced function and
improved self-efficacy. Tai-Chi is low-to-moderate intensity
exercise form, which is linked in a continuous sequence,
involving slowly and smoothly from one movement to
another. This exercise emphasises stable rhythm, balance,
weight shifting and breathing control (Wang et al. 2004).
Literature suggests that Tai-Chi provides aerobic benefit
and can have a positive effect on balance control, flexibility
and cardiorespiratory fitness (Wang et al. 2004). In particular, Tai-Chi places specific emphasis on training of balance
and muscle strength of lower extremities, it has been shown
to improve mobility and reduces the risk of falls in older
people (Wang et al. 2004). In addition, Tai-Chi is generally
safe and it does not usually do aggravate pre-existing pain
or discomfort caused by diseases (Adler & Roberts 2006).
Globally, Tai-Chi has become one of the best known forms
of meditative movements. Through enhancement of physiological function, it would appear to be an ideal exercise for
older people.
Resistance exercise has potential to improve muscle
strength, muscle mass and functional capacity in older people (Von-Bonsdorff et al. 2006). Resistance training may
also reverse tendon stiffness and reduce the risk of strain
injuries (Reeves 2006) and prevents age-related frailty (Peterson et al. 2010). Various devices can be used to facilitate
resistance training. Thera-band (or elastic band) is one such
device used in resistance training (Shields et al. 2005). It is
considered to be an inexpensive, safe and easily operated
device (Melchiorri & Rainoldi 2011). Thera-band resistance
training can help older adults gain strength in a similar way
to that of using free weights or a weight training machine
(Melchiorri & Rainoldi 2011). It can be used to perform a
large range motions and initiate eccentric and concentric

2015 John Wiley & Sons Ltd

Journal of Clinical Nursing, 24, 13571366

Original article

muscle contractions and also allows users to exercise by

adjusting grip width or rubber stiffness to achieve a greater
or lesser intensity of effort (Melchiorri & Rainoldi 2011).
Previous studies suggest that resistance exercise using theraband is effective for improving gait, mobility, balance and
physical functions (Page & Ellenbecker 2003), as well as
reversing age-related changes and enhancing quality of life
among older people (Claflin et al. 2011).
Few studies have evaluated the effects of Tai-Chi together
with thera-band resistance training. Robitaille et al. (2005)
conducted a study to examine the effects of Tai-Chi and legstrengthening exercises with elastic bands. Older people who
had improved lower muscle strength through Tai-Chi and
resistance training on lower extremities may improve their
functional performance, such as walking, climbing steps or
standing up from a chair (Liu & Latham 2009). Exercise
programmes which strengthen muscle of both upper and
lower extremities may further promote and enhance activities of daily living in older people. The design of studies of
Tai-Chi and resistance exercise has most commonly used
Tai-Chi on its own as part of the exercise programme following by resistance exercise; to date, no study has incorporated
the manipulation of thera-bands while performing Tai-Chi.

Methods
Design
This study used a cluster randomised trial design.

Participants and setting

Forty-seven registered older people day care centres were
stratified in northern, middle and southern regions of Eastern
Taiwan. Six older people day care centres were randomly
selected from these clusters and older people were recruited
from the six centres. Three centres were randomly assigned to
TCTR group and three centres to control group (Fig. 1). The
inclusion criteria were: (1) people aged 65 years and above;
(2) had no cognitive impairment; (3) could follow simple
instructions; (4) could walk without assistance (5) could communicate in Chinese or Taiwanese; (6) provided informed
consent. Participants who exhibited acute or unstable medical
conditions, serious musculoskeletal disorders and standing or
walking difficulties were excluded from the study.
With consideration of medium to large effects results
found in studies related to Tai-Chi exercise on physical
performance among older people (Taylor-Piliae 2008) and
Cohens power analysis (Cohen 1992), a total of 90
participants (45 in each group) were required for achieving
2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 13571366

Tai-Chi with thera-band exercise for older people

the power of 80% with significance level of 0
05 for effect

size of 0
6 based on the independent t-test. Twenty per cent
attrition rate was estimated. Therefore, 54 participants in
each group were recruited in this study.

