Client-Centered Nursing Care Novoember 2017. Volume 3.

Number 4

Research Paper:
Effect of Tai Chi Exercise on the Stress of Elderly Women
With Hypertension
Elnaz Talebi1, Farideh Bastani1* , Hamid Haqhani2

1. Department of Geriatric Nursing, School of Nursing & Midwifery, Iran University of Medical Sciences, Tehran, Iran.
2. Department of Biostatistics, School of Health, Iran University of Medical Sciences, Tehran, Iran.

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Citation: Talebi, E., Bastani, F., & Haqhani, H., 2017. Effect of Tai Chi Exercise on the Stress of Elderly Women With
Hypertension. Journal of Client-Centered Nursing Care, 3(4), pp. 263-268. https://doi.org/10.32598/jccnc.3.4.263
: : https://doi.org/10.32598/jccnc.3.4.263

Article info: AB STRACT

Received: 14 Apr 2017
Accepted: 23 Aug 2017
Background: Hypertension or high blood pressure is one of the most common chronic diseases
among the geriatrics having a strong association with psychological factors such as perceived
stress. Aerobic exercises are effective in the prevention and treatment of hypertension and stress
management. In the same regard, this paper is an attempt to investigate the effect of Tai Chi
exercise on the stress of Iranian older women with hypertension.
Methods: This clinical trial with pre and posttest quasi-experimental design was conducted on
64 elderly women with hypertension at two elderly care centers in Tehran. This study included
8-form Tai Chi exercise for a period of six weeks. For collecting data, two questionnaires with
demographic characteristics and the Perceived Stress Scale (PSS) were used, and for analyzing
data, descriptive and inferential statistics were employed in SPSS-PC V21 software.
Results: The results showed that there was no significant difference in perceived stress in both
experimental and control groups, before and after the intervention. The results of repeated
measures ANOVA also showed that the mean of perceived stress score before and after
intervention was not statistically significant (P = 0.557 and 0.489).
Keywords: Conclusion: Since the 8-form Tai Chi exercise is a safe intervention for the elderlies has led to
Elderly, Stress, a significant difference in the level of perceived stress among the elderly women, further studies
Hypertension, Tai Chi are suggested to find a suitable and effective style of this exercise.

1. Background the world’s population over 60 years will double from

T
about 11% to 22%, and it is expected to increase from
he increase in life expectancy, as well as 605 million to 2 billion over the same period. Aged peo-
growing older population in the world, is ple are confronted with several disabilities and limita-
a major challenge. According to a report tions. Among these, hypertension or high blood pressure
by the World Health Organization (2013), is considered as an important disease (Lloyd Sherlock et
between 2000 and 2050, the proportion of al. 2014). Stress is one of the major factors in hyperten-

* Corresponding Author:
Farideh Bastani, PhD
Address: Department of Geriatric Nursing, School of Nursing & Midwifery, Iran University of Medical Sciences, Tehran, Iran.
Tel: +98 (936) 5220789
E-mail: [email protected]; bastani,[email protected]

