THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 00, Number 0, 2016, pp. 1–5 Original Article

ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2015.0230

Acute Effects of T’ai Chi Chuan Exercise

on Blood Pressure and Heart Rate
in Peripheral Artery Disease Patients

Filipe Fernandes Oliveira Dantas, PhD,1 Fábio da Silva Santana, BS,2 Thiago Souza Rosas da Silva, BS,2
Gabriel Grizzo Cucato, PhD,3 Breno Quintella Farah, MS,4,5 and Raphael Mendes Ritti-Dias, PhD3

Abstract

Objective: To investigate the acute effect of a t’ai chi chuan session on blood pressure and heart rate in patients
with peripheral artery disease (PAD).
Design: Randomized crossover intervention study.
Setting: Outpatient therapy center.
Participants: Seven patients with PAD, aged 50–79 years, not using b-blockers, calcium-channel blockers, or
nondihidropiridinic vasodilators.
Intervention: T’ai chi chuan and control session (both sessions lasted 40 minutes).
Outcome measures: Systolic and diastolic blood pressure and heart rate, which were evaluated before and after
the intervention (10, 30, and 50 minutes).
Results: T’ai chi chuan exercise acutely decreased systolic blood pressure at 30 minutes after exercise ( p = 0.042)
and increased diastolic blood pressure at 50 minutes after exercise ( p = 0.041). Heart rate did not change after t’ai
chi chuan exercise.
Conclusion: T’ai chi chuan acutely decreases systolic blood pressure in patients with PAD.

Introduction
P eripheral artery disease (PAD) is an atherosclerotic
disease characterized by occlusion or stenosis of the lu-
men of peripheral arteries, reducing blood flow and oxygen to
the muscle in lower limbs.1 PAD affects between 3% and
10% of the adult population, and more than 15% of those
older than 70 years.2–4 Intermittent claudication, which is the
most prevalent symptom of PAD,1 leads to walking impair-
ment, reduced physical activity levels,5,6 and, consequently,
worsened physical fitness in these patients.7,8
Hypertension is highly prevalent in patients with PAD.9
Moreover, the risk for cardiovascular events in patients with
PAD is 30% higher than in patients with other atheroscle-
rotic diseases, such as coronary heart disease and cerebral
arterial disease.10 Consequently, strategies to control car-
diovascular risk factors, especially the reduction in blood
pressure (BP), have been recommended as a target in the
therapeutic approach of these patients.1,11
Previous studies have shown that both walking and resis-
tance exercises have promoted lowering BP in patients with
PAD until an hour after exercise.12–15 However, because
walking and resistance exercises promote pain symptoms,
considered a main barrier for physical activity practice in
patients with PAD,16,17 alternative exercise strategies to re-
duce cardiovascular risk without symptoms must be studied.
T’ai chi chuan (TCC) is a traditional Chinese martial art that
has been practiced in China for many centuries. It combines
deep diaphragmatic breathing and relaxation with many fun-
damental postures that flow imperceptibly and smoothly from
one to the other through slow, gentle, graceful movements.18
TCC is practiced to promote good health, memory, concen-
tration, digestion, balance, and flexibility. Moreover, it is also
thought to improve psychological conditions, such as anxiety
and depression.19 In addition, a systematic review has found
that TCC is effective in lowering BP after a training period in
hypertensive patients and those with cardiovascular disease.20
However, whether TCC decreases BP and heart rate (HR) in

1
Associate Graduate Program in Physical Education, Federal University of Paraiba, João Pessoa, Brazil.
2
University of Pernambuco, Recife, Brazil.
3
Hospital Israelita Albert Einstein, São Paulo, Brazil.
4
Associate Graduate Program in Physical Education, University of Pernambuco, Recife, Brazil.
5
Group Research in Health and Sport, ASCES College, Caruaru, Brazil.

1
2 DANTAS ET AL.