TCTR exercise
The TCTR exercise programme was designed by a Tai-Chi
master and academic with specific expertise in sport education. This 60-minute programme consisted of (1) 15-minute
warm-up exercises, including stretching and flexibility exercise, and training in natural inspiration and expiration; (2)
30 minutes of TCTR exercise; and (3) 15 minutes of cooldown exercises, including spinal rotation, bouncing up and
down, left and right twisting movements and arm swinging.
The 30-minute TCTR exercise consisted of manipulating
the thera-bands by both hands while performing ten simple
Tai-Chi forms. The exercise instructor who led the TCTR
exercise for the participants in TCTR group was a trained
nurse had been practicing Tai-Chi exercise for several
years. Soft, slow and soothing music was played to facilitate exercise movements during TCTR sessions. The exercise was performed in a group setting in a spacious and
well ventilated indoor activity room. During the exercise
programme, participants were encouraged to relax their
waist line and the lower body was placed in a slight squatting position. The spine was used as the axis for stretching
and rotating. While performing the Tai-Chi exercise forms,
the participants used upper extremities to pull the theraband and these were held for about six seconds during
each motion. Participants started with two sets of four repetitions for each exercise and then progressed to two sets
of ten repetitions, and they alternated the same exercises
for both sides of their body. Thera-bands are colour-coded
to indicate different levels of resistance. The participants
were encouraged to progress to a band of higher resistance
[yellow (thin) to red (medium) or green (heavy) bands] during the study according to individual capacity. They were
also encouraged to increase the level of resistance by
adjusting the grip width to achieve a greater intensity of
effort. Participants maintained their rating of perceived
exertion (RPE) at a level between 1214 (slightly difficult).

Measures
Functional fitness was assessed by the Senior Fitness Test
(SFT), which is a valid and comprehensive tool for assessing
functional fitness levels for older adults. The SFT has
demonstrated good intraclass reliability and criterion validity (Rikli & Jones 1999). It includes six measures: (1) arm

1359

S-F Lin et al.

47 Registered
senior day care centres

6 Centres
randomized

Allocated to TCTR group

Allocated to control group

3 centres (n = 67)

3 centres (n = 71)

Excluded (n = 13)
Did not meet criteria

Time 0 (baseline assessment) (n = 54)

Withdrew (n = 5)
Relocated (n = 1)

Excluded (n = 17)
Did not meet criteria

Time 0 (baseline assessment) (n = 54)

Withdrew (n = 5)
Relocated (n = 2)

Time 1 (week 8) (n = 48)

Time 1 (week 8) (n = 47)

Time 2 (week 16) (n = 48)

Time 2 (week 16) (n = 47)

Included in analysis (n = 48)

Included in analysis (n = 47)

curl for 30 seconds to assess upper-body strength (using

eight-pound dumbbell for men and five-pound for women,
using the dominant arm); (2) chair-stand-up for 30 seconds
to assess lower body strength (from a seated position and
the repetitions of stands from a chair); (3) back-scratch to
assess upper-body (shoulder) flexibility (assessed the gap of
middle fingers together behind the back, the best side score
was used in analysis); (4) chair sit-and-reach test to assess
the flexibility of lower extremities (assessed the gap
between the middle finger of overlapping hands and the toe
of the extended leg, the best side score was used in analysis); (5) six-minute walk test to assess aerobic endurance
(measured the distance of walk during six minutes); (6)
eight-foot up and go to assess agility/and dynamic balance
(the time to rise from a chair, walk 8-foot and return to the
chair to a seated position; two trails were carried out for
test, and the best score was used in analysis).

1360

Figure 1 Flow chart of cluster randomised

controlled trial.

Muscle strength was measured by the manual muscle

tester (model 01163, Lafayette Instrument Company,
Lafayette, IN, USA) for the motions of shoulder flexion,
elbow flexion, hip flexion and knee extension of both
sides of the body. The muscle dynamometer is a handheld device for objectively quantifying muscle strength.
The intraclass correlation coefficient for the manual muscle tester of all measures was above 0
93 (p < 0
001).
The same research assistant held the actuator in one
hand, while participants sat on a chair with their trunk
firmly fixed. They used maximal effort to push against
the research assistant until they heard an audible beep.
The peak force (in pound) from the participant within
three seconds was noted on the digital display of the tester. The best score of two separate measures for each
motion of all extremities was recorded for the purposes
of analysis.
2015 John Wiley & Sons Ltd
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Original article