263
Novoember 2017. Volume 3. Number 4 Client-Centered Nursing Care

sion (Hapunda et al. 2015) and the mean stress intensity Multi-stage sampling method was applied. Firstly, the
in people with hypertension is significantly higher than names of all elderly care centers which were introduced
those who are not affected with the disease (Vahedian by the Welfare Organization and their readiness to carry
Azimi et al. 2012). It is also important to note that the out the study, were placed inside the envelope; then the
perceived stress level in women is much higher than that names of the two centers were randomly taken out (Arad
in men. Regular aerobic exercises are one of the basic and Tohid elderly centers). Next, from these two centers,
strategies for the prevention and treatment of hyperten- by tossing a coin, the Arad center was selected for the
sion (Lan et al. 2013). test group and Tohid center for the control group. Inclu-
sion criteria for the older women who, according to the
One of the best exercises in this field is called Tai Chi, definition of the World Health Organization, should be
a multifactorial sport and an elderly-friendly solution ac- over 60 years having no cognitive impairment by using
cording to American Society of Aging (Pho et al. 2012). Tai Abbreviated Mental Test (AMT) instrument, having high
Chi is a traditional Chinese mind-body exercise. In Tai Chi, blood pressure with no history of depression or anxiety
smooth and rhythmic movements are linked, causing the disorder according to the patient or her medical record,
transfer of body weight from one leg to other resulting in no drug addiction or mediation or Tai Chi exercises.
better balance (Lan et al. 2013).Tai Chi exercise has several
forms that vary in different situations (Azimzadeh, Hosse- At both the centers, Tohid and Arad, informed consent
ini & Nourozi Tabrizi 2013). A simplified 8-form program was taken from the study subjects (which came under
of Tai Chi which is derived from a complex 24-form, al- the inclusion criteria) and were explained about the goals
lows the elderlies to perform it either by standing or sitting, and stages of the research. The elderlies were examined
and let them enjoy Tai Chi exercise without having to wor- with the help of cognitive impairment test and after
ry about remembering different movements, an important ensuring that they had none, a demographic data form
method of controlling their stress (Lee 2017).One of the surveying age, weight, height, body mass index, dura-
researches on Tai Chi exercise conducted by Taylor-Piliae tion of hypertension, underlying disease, marital status,
(2014) showed that Tai Chi Quan is a safe form of exercise educational level, economic situation and use of mobility
to prevent and manage cardiovascular disease with no side aids was completed by the participants. To measure the
effects. They suggested that the extent and routine of Tai stress level, Perceived Stress Scale (PSS) was used that
Chi (number of sessions, frequency, and duration) are fac- was developed by Cohen et al. (1983). This tool is very
tors that can influence the outcomes of this exercise. Yeh suitable for measuring the people’s perception of stress
et al. (2008), in a systematic review, investigated the effect against the unpredictable and uncontrollable events of
of Tai Chi exercise on blood pressure. They concluded that life. It has 14 items based on 4-point Likert scale rated as
Tai Chi may reduce blood pressure and serve as a practi- O = never, 1 = almost never, 2 = sometimes, 3 = fairly of-
cal, non-pharmacologic method for hypertension manage- ten, and 4 = very often. Scores are obtained by reversing
ment. According to them, there are different forms of Tai the responses to the positively stated items (items 4, 5, 6,
Chi. Biglari et al. (2016) studied the Effect of 8-Week Tai 7, 9, 10, 13). In total, scores are from zero to 56. Reliabil-
Chi Quan exercise and walking on cardiovascular-related ity and validity of this tool have been reported by using
indicators among Iranian elderly women. Their results in- Cronbach’s alpha coefficient ranging from 0.74 to 0.93.
dicated that Tai Chi Quan training can be recommended to
people who have not enough mobility to exercise, low cost, The sample size was determined as n = 38 at 95% confi-
simplicity, and its beneficial therapeutic properties. dence level and 80% test strength in each, test and control
group. Due to the long duration of intervention and the lack
Considering previous studies on Tai Chi exercise and of familiarity of the elderlies with this exercise, three sub-
lack of research on its effect on the stress of older wom- jects in the test group due to lack of interest in continuing
en as a vulnerable group, this paper is aimed to study the the Tai Chi exercise, two subjects due to cold and weak-
effect of Tai Chi exercise on the perceived stress of older ness, and one subject because of a stroke were excluded
women suffering from hypertension. from intervention. In the control group, five elderly women
said that they were not interested in filling out a post-test
2. Materials and Methods questionnaire, and one woman died. Finally, data from 32
samples in each, test and control group, were analyzed.
This study is a clinical trial with pre and posttest quasi-
experimental design. Study population consists of geri- Intervention included 8-form Tai Chi exercise for
atric women with hypertension in elderly care centers thrice a week sessions, each for 40 mins, for six weeks.
in Tehran under the supervision of welfare organization. It should be noted that the elderly carried out Tai Chi ex-

264 Talebi, E., et al., 2017. Effect of Tai Chi Exercise on the Stress of Elderly Women With Hypertension. JCCNC, 3(4), pp. 263-268.
Client-Centered Nursing Care Novoember 2017. Volume 3. Number 4

ercise under the supervision of a researcher with Tai Chi pleting six weeks of intervention, the perceived stress
certification. Also, the exercise was performed in the hall questionnaire was completed by both test and control
which can accommodate all the elderly women together. groups. Data were analyzed using SPSS V. 21 software.
The details of the intervention are as following: Descriptive statistics (frequency, percentage, mean and
standard deviation) were used to analyze the data and
Five minutes for warm-up which included relaxation to determine the statistical significance inferential statis-
and balancing exercises (by considering the ability of tics (Chi-square, Fisher’s exact test, independent t-test,
each elderly woman); paired t-test, and repeated measures ANOVA) were used.