patients with PAD, who have endothelial dysfunction,21 in- Thereafter, patients returned to the resting seated position
creased arterial stiffness,22 and increased cardiac sympathetic for 60 minutes (postintervention period). BP and HR were
modulation to the heart,23 is unknown. obtained at 10, 30, and 50 minutes, respectively. For anal-
Because previous studies have demonstrated that a single ysis, D values were considered (postintervention – preinter-
exercise session can predict the chronic response of exercise vention values).
training,24,25 the aim of this study was to investigate the
acute effect after a single TCC session on BP and HR in Statistical analysis
patients with PAD. Normality of the data was not confirmed by the Shapiro-
Wilk test, and nonparametric analysis were performed. The
Materials and Methods
Friedman test was used to analyze the variables within each
Participants group. When significant differences were found between the
values analyzed, comparisons were made of the paired data
Patients with PAD were recruited at public hospitals and
between each of two measurements (Wilcoxon test), pe-
private clinics in Recife, Pernambuco, Brazil. Patients were
nalizing the p-values found by the Bonferroni procedure.
screened by a physician and were included if they (1) were
The Wilcoxon statistical test was used for comparisons be-
aged 50 years or older; (2) had claudication symptoms; (3)
tween sessions in each time deemed. Data are presented as
had an ankle brachial index of 0.90 or less; (4) had systolic
median and interquartile range (IQR; 25th–75th percentile
and diastolic BP lower than 160 mmHg and 105 mmHg,
values). Significance was set at p < 0.05.
respectively; (5) had not undergone coronary artery bypass
surgery or angioplasty in the last year; (6) were not using Results
b-blockers, calcium-channel blockers, or nondihidropiridi-
nic vasodilators; (7) did not present complex arrhythmias or Table 1 shows the general characteristics of participants
myocardial ischemia; and (8) did not have amputated limbs. in this study.
Information regarding the self-reported stress was also ob- The preintervention systolic BP values were similar between
tained. Seven patients were included in this study and signed sessions (control: median, 122 mmHg [IQR, 22 mmHg]; TCC:
a written consent form. This study was approved by the median, 119 mmHg [IQR, 20 mmHg]; p = 0.249). The TCC
Research Ethics Committee of the University of the Per- session decreased systolic BP at 30 minutes after the inter-
nambuco, Brazil (#0265.0.097.000-10). vention (p = 0.042) (Fig. 1).
The preintervention diastolic BP values were similar be-
Procedures tween sessions (control: median, 74 mmHg [IQR, 12 mmHg];
TCC: median, 73 mmHg [IQR, 8 mmHg]; p = 0.063). TCC
All patients underwent two experimental sessions (control
session increased diastolic BP at 50 minutes after the inter-
and TCC session) conducted in random order and separated
vention ( p = 0.041) (Fig. 2).
by at least 72 hours. Sessions were started between 7 am and
The preintervention HR values were similar between pro-
8 am; patients were instructed to have a light meal at least
tocols (control: median, 79 beats/min [IQR, 15 beats/min];
2 hours before arriving at the laboratory and not to ingest
TCC: median, 79 beats/min [IQR, 18 beats/min]; p = 0.865).
coffee, tea, cola, or other stimulants thereafter. In addition,
There were no significant changes in HR after the interven-
they were instructed to refrain from vigorous physical ac-
tion (Fig. 3).
tivity in the previous 48 hours and from alcohol ingestion in
the previous 24 hours. Smokers were instructed not to Discussion
smoke before testing sessions, and all patients continued to
take their regular medication on experimental days. The results of this study indicated that a single session of
In each experimental session, patients arrived at the labo- TCC exercise decreases systolic BP and did not change HR
ratory and initially rested in a seated position for 20 minutes.
After this period, BP and HR were obtained (preintervention Table 1. Patient Characteristics
period). BP and HR measurements were taken with the auto- Characteristic Values
matic digital Microlife device (Widnau, Switzerland), BP
3AC1-1 model, validated according to the British Association Age (yr) 63 (59–71)
of Cardiology specifications for measurements taken at rest;26 Weight (kg) 61.5 (60.0–79.1)
all measurements were taken by the same researcher. The Height (m) 1.53 (1.48–1.66)
mean value of the three measurements was considered to es- Body mass index (kg/m2) 28.1 (21.8–30.8)
tablish values at preintervention period. After this period, Ankle brachial index (right) 0.71 (0.66–0.77)
patients started the control or TCC intervention. Ankle brachial index (left) 0.72 (0.59–0.82)
The TCC intervention started with a specific warm-up with Risk factors (%)
the first part of the lian gong shi ba fa technique (5 minutes). Stress 86
After warm-up, patients performed postural movements, as Actual smoker 14
Hypertension 86
ma-pu (rider posture), kun-ma (bow and arrow posture), and
Diabetes mellitus 43
leg false posture. At the end, they performed movements with Obesity 43
arms and yang simplified position (Pequim 24). The complete
Medication (%)
session lasted 40 minutes. All movements were carried out
Antihypertensive agent 86
according to the guidelines and were supervised by an expe- Antidiabetic agent 43
rienced TCC instructor. In the control condition, patients re-
mained in a seated position for 40 minutes. Data are presented as median (interquartile range) or frequency.
T’AI CHI CHUAN AND POSTEXERCISE HYPOTENSION
