An Analysis of Tai Chi Posture Effects on Knee pains: An approach for improving the Implementation Tai Chi.

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Darrin Sime Nkemeni, Zhenyu Liu, Tiegang Zhang, Fangfang Xu, Duangchit Chanthavone, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8566281/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Tai Chi is a form of physical activity characterized by slow movements that induce a state of meditation synchronized with breathing, to achieve spiritual tranquility. This kind of training exercise has a light-to-moderate-intensity with a metabolic activity varying between 2.5 and 6.5 METs, is suitable for all age groups. This review begins with a compelling meta-analysis that sheds light on the significant relationship between posture, knee pain, and knee movements. Prepare to uncover valuable insights that could transform our understanding and management of knee health during Tai Chi practice. Additionally, it investigates the proportion of knee pain between Tai Chi practitioners, and the findings suggest that there is a notable prevalence of knee pain among Tai Chi practitioners, with reported rates ranging from 48% to 57% in different research studies. This knee pain is caused by movements involving high knee rotation and high knee extension/abduction, owning to the posture level. This indicates the need for practitioners to be mindful of their knee movements during Tai Chi practice in order to minimize the risk of knee pain. Furthermore, it outlines the role of the hip in knee pain and indicates the need for further research. In the review part, the selected results were analyzed based on three primary categories: characteristics of Tai Chi practice, health benefits of Tai Chi, and its implementation. The findings revealed that Tai Chi greatly enhances both physical and psychological well-being. It similarly proposes how the implementation of Tai Chi can be beneficial to private and public sector and further outlines some limitation faced by Tai Chi. Educational Psychology Physical Medicine & Rehab knee pain Tai Chi health benefits physical fitness implementation Figures Figure 1 Figure 2 Introduction According to the WHO, 1.4 billion adults, representing more than a quarter of the global adult population, are not engaging in enough physical activity. About 33% of women and 25% of men fail to do enough physical activity to stay healthy. [ 1 – 4 ]. Physical fitness has a multitude of impacts on one's overall health, encompassing health-related attributes such as body balance, flexibility, muscular endurance, coordination, body composition, and cardio-vascular endurance, as well as skill-related attributes like speed, strength, response time, agility, and power [ 5 – 7 ]. The decrease in physical activity is exacerbated by a troubling increase in sedentary behavior, reaching alarming levels. With more people embracing inactive lifestyles influenced by technology and urban living, the adverse health effects are increasingly clear. This inactivity leads to various physical and mental health problems, including obesity, cardiovascular diseases, and anxiety disorders. Tackling this issue is essential for enhancing overall well-being. Promoting active lifestyles through community initiatives, accessible recreation options, and health education can help counteract this trend, fostering a healthier and more engaged population. Pertinently, the practice of physical activities that involve an organized regimen of exercise such as Tai Chi and Ba Duan Jin, has been shown to have good benefit on both mental and physical health across all age demographics [ 8 , 9 ]. These exercises such as Tai Chi; a traditional Chinese martial art that integrates physical activity with mindfulness, facilitating harmony, synchronization, and tranquility [ 10 – 13 ]. The practice is based on the foundational concepts of Yin and Yang, which encompass a sequence of deliberate, continuous movements paired with mindful, regulated breathing techniques [ 14 , 15 ]. Yin and Yang are qualified by the fundamental rhythm that animates Qi, while Qi represents life energy. Tai Chi practice can improve Qi, which animates the human organs [ 16 ]. Adherence to Tai Chi has been shown to ameliorate various aspects of an individual's health, including posture, balance, coordination, relaxation, cardiovascular health, fitness levels, and it may contribute to a reduced incidence of falls, as well as diminished levels of depression, anxiety, and stress [ 17 , 18 ]. Given its low to moderate exercise intensity, reflecting metabolic equivalents ranging from 2.5 to 6.5, Tai Chi is deemed appropriate for individuals of varying ages [ 19 , 20 ]. However, certain studies have illuminated concerns regarding the potential of Tai Chi to induce strain or injury specifically in the knees of some practitioners. This issue is becoming a considerable factor that not only affects the uptake of Tai Chi but also contributes to some practitioners leaving the discipline. The movements involved in Tai Chi, particularly those that require bending and supporting body weight, may place strain on the knee. Consequently, this has brought the safety of the practice into question, especially for people with existing knee conditions or those who might not be accustomed to regular physical activity. As Tai Chi gains in popularity, it is important that individuals receive proper guidance and adequate exercises to suit their personal capabilities to reduce the risk of injury. Therefore, balancing the positive aspects of Tai Chi with these emerging concerns about knee health is crucial for both new and experienced practitioners. The aim of this research is to highlight the significance importance of the fundamental components of Tai Chi practice, such as static-stance exercise, breathing, slow movement single-form and combination practice, and routine practice. It also aims to conduct a meta-analysis to explore the statistics and reasons behind knee injuries in Tai Chi practitioners. Furthermore, this review provides The aim is to systematically evaluate and synthesize existing research on how Tai Chi postures influence knee pain. This study seeks to identify effective techniques that can improve the application of Tai Chi in managing knee pain, thereby offering insights into best practices for practitioners and enhancing patient outcomes. By reviewing modern methodologies, the analysis aims to provide recommendations for optimizing Tai Chi interventions for individuals suffering from knee pain. Material and methods 3.1 Meta-Analysis Search Strategy and Study Selection Criteria: A comprehensive search was conducted across five major databases: PUBMED, Web of Science, EMBASE, CNKI, and Google Scholar, with no restrictions on language. The search terms used covered numerous variations and related phrases of Tai Chi, arranged in the following manner: (Tai Ji OR Tai Chi OR Tai Ji Quan OR Tai Chi Chuan OR Tai Chi Quan) AND (injuries OR knee pain). Studies were considered eligible for this meta-analysis if they met the following criteria: 1) they investigated the issue of knee pains in relation to Tai Chi; and 2) they included an intervention that specifically involved Tai Chi exercise training causing knee pian. 3.1.1 Screening process The screening process and data extraction were done in four parts, with the first step's basic screening criterion being the title and abstract. Second, research-related papers that did not fall under this category were not included. Third, any search results that included Tai Chi alongside another sort of exercise (for example, yoga, qigong, etc.) were also removed. At a later time, full-text eligibility was implemented. Using a pre-piloted form, data from the selected studies were gathered. The obtained data comprised study design, sample size, and results. 