20-30 minutes for performing 1-8 movements of Tai 3. Results

Chi as following hand and body positions by listening to
Tai Chi music: 1 = Commencing form where both hands The results of the demographic analysis showed that the
rise to shoulder level; 2 = Curving back arms; 3 = Step- participants of both the groups had no significant difference
ping sideways and moving arms; 4 = Moving hands like in terms of age, weight, height, body mass index, duration of
clouds; 5 = Diagonal strides; 6 = Standing on one leg; 7 = hypertension, underlying disease, marital status, educational
Stepping and pushing; and 8 = Closing form where both level, economic situation and use of mobility aids (Table 1).
hands fall to the side and left leg drawn to the right leg.
The comparison of results for the perceived stress
Five minutes for cooling down involving deep breath- was done for the participants in both the groups, test
ing and muscular relaxation. and control. The pre-intervention stage, by indepen-
dent t-test, showed that the two groups did not have
The control group did not receive any special interven- any significant statistical difference (P = 0.575). The
tion apart from the routine care. Immediately after com- mean score of stress, before intervention, in the test

Table 1. Demographic characteristics of study participants

Test Group Control Group

Variables Group P
N % N %
60-64 years 6 18.8 5 15.8

65-69 years 14 43.8 14 43.8

Age 0.555
70-74 years 4 12.5 7 21.9

> 75 years 8 25 6 18.8

Unlettered 7 21.9 5 15.6

Lettered 21 65.6 21 65.6

Educational level 0.676
Secondary school 4 12.5 4 12.5

Academic 0 0 2 6.2

< 25 months 14 43.8 8 25

25-74 months 8 25 6 18.8

Duration of hypertension 0.353
75-125 months 6 18.8 16 50

> 125 months 4 12.5 5 15.6

Married 17 53.1 21 65.6

Marital status Divorced 1 3.1 0 0 0.446

Widowed 14 43.8 11 34.4

Good 1 3.1 15 46.9

Economic situation Fair 22 68.8 16 50 0.001

Poor 9 28.1 1 3.1

Client-Centered Nursing Care

Talebi, E., et al., 2017. Effect of Tai Chi Exercise on the Stress of Elderly Women With Hypertension. JCCNC, 3(4), pp. 263-268. 265
Novoember 2017. Volume 3. Number 4 Client-Centered Nursing Care

Table 2. Mean ± SD and ANOVA results of the perceived stress before and after the intervention in both the study groups

Test Group Control Group Repeated Measures ANOVA

Mean ± SD Mean ± SD Intra-group Inter-group

Before intervention 25.16 ± 7.56 26.45 ± 10.49 Greenhouse-‐Geisser

F = 10.27 test
P = 0.489 F = 2.54
After intervention 23.84 ± 6.64 25.44 ± 9.87 P = 0.115

t = 0.208
Variations -1.31 ± 6.49 -1.01 ± 5.05 df = 62
P = 0.836
Client-Centered Nursing Care

Table 3. Mean ± SD and paired t-test results of the perceived stress before and after intervention in both study groups

Test Group Control Group

Mean ± SD Mean ± SD

Before intervention 25.16 ± 7.56 26.45 ± 10.49

After intervention 23.84 ± 6.64 25.44 ± 9.87

t = 0.130
t = 1.144, df = 31
Paired t-test df = 31
P = 0.262
P = 0.267
Client-Centered Nursing Care

group was 25.16 and in the control group was 26.45. in the range of 65-69 years. It should be noted that these
Independent t-test results also showed that after inter- mean ages are below the younger aged group ranging
vention, the mean score of stress in the test group was from 60 to 74 years old. Regarding the Body Mass In-
23.84 and in the control group was 25.44, but there dex (BMI), BMI was 23 for test group, and it was 22 for
was no significant difference between the two groups control group, presenting that there was no significant dif-
after the intervention. Also, the results of ANOVA with ference between the two groups (P = 0.579). According
repeated measures (inter-group effect) showed that the to the division of the body mass index the elderly in this
mean score of perceived stress before and after the in- study are in the normal range, but it should be noted that
tervention was statistically insignificant (P = 0.557). the mean BMI of women is significantly higher than that
For intra-group effect, the mean score of the two of men. On the other hand, BMI is related to blood pres-
groups had an insignificant statistical difference (P = sure therefore in hypertensive patients it is significantly
0.489) (Table 2). Independent T-test also showed that more than those with normal blood pressure.
there was no significant difference in perceived stress
variations in both groups (P = 0.836). Overall, there There was no significant difference between the two
was no significant difference in the perceived stress in groups regarding the duration of hypertension (P =
test group (P = 0.262) and control group (P = 0.267) 0.353). In the test group, the hypertension duration for
before and after the intervention (Table 3). 43.8% of women was 25 months and less, while in the
control group, for 50% of them it was between 75-125
4. Discussion months. The two groups did not have any significant dif-
ference with respect to the underlying disease, history of
The aim of this study was to investigate the effects of the disease and were homogeneous (P = 0.106). 59.4%
Tai Chi exercise on the perceived stress of elderly wom- in the test group and 78.1% in the control group had un-
en with hypertension. The mean age of elderly women derlying diseases other than hypertension. Participants
with hypertension in the two groups, test (71 years) and reported the abnormalities in the cardiovascular system,
control (70 years), was not statistically significant (P = liver and endocrine system, musculoskeletal system as
0.555). Also, the highest age frequency of elderlies was well as neurological, immune and visual systems which

