THATPOSE CHALLENGES TO ITSSCIENTIFIC EVALUATION
The scientific study of
, and generalizations aboutits therapeutic effects and safety, are complicated by its plu-ralism.
is an evolving art, and new styles have beendeveloped based on the unique insights (and interpretations)of generations of practitioners. Currently, a number of styles(named after the originator or “lineage” holder) are widelyrecognized, including among others, the
Yang, Chen, Wu,Sun
styles. Each of these styles is characterizedby slightly different emphases in training content as well ascore
Additionally, within each style,there are many substyles, which further contribute to
’s pluralism. For example, within the
style lineage,distinct forms have been developed that vary with respectto the numbers of choreographed movements and postures(e.g., 24-, 37-, 72-, 108-, and 150-movement forms), as wellas overall emphasis (e.g., health maintenance, martial skills,meditation and self-realization, competitive performingarts). Many styles also include a rich variety of
weapons training and 2-person interactive practices.In addition to variation across
is taught and transmitted adds further heterogeneity to
students’ experiences. For example, some schools thatadopt more “traditional” methods or where language barri-ers exist may emphasize nonverbal instruction (mimicry,shadowing, physical posture adjustments), whereas othersemphasize verbal instruction. There is also variability in theformat of training programs, with some centered on group-based curricula where students progress as a cohort, whileothers are more individually based and students progress attheir own rate. Additionally, there is great variability evenwithin a school or lineage, depending on individual teach-ers. Most lineages do not have formalized teacher-certifica-tion programs, and there are no established criteria for la-beling someone as a teacher or master. Although some recentprograms have developed formal teacher training prog-rams, there is no national or international organizing bodyanalogous to the American Medical Association or NationalCertification Commission for Acupuncture and OrientalMedicine to evaluate program criteria or to administer com-petency examinations.In summary, the pluralism of
generated by dif-ferent styles and teaching systems results in significant het-erogeneity in the training that
students experiencein both research- and community-based settings. This het-erogeneity poses significant limitations regarding the con-clusions that can be drawn from individual studies, as wellas the inferences that can be drawn from comparisons be-tween studies. Some recommendations for better character-izing and accounting for
’s pluralism are discussedbelow.
Evaluation of the results of any clinical trial requires someknowledge of the dose of the therapy employed.
’scomplexity and pluralism poses challenges for developing aconcept of dose that is equivalent to that commonly used inpharmacology (i.e., the quantity of an active agent taken inor absorbed at any one time). There are two aspects of dosage that should be considered in developing this conceptfor
; a gross or obvious aspect, and a more subtle andfunctional one. At the gross level, dosage essentially in-volves practice time. Longer-term interventions, more fre-quent classes, and longer individual practice sessions corre-spond with higher doses. However, even at this gross level,one might expect that the dosage effects of 100 hours of
for styles that vary in their relative emphasis of compo-nents (e.g., meditative breathing versus physically demand-ing movements) would be different. What is even more chal-lenging is quantifying the more subtle distinction betweenwhat we will call here, “clock time” doing
versus“effective practice time” doing
. Using a pharma-ceutical as an analogy, there is a distinction between the ad-ministered dose and the effective bioavailable dose across apopulation of patients, due to differences among patients indrug absorption rates and other pharmacokinetic processes.Similarly, there will be variations across
practition-ers in the benefits they experience after 100 hours of a givenstyle of
, due to different levels of training, practi-tioner commitment, and specific proficiencies. Some rec-ommendations for better characterizing dosage in
studies are presented below.Although a growing number of studies have demonstratedthat
interventions as short as 10 to 12 weeks canhave marked effects on balance,
is more commonly viewed as a ther-apy that has rehabilitative and preventative benefits that takeplace over many years.
Moreover, like good wine, itis believed that the magnitude of the benefits of
in-creases over time as practitioners’ skills improve. Conse-quently, short-term prospective studies may regularly un-derestimate the potential benefits of
Long-term prospective controlled studies are not practi-cal, and very few prospective controlled
studies havebeen conducted for as long as 1 year.
Although numerouscross-sectional studies comparing physiologic characteris-tics of long-term practitioners to nonpractitioners have beenconducted, conclusions from many of these studies are lim-ited by biased choices of control groups and other method-ological deficiencies.
As discussed below, to account for
’s long-term benefits, evidence from prospective con-trolled studies must be complemented by well-designed
WAYNE AND KAPTCHUK192