Procedure
This study was approved by the Institutional Review Board
of the National Taiwan Sport University in Taiwan (IRB
No. 9930). After obtaining permission from the supervisors
of the six older people day care centres, detailed explanations were provided to the potential participants about the
research objectives and study procedures. Written informed
consent was obtained for each participant before starting
the study. Research assistants were trained in data collection prior to commencement of the study, and they were
also trained in instrument calibration. Baseline and post-test
measures were assessed for each participant by the same
research assistant who was blinded to all participants. During the study, both the TCTR group and control group
maintained their regular activities of daily living and routine activities. The older people day care centre activities
mostly focused on sedentary activities, included art and
craft activities. The TCTR group received 60-minute TCTR
exercise twice a week in the morning for 16 consecutive
weeks in addition to their routine. The control group
underwent routine activities with no Tai-Chi or resistance
exercise. All assessments were conducted in the senior day
care centres for both groups at baseline, week eight and
after 16 weeks.

Data analysis
Data were analysed using the SPSS for Windows 19.0 (SPSS
Inc., Chicago, IL, USA). Descriptive statistics were used to
show participants baseline characteristics. Two-sample
t-test and Chi-squared test were performed to determine the
baseline homogeneity between the two groups. Paired t-test
was used to examine difference in pretest and post-test outcomes. Generalised estimating equations (GEE) analysis
was performed to assess the effect of TCTR exercise on all
outcomes adjusted for the time trend and study covariates
of age, gender, frequency of exercise. The significance level
was set at 0
05 for all analysis.

Results
Demographic characteristics
Forty-eight participants in the TCTR group and 47 participants in the control group completed the study. In the
TCTR group, six participants did not complete the study,
five chose to withdraw and one participant moved location.
In the control group, two relocated and five failed to complete the post-test assessments. No significant differences in
2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 13571366

Tai-Chi with thera-band exercise for older people

the demographic data were observed between the two

groups. The average age was 73
9 years (SD 7
2) for the
TCTR group and 74
2 (SD 7
0) for the control group (CG).
Over half of the participants in both groups were women.
A total of 89
6% of TCTR group had at least one or more
chronic illnesses and 74
5% for control group. Hypertension accounted for the highest level of chronic illnesses in
both groups. The majority of participants reported that
they involved in some form of exercises three days or more
per week, mostly walking (TCTR: 85
4% and CG: 80
9%).
There were no statistically significant differences in the
demographic variables between groups (Table 1).

Effects of TCTR exercise on functional fitness

There were no significant differences on baseline scores of
all measures of Senior Fitness Test between groups. After
receiving the 16-week TCTR exercise programme, the mean
number of arm curls in 30 seconds with a dumbbell
improved gradually from 20
3 (SD 3
6) at baseline to 22
9
(SD 4
2) at week 16, while mean number of 30-sec chair
stand also improved gradually from 18
2 (SD 3
9) at baseline to 19
7 (SD 4
3) at week-16 in the TCTR group. The
level of the chair sit-and-reach test significantly improved
from 4
1 cm (SD 7
3) at baseline to 9
1 cm (SD 8
9). The
back-scratch score also gradually improved over time. The
mean score of the six-minute walk test slightly improved
from 401
5 (SD 70
4) at baseline to 430
7 (SD 82
5) at

Table 1 Demographics of the participants at baseline (n = 95)

Variables
Age (Mean  SD)
Gender
Female
Male
Marital status
Married
Single or widowed
Education
None
Elementary
High school
Chronic illness
None
One
Two or more
Frequency of exercise
<3 times per week
3 times per week

TCTR
group
(n = 48)

Control
group
(n = 47)

v2/t

73
97
16

74
27
04

0
02

0
81

30 (62
5%)
18 (37
5%)

31 (66%)
16 (34%)

0
12

0
83

27 (56
2%)
21 (43
8%)

21 (44
7%)
26 (55
3%)

1
27

0
31

12 (25
0%)
25 (52
1%)
11 (22
9%)

13 (27
7%)
23 (48
9%)
11 (23
4%)

0
11

0
95

5 (10
4%)
18 (37
5%)
25 (52
1%)

12 (25
5%)
15 (31
9%)
20 (42
6%)

3
70

0
16

7 (14
6%)
41 (85
4%)

9 (19
1%)
38 (80
9%)

0
35

0
59

1361

S-F Lin et al.