266 Talebi, E., et al., 2017. Effect of Tai Chi Exercise on the Stress of Elderly Women With Hypertension. JCCNC, 3(4), pp. 263-268.
Client-Centered Nursing Care Novoember 2017. Volume 3. Number 4

indicated the diverse diseases that the elderlies were in- trainer and his experience are all factors that can influence
volved with. This would result in the exponential growth the outcome of Tai Chi’s exercise. Although the duration
of health costs (Rasel & Ardalan 2007). of intervention and its frequency are mentioned in most
studies; however, the time taken by any participant in the
There were insignificant differences between the two study to learn the exercise has not been taken into account,
groups in terms of educational level (P = 0.676). Sixty- which can be an important factor for the conclusion. In
six percent of patients in each group were literate enough sports like Tai Chi, it’s important to use visual senses,
to read and write. The mean of stress severity in people imagining, relaxation and remembering the type and se-
with different educational levels had a significant differ- quence of movements which affects the results. Each
ence with each other. There was a significant difference study has implemented a specific style of Tai Chi exercise;
between the two groups in terms of economic status (P maybe because there is no unique and specific protocol
< 0.001) and more than half of the participants had a fair of Tai Chi for the elderlies (Miller & Taylor Piliae 2014).
economic status. It seems that since the participants in
this study were from the two private elderly care centers Cultural differences also influence the results of inter-
in Tehran where it requires a fair income level in order to vention by Tai Chi exercise. The familiarity of the elder-
pay the tuition; this statistical finding can be acceptable. lies with this sport and its amalgamation with their lives
Overall, it was concluded that there were no significant is an important issue (Yeh et al., 2008). More positive
differences in the perceived stress in both test and control results have been reported from the studies conducted in
groups, before and after the intervention. Asian countries, especially China because this exercise
is not strange to the elderly with Chinese background
Several studies have been conducted over the Tai Chi and is not in conflict with their lifestyle. While in Iran
exercises, some of these studies have shown results that there is not enough awareness about this sport, which re-
substantiate our findings, and with others, there were no duces the motivation of the elderly to start and pursue it.
agreements. Lee et al. (2017) investigated the effects of This lack of familiarity, made some elderly people think
Tai Chi on waist circumference and blood pressure of 68 that these movements are useless or do not concentrate
elderly women aged 65 years. Simplified Yang style 24- enough on the movements of this exercise. Old people
form Tai Chi was used as the intervention, which was con- living in elderly care centers think that they are worthless,
ducted for 5 sessions per week (60 minutes per session), feel themselves closer to death and can lose hope to live.
for 6 weeks. They concluded that Tai Chi can be used as This has led elderly residents of care centers to be consid-
an effective intervention to improve waist circumference ered as the most vulnerable group who experience a lot of
and blood pressure in the elderly. In another study by Kim stress (Naseh et al. 2014). These factors and continuous
et al. (2016), the mental-attention Tai Chi effect on 64 stress sometimes make them indifferent, unconcerned
Chinese and non-Chinese adults (51–87 years old) was or disinterested to engage in activities. According to the
investigated. Their results suggested that Tai Chi can im- study of Kim et al. (2016) on mental-attention effect of
prove mental-attention, vigilance and executive control, Tai Chi on older adults, this exercise should be repeated
when participants are sufficiently motivated to pursue and practiced in non-familiar cultures, but it was not pos-
this practice which was observed among Chinese elders. sible to do it in a privately managed elderly care center.
Miller and Taylor Piliae (2014), in a review of recent re- Moreover, the elderly participants in our study did not
searches on the effects of Tai Chi on cognitive function concentrate enough on the movements of this exercise.
in community-dwelling older adults, indicated some stud-
ies that reported no significant effect of Tai Chi exercise Tai Chi is a complementary therapy, in recent years,
on the performance of the study community. According non-pharmacological methods have attracted the atten-
to them, some of the factors such as the lack of a well tion of patients and health care providers (Azimzadeh et
designed methodology for performing Tai Chi in the el- al. 2013). In elderly nursing, since a holistic look and at-
derly, can cause failure to have appropriate results from tention to all the needs of an elderly person is very much
this exercise. From the review of results of various studies important; therefore, implementation of this exercise can
and their comparison with the results of our current study, promote the health of the geriatrics and find a clear or ef-
it can be said that these contradictory results may be due fective form for this sport in the elderly population.
to the selection of subjects, their gender, physical fitness,
history of illness, Tai Chi style, its severity, and duration. One of the limitations of this research was lack of ade-
quate open space for Tai Chi exercise. The research space
Different forms of Tai Chi exercise which include the had no suitable and safe sports hall for the elderly. During
style of performance, the duration of exercise and the the intervention, the elderly who did not have the ability