FIG. 1. Postintervention acute response of systolic blood
pressure. The values are presented as median and inter-
quartile range. *p < 0.05 between sessions.
in a recovery period, suggesting that TCC could be incor-
porated as an alternative exercise strategy to reduce acute
cardiovascular load in patients with PAD.
This is the first study to analyze the acute cardiovascular
effects of TCC exercise in patients with PAD. The results
showed that TCC decreased systolic BP at 10, 30, and 50
minutes after exercise, although statistical significance was
reached only at 30 minutes after exercise. The net reductions
of systolic BP calculated by ([post-TCC - pre-TCC] - [post-
control - pre-control]) were -7.4 – 7.3 mmHg. This magnitude
of reduction was similar to those observed after resistance
and walking exercises in these patients.12 Furthermore, it is
known that reductions of about 5 mmHg in BP decrease
mortality from coronary heart disease in 9% and stroke in
14%.27 Thus, the magnitude of reduction in systolic BP ob-
tained by TCC can be considered clinically relevant for these
patients.
In the present study, TCC session increased diastolic BP
at 50 minutes. Given that systolic BP is mainly influenced
by cardiac output, whereas diastolic BP is mainly influenced
by peripheral vascular resistance, the increases in systemic
vascular resistance may have occurred to compensate for the
decreases in cardiac output. The divergent responses be-
tween systolic and diastolic BP has already been observed in
other types of exercise and different populations28–31 and
may reflect the orthostatic stress produced by the prolonged
time in a sitting position.30 These responses are probably
potentiated in patients with PAD evaluated in this study
because these patients are known to have endothelial dys-
FIG. 2. Postintervention acute response of diastolic blood
pressure. The values are presented as median and inter-
quartile range. *p < 0.05 between sessions.
3
FIG. 3. Postintervention acute response of heart rate. The
values are presented as median and interquartile range.
function and increased arterial stiffness.21,22 Future studies
should examine the effects of TCC session in systemic
vascular resistance, arterial stiffness, and endothelial func-
tion in order to clarify the mechanisms involved in the in-
creased diastolic BP after a TCC session.
Previous studies have frequently demonstrated an in-
crease in HR during the recovery period after different
modalities of exercise,29,32 promoted by the increase in
sympathetic modulation to the heart.33 Interestingly, our
results indicated maintenance of this variable after a TCC
exercise session. A decrease in HR in favor of TCC session
was probably not evidenced because of the small sample
size. In fact, previous studies have found that a TCC session
can alter cardiac autonomic modulation by enhancing the
parasympathetic and reducing the sympathetic modulation,
consequently reducing the HR in adults.34
Hypertension is highly prevalent in patients with PAD,9
and exercise is recommended for the control of cardiovas-
cular risk factors.1 This study amplifies the current knowl-
edge showing acute benefits on BP in PAD. However, it
would be clinically significant if this reduction were also
observed over the long term. Some studies in hypertensive
and patients with coronary artery disease showed that TCC
exercise training decreased BP during a long-term period.
Channer et al.35 showed that an 8-week, low-intensity TCC
program was effective for reducing BP in patients with acute
myocardial infarction. Lai et al.36 studied 2-year trends in
cardiovascular function among elderly TCC practitioners
and sedentary participants and found that regular TCC might
delay the decline of cardiovascular function in elderly per-
sons. Thus, the long-term effects of TCC on cardiovascular
risk in patient with PAD must be investigated in the future.
This study had some important limitations. First, the
statistical power was compromised by the small sample size.
Second, patients receiving b-blockers, calcium-channel
blockers, or nondihidropiridinic vasodilators were not in-
cluded in this study, which precludes the applicability of the
results to patients receiving these medications. Patients in this
study had systolic and diastolic BP lower than 160 mmHg and
105 mmHg, respectively. Thus, the results cannot be extrap-
olated to patients with PAD at other stages of hypertension.
Finally, ambulatory BP monitoring was not included, and it is
not possible to state that the reduction in systolic BP observed
in this study after TCC exercise would be prorogated during
patients’ daily activities.
In conclusion, a TCC session promotes a decrease in
systolic BP and maintenance of HR after exercise. Thus,
4 DANTAS ET AL.
TCC could be incorporated as an alternative exercise strat-
egy to reduce acute cardiovascular load in patients with
PAD. However, future studies are needed to understand the
mechanisms involved in these responses.
Acknowledgments
The authors are thankful for the support provided by
public hospitals and private clinics in the city of Recife and
the National Counsel of Technological and Scientific De-
velopment, and for a grant from Conselho Nacional de
Desenvolvimento Cientı́fico e Tecnológico (CNPq).
Author Disclosure Statement
No competing financial relationships exist.
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Address correspondence to:
Filipe Fernandes Oliveira Dantas, PhD
Associate Graduate Program in Physical Education
Federal University of Paraiba
João Pessoa 58051-900
Brazil
E-mail: filipepersonal@hotmail.com