week 8, this decreased to 429
6 (SD 67
2) meters at week

16. The mean second of the eight-foot up-and-go test gradually decreased from 7
1 (SD 1
7) at baseline to 6
7 (SD
1
7) seconds at week 8 to 6
6 (SD 2
0) at week 16, indicating a gradual improvement in walking speed and levels of
balance. There were no significant pretest to post-test differences observed in the control group except for the 8-foot
up-and-go test (Table 2). Table 3 illustrates the TCTR
exercise effects on all six measures of SFT according to
GEE, adjusting for age, gender and frequency of exercise.
The TCTR exercise significantly improved 30-sec arm curl
(upper body strength) (b = 3
22, p = 0
001), sit-and-reach
(lower body flexibility) (b = 5
1, p < 0
001), six-minute
walk (aerobic endurance) (b = 32, p = 0
001) and 8-foot
up-and-go (agility/dynamic balance) (b = 0
89, p = 0
001)
during the 16-week intervention period. However, the intervention had no significant effect on 30-second chair-standup (lower body strength) and back-scratch (upper body
flexibility) tests (p > 0
05).

Effects of TCTR exercise on muscle strength

There was no significant difference in levels of muscle
strength between groups at baseline. All measures of the
muscle strength of TCTR group gradually increased from
baseline to week 16, with the exception of right knee exten-

sion and left knee extension. The muscle strength of right

knee extension of TCTR group, which improved from 24
pounds (SD 5
4) at baseline to 25
8 (SD 6
5) at week 8,
once again a slight decrease was noted at week 16 [25
1
(SD 5
5]. The muscle strength of left knee extension of
TCTR group improved from 23
4 pounds (SD 5
6) at baseline to 25
0 (SD 7
1) at week 8, but slightly decreased to
24
8 (SD 5
7) at week 16. In the control group, no significant differences in muscle strength were recorded between
week 8 and week 16 when compared to baseline for all of
the upper extremities. However, there was a significant
decrease between week 16 and baseline for all of lower
extremities, including left hip flexion and right and left
knee extension, right hip flexion being an exception
(Table 2).
The TCTR exercise effects on muscle strength of upper
extremities according to GEE, adjusting for age, gender and
frequency of exercise is presented in Table 4. There were
significant differences between TCTR group and control
group in all four measures of muscle strength of upper
extremities, including right shoulder flexion (b = 3
02,
p < 0
001), left shoulder flexion (b = 2
94, p < 0
001),
right elbow flexion (b = 3
17, p = 0
02) and left elbow flexion (b = 5
05, p = 0
001) during 16-week intervention period. In addition, there were significant between-group
differences in the three measures of muscle strength of

Table 2 Mean (SD) and paired t-test of Senior Fitness Test and muscle strength of TCTR group and control group at baseline and week 8
and week 16 (n = 95)
TCTR group (n = 48)
Variables
Senior Fitness Test
30-seconds arm curl (reps)
30-seconds chair stand (reps)
Back scratch (cm)
Chair sit-and-reach (cm)
Six-minute walk (m)
8-foot up & go (sec)
Muscle strength
Rt shoulder flexion (lb)
Lt shoulder flexion (lb)
Rt elbow flexion (lb)
Lt elbow flexion (lb)
Rt hip flexion (lb)
Lt hip flexion (lb)
Rt knee extension (lb)
Lt knee extension (lb)

Control group (n = 47)

Baseline
Mean (SD)

Week 8
Mean (SD)

Week 16
Mean (SD)

Baseline
Mean (SD)

Week 8
Mean (SD)

Week 16
Mean (SD)

20
3
18
2
10
4
4
1
401
5
7
1

(3
6)
(3
9)
(10
6)
(7
3)
(70
4)
(1
7)

22
7
19
6
9
8
8
2
430
7
6
7

(4
7)*
(5
1)*
(11
9)
(8
7)*
(82
5)*
(1
7)*

22
9
19
7
9
3
9
1
429
6
6
6

(4
2)*
(4
3)*
(10
7)
(8
9)*
(67
2)*
(2
0)*

20
2
17
5
12
8
6
5
423
3
7
7

(3
9)
(5
3)
(13
4)
(7
3)
(95
0)
(2
2)

20
9
18
3
14
4
6
0
418
1
8
1

(5
5)
(5
0)
(13
5)
(7
8)
(87
7)
(1
9)