Talebi, E., et al., 2017. Effect of Tai Chi Exercise on the Stress of Elderly Women With Hypertension. JCCNC, 3(4), pp. 263-268. 267
Novoember 2017. Volume 3. Number 4 Client-Centered Nursing Care

to stand up, sat on the chair and made the movements Jacob, L., Breuer, J. & Kostev, K., 2016. Prevalence of chronic dis-
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according to their ability and an emphasis on increasing
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the upper extremity movement. It should be noted that
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with older adults. BMC Psychology, 4(1), p. 29. [DOI:10.1186/
near each elderly in order to be used in case of tiredness s40359-016-0137-0]
or imbalance. The care givers responsible for each par-
ticipant in the elderly care centers had to be present near Lan, C. et al., 2013. Tai Chi Chuan exercise for patients with car-
diovascular disease. Evidence-Based Complementary and Alter-
the elderly and help them in the risk of imbalance. native Medicine, 2013, pp. 1–9. [DOI:10.1155/2013/983208]

In this study, due to the type of research design (random- Lee, Y. M., 2017. The effects of Tai Chi on waist circumference
and blood pressure in the elderly. Journal of Physical Therapy
ized quasi-experimental), generalization of the results of Science, 29(1), pp. 172–5. [DOI:10.1589/jpts.29.172]
this study to a large extent is not possible; therefore, using
the findings of this study should be done with caution. Lloyd Sherlock, P. et al., 2014. Hypertension among older adults
in low- and middle-income countries: prevalence, awareness
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Miller, S. M. & Taylor Piliae, R. E., 2014. Effects of Tai Chi on

This paper was extracted from a MS. thesis approved under cognitive function in community-dwelling older adults: A
clinical trials registration code: IRCT2015072923408N1. review. Geriatric Nursing, 35(1), pp. 9–19. [DOI:10.1016/j.ger-
The author would like to thank the research branch of the inurse.2013.10.013]
Faculty of Nursing and Midwifery at Iran University of Naseh, L., Shaikhy, R., & Rafii, F., 2014. [Quality of life and its
Medical Sciences and the elderly participated in this study related factors among elderlies living in nursing homes (Per-
for their valuable cooperation. The authors are also grate- sian)]. Iran Journal of Nursing, 27(87), pp. 67-78.
ful to the respected master of Tai Chi, Mrs. Janbaz, who Pho, A. T. et al., 2012. Nursing strategies for promoting and
played an important role in acquainting us with the Tai Chi maintaining function among community-living older adults:
The CAPABLE intervention. Geriatric Nursing, 33(6), pp. 439–
exercise and acquiring the certification.
45. [DOI:10.1016/j.gerinurse.2012.04.002]

Conflict of Interest Rasel, M., Ardalan, A., 2007. [The future of ageing and its health
care costs: A warning for health system (Persian)]. Salmand,
2(2), pp. 300-5.
The authors declare that they have no conflict of interest.
Sato, S. et al., 2010. Effect of Tai Chi training on baroreflex sen-
sitivity and heart rate variability in patients with coronary
heart disease. International Heart Journal, 51(4), pp. 238–41.
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Taylor Piliae, R. E., 2014. Tai Ji Quan as an exercise modality to

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