3.1.2 Data extraction Potential papers were screened for inclusion. We retrieved potentially relevant studies and determined their eligibility. Discrepancies were resolved through consensus. The extracted information included the following categories: 1) Publication details, such as the last name of the first author and the year of publication; 2) Characteristics of the study participants, including sample size; 3) Details of the interventions, for example, type of intervention, and the effect on knee, and posture level. 3.1.3 Quality assessment The quality assessment was based on Prisma technique [ 21 ]. The papers included in this study were critically analyzed. Classifications in the following areas were assigned based on perceived low value, ambiguity, or elevated risk of bias: the randomness of sequence generation, allocation concealment, blinding methods, instances of incomplete outcome data, potential for selective reporting of outcomes, and other sources of bias. 3.2 Characteristics of Tai Chi Practice and Impart on health The literature search was conducted in PUBMED, Web of Science, CNKI, and Google Scholar. The search was restricted to English only and had no restriction on the publication date from its inception to the end of 2022. The search was examined based on three major categories: the fundamentals of Tai Chi practice, the health benefits of Tai Chi, and the implementation of Tai Chi. The keywords used were Tai Ji OR Tai Chi OR Tai Ji Quan OR Tai Chi OR Tai Chi Chuan OR Tai Chi Quan. Data from the study was uploaded into Endnote for structured organization. The software assisted in categorizing the findings into three distinct themes and streamlined the deletion of any repetitive entries. To enhance accuracy, specific keywords were utilized within each classification. For the fundamentals of Tai Chi practice, the search was conducted using the slow movement, static stance, posture, breathing, single form, self-defense, and routine. For the health benefits of Tai Chi, the keywords were stress, anxiety, depression, sleep, well-being, mental health, cognitive fitness, cardiopulmonary and vascular, blood pressure, and lipids. In this section, the result was subjected to a meta-analysis, where a Prisma diagram was derived. In addition, in this category, studies that did not have anything in common with the health benefits of Tai Chi were excluded. Finally, for the implementation of Tai Chi, the keywords used were application, modern technology, motion capture, implementation, and therapy. For this part, the papers were selected directly from the research database and included another form of exercises such as yoga. A condensed structure of the work is shown in Fig. 2 . Results and Discursion 4.1 Meta-Analysis of Tai Chi posture difference on the health. Tai Chi is known around the world for its ability to rehabilitate and provide health benefits. However, recent studies have suggested that certain Tai Chi movements could potentially harm the joints in the lower body. While various research points to Tai Chi as a potential therapeutic approach for knee pain and injuries, the full extent of its benefits and the impact on overall health remain somewhat unclear. This meta-analysis aims to raise awareness about the risks of performing incorrect Tai Chi movements and to emphasize the importance of further research into injury occurrence within Tai Chi practice, as it is a critical aspect that can influence Tai Chi practitioners. Table 1 presents data collected from four studies (HE et al. [ 22 ], Zhu et al. [ 23 ], Hou et al. [ 24 ], Xing et al. [ 25 ]) focusing on the relationship between practicing Tai Chi and the incidence of knee pain. The table is organized with authors of the studies in the first column, followed by the research method they used, the number of participants in their studies, and various statistics related to knee pain before, during, or after practicing Tai Chi. The studies involve a large number of participants of 3148 individuals and used questionnaires to investigate knee pain in relation to Tai Chi practice. From Table 1 , In all the study, a majority of participants experienced knee pain after Tai Chi practice. Zhu et al. [ 23 ] provided detailed percentages of participants at different Tai Chi levels, showing a relationship between participants' Tai Chi practice level and the impact on knee pain. A majority (57%) of participants in the "Initial Stage" experienced knee pain, while fewer participants reported as their Tai Chi practice level progressed. At the "High Level," only 3.4% reported knee pain. This shows that as the proficiency of Tai Chi increase the probability of having knee pain equally decreases. Additionally, Zhu et al. [ 23 ] indicate that a large portion (48.20%) of participants still had knee pain after practicing Tai Chi. And for those who had knee pain before taken Tai Chi, 60.8% still indicate knee pain and 39.2% were found their pian relived. Xing et al. [ 25 ] also reported a significant percentage of participants (49.09%) having knee pain after practicing Tai Chi. Meanwhile in HE et al. [ 22 ], and Hou et al. [ 24 ] indicate that, the percentage of participants having knee pain after practicing Tai Chi was 49.03% and 52.78%, respectively. Xing et al. [ 25 ] also reported a significant percentage of participants (49.09%) having knee pain after practicing Tai Chi. Table 2 present the summary of findings from three different studies that investigated the relationship between posture level, knee pain, and knee movement. The studies appear to have focused particularly on knee pain associated with various postures and movements potentially occurring during activities like Tai Chi. Below is an analysis of the information provided for each study: In interpreting the information presented in the Table 2 , it is evident that the relationship between posture level, knee pain, and knee movements is complex and requires further