19
5
18
1
12
4
6
3
419
4
8
0

(3
8)
(4
5)
(12
0)
(8
5)
(91
3)
(2
7)

24
6
23
7
26
3
26
1
27
9
28
1
24
0
23
4

(7
5)
(7
5)
(9
2)
(9
4)
(7
1)
(7
2)
(5
4)
(5
6)

25
4
24
7
28
7
28
1
29
3
28
7
25
8
25
0

(6
7)
(7
1)
(8
9)*
(9
5)*
(8
1)
(7
4)
(6
5)*
(7
1)*

26
6
26
5
31
2
32
7
29
8
30
4
25
1
24
8

(7
7)*
(7
4)*
(9
6)*
(10
5)*
(7
8)*
(8
7)*
(5
5)
(5
7)*

25
2
25
7
25
7
27
0
29
3
31
1
26
0
25
2

(7
8)
(8
2)
(10
1)
(8
9)
(8
0)
(9
5)
(7
0)
(5
7)

24
9
26
0
27
0
28
5
30
4
30
8
27
0
25
3

(7
9)
(7
8)
(8
8)
(8
8)
(8
2)
(8
6)
(7
7)
(7
5)

24
2
25
6
27
4
28
5
29
2
28
9
24
0
23
6

(6
6)
(7
0)
(7
4)
(7
9)
(6
7)
(7
0)
(5
2)
(5
3)

SD, Standard deviation.

*Significant positive change from baseline by paired t-test (p < 0
05).

Significant negative change from baseline by paired t-test (p < 0
05).

1362

2015 John Wiley & Sons Ltd

Journal of Clinical Nursing, 24, 13571366

0
01*
0
32
0
82

<0
001***
0
16
0
07
0
08
0
001**
0
30
0
42
0
19
0
22
0
27
7
69
0
59
0
36
0
39
0
89

Discussion

<0
001***
7
31
34
44
0
001**
1
35
4
55

<0
001***
0
20
0
61
0
31
0
001**
12
09
17
01
7
73
5
19
10
88
423
34
21
84
3
94
5
26
32
00
<0
001***
0
16
0
85
0
65
<0
001***

0
07
1
18
2
13

<0
001***
0
32
0
68
0
09
0
55
1
93
2
45
0
87
0
91
1
08

2015 John Wiley & Sons Ltd

Journal of Clinical Nursing, 24, 13571366

T1, week 8; T2, week 16.

Adjusting for age, gender, frequency of exercise.
*p < 0
05, **p < 0
01, ***p < 0
001.

0
08

0
65

0
50

0
19
0
94
1
67

<0
001***
0
84
0
29
0
28
0
001**

17
49
0
68
0
64
0
79
0
88

0
69
0
97
0
52
0
35
0
73
0
63
0
89
0
64
0
67
0
90
20
15
0
18
0
68
0
72
3
22

Intercept
Group
T2
T1
Group=1
*T2
Group=1
*T1

SE

SE

p
b
b
Variables

<0
001***
0
49
0
22
0
03*
0
23

12
80
2
44
0
36
1
55
0
65

SE

6
46
2
33
0
14
0
44
5
10

1
19
1
67
0
73
0
96
1
03

SE
b
SE

6-minute walk
Sit-and-reach
Back scratch
30 seconds chair stand
30 seconds arm curl

Table 3 GEE analysis on the effect of TCTR exercise on Senior Fitness Test at baseline and week 8 and week 16 (n = 95)

lower extremities, including left hip flexion (b = 4
5,

p < 0
001), right knee extension (b = 3
06, p = 0
01) and
left knee extension (b = 3
09, p = 0
001), but not on right
hip flexion (p > 0
05) (Table 5).

SE

Tai-Chi with thera-band exercise for older people

8-foot up & go

Original article

The TCTR exercise programme is a complex intervention

to evaluate and our study was conducted in accordance
with Medical Research Council guidance for evaluation of
complex interventions, to ensure high levels of rigour
within the study (Craig et al. 2008). Our results showed
that the TCTR group performed significantly better than
the control group on four of the six items of the Senior Fitness Test, including 30-seconds arm curl, chair sit-andreach, six-minute walk and 8-foot up-and-go over time.
Furthermore, the 16-week TCTR exercise programme significantly improved the majority of measures of muscle
strength of upper and lower extremities, with exception of
right hip flexion over time.
One previous study found that a low-intensity resistance
exercise increased muscle strength and improved physical
abilities (Takarada & Ishii 2002). This result is consistent
with those in our study, we also found that the TCTR exercise with low-to-moderate intensity improved upper body
strength of SFT and muscle strength of most upper and
lower extremities in community-dwelling older people.
These results are also consistent with those of another study
(Fahlman et al. 2011), which found thera-band resistance
training exercise significantly improved upper body strength
and lower body strength among older people with functional limitations. Our results are also consistent with those
of previous studies (Cyarto et al. 2008, DiBrezzo et al.
2005, Yamauchi et al. 2005, Rogers et al. 2002). We found
that thera-band exercise significantly increased upper and
lower body strength and agility/dynamic balance. It has
been suggested that older people who improve muscle
strength of their upper and lower extremities may also
improve their performance of activities of daily living (Liu
& Latham 2009). The most recent recommendations from
American College of Sports Medicine and the American
Heart Association suggest that increased physical activity
provides additional health benefits and results in higher
general levels of physical fitness (American College of
Sports Medicine et al. 2009, Nelson et al. 2007). Therefore,
we suggest that older people should be encouraged to
increase exercise intensity by adjusting the pull force of
thera-bands, keeping body gravity at a lower position or
changing to thera-bands with a higher level of resistance
while doing TCTR exercise.

1363

S-F Lin et al.

Table 4 GEE analysis on the effect of TCTR exercise on muscle strength of upper extremities at baseline and week 8 and week 16 (n = 95)
Right shoulder flexion

Left shoulder flexion

Right elbow flexion

Left elbow flexion

Variables

SE

SE

SE

SE

Intercept
Group
T2
T1
Group = 1*T2
Group = 1*T1

25
17
0
56
1
02
0
30
3
02
1
12

1
13
1
55
0
64
0
81
0
77
0
98

<0
001***
0
72
0
11
0
71
<0
001***
0
25

25
74
2
02
0
13
0
21
2
94
0
72

1
18
1
60
0
68
0
86
0
81
1
00

<0
001***
0
21
0
85
0
81
<0
001***
0
47

25
68
0
64
1
68
1
33
3
17
1
09

1
45
1
95
1
10
1
17
1
34
1
40

<0
001***
0
744
0
13
0
26
0
02*
0
44

26
96
0
84
1
56
1
53
5
05
0
48

1
28
1
85
1
13
1
18
1
55
1
44

<0
001***
0
65
0
17
0
19
0
001**
0
74

T1, week 8; T2, week 16.

Adjusting for age, gender, frequency of exercise.
*p < 0
05, **p < 0
01, ***p < 0
001.

Table 5 GEE analysis on the effect of TCTR exercise on muscle strength of lower extremities at baseline and week 8 and week 16 (n = 95)
Right hip flexion

Left hip flexion

Right knee extension

Left knee extension

Variables

SE

SE

SE

SE

Intercept
Group
T2
T1
Group=1*T2
Group=1*T1

29
28
1
40
0
05
1
13
1
93
0
30

1
15
1
54
0
90
0
96
1
11
1
21

<0
001***
0
36
0
96
0
24
0
08
0
81

31
12
3
02
2
22
0
31
4
50
0
93

1
36
1
71
1
00
0
97
1
23
1
11

<0
001***
0
08
0
03*
0
75
<0
001***
0
40

26
03
2
03
1
99
0
95
3
06
0
87

1
01
1
27
0
90
0
91
1
12
1
11

<0
001***
0
11
0
03*
0
30
0
01*
0
44

25
20
1
81
1
63
0
13
3
09
1
50

0
82
1
15
0
68
0
82
0
93
1
03

<0
001***
0
11
0
02*
0
88
0
001**
0
15

T1, week 8; T2, week 16.

Adjusting for age, gender, frequency of exercise.
*p < 0
05, **p < 0
01, ***p < 0
001.

Our study found that no falls occurred in the TCTR

group during their 16-week intervention period, however,
there were two fall reported among participants in control
group. This result indicated that the TCTR exercise
improved lower body muscle strength and dynamic balance,
and thus potentially prevented falls. A meta-analysis (Park
& Song 2013) also concluded that Tai-Chi can improve
balance, muscle strength and fall-related variables.
Our study found that TCTR exercise significantly
improved lower body flexibility, but not upper body flexibility. This flexibility test has been used as an outcome
measure in three thera-band studies (Cyarto et al. 2008,
Rogers et al. 2002, Yamauchi et al. 2005). Rogers et al.
(2002) found that exercise using thera-bands and dumbbells
did not improve upper body flexibility and lower body flexibility. Another study involving thera-band with walking
and flexibility exercises reported both upper and lower
body flexibility was improved (Yamauchi et al. 2005).
Cyarto et al. (2008) using graded bands, body weight and
balance exercise in older people reported improvement in
lower body flexibility, but not on upper body flexibility.
Cyartos study results are consistent with those of our

1364

results. In our study, TCTR exercise combined Tai-Chi and

thera-band resistance exercise movements, these motions
involved waist bending and waist stretching which effectively improved flexibility, particularly lower body flexibility. It appeared to have little effect on upper body
flexibility.
The effects of Tai-Chi on older people have been examined in a large number of studies. The majority of the studies have evaluated its effect on balance, cardiorespiratory
fitness, mostly concentrating on lower body strength. TaiChi is usually performed with free hands without resistance
training and mostly focus on training lower extremities.
Strategies such as adding thera-bands in conjunction with
Tai-Chi exercise can strengthen the muscle and upper body
flexibility. Some studies of Tai-Chi and resistance exercise
usually conducted Tai-Chi individually as a part of the
exercise programme, following by resistance exercise or
only focused on lower extremities, but none of the studies
incorporated manipulating thera-bands while performing
Tai-Chi. In this study, the TCTR exercise which consisted
of manipulating the thera-bands by both hands while performing Tai-Chi forms was uniquely designed by a Tai-Chi
2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 13571366

Original article

Tai-Chi with thera-band exercise for older people

master in Taiwan and resulted in improved muscle strength.

However, our study found that the improvement on upper
body flexibility was limited. Therefore, it is suggested that
motions and repetitions of pulling thera-bands with upper
body to improve upper body flexibility are increased in
future TCTR exercise programmes.
In this study, no participants complained of discomfort
when practicing TCTR exercise. There were no adverse
effects during the study. Tai-Chi has been consistently
reported as a safe form of intervention in older people
(Rogers et al. 2009). From a safety perspective, it is important that TCTR should be discontinued in older people
who demonstrate symptoms of physical discomfort during
the exercise.
There were several limitations in this study, which may
limit the ability to generalise the study results. There is
also the possibility of the Hawthorne effect occurring
because of the fact that participants had awareness of
participation in the study. Comparison of Tai-Chi with
thera-band or thera-band separately is needed to evaluate
the effects on physiological and psychological functions of
older people. In addition, 54 participants were required
for each group with consideration of attrition rate in this
study, and we did not reach the required sample size, the
sample was large enough to draw valid and meaningful
conclusions. Future studies could measure bone density
and also give attention to subjective parameters, such as
psychological perspectives, quality of life, self-efficacy or
satisfaction.

Conclusion
Thera-band resistance exercise is a combination of aerobic
exercise (Tai-Chi) and resistance training (thera-band) in
one programme and is considered as a low-to-moderate
intensity exercise intervention. Our study suggests that
older people participated in 16 weeks of TCTR exercise
have the potential to improve muscle strength of upper and
lower extremities, lower body flexibility, aerobic endurance

and agility/dynamic balance. Tai-Chi, a traditional Chinese

exercise, is familiar to most of Chinese and Taiwanese
older people. Although all the participants in the study
were of Chinese origin, Tai-Chi is increasingly being practiced in the Western world and these findings have global
relevance. As such, TCTR exercise provides an attractive
and potentially effective approach to improve physical function for older people and may further improve their daily
function and independence.

Relevance to clinical practice

A Tai-Chi with thera-band resistance exercise provides a
safe, inexpensive and suitable activity and can be incorporated into routine programmes in community health promotion or care centres for older people to improve muscle
strength and functional fitness. Nurses could be easily
trained to deliver this potentially effective intervention for
older people.

Acknowledgements
We thank the senior day care centre staff for their assistance and the participants for their participation.

Disclosure
The authors have confirmed that all authors meet the
ICMJE criteria for authorship credit (www.icmje.org/
ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data
or analysis and interpretation of data; (2) drafting the
article or revising it critically for important intellectual
content; and (3) final approval of the version to be
published.

Conflict of interest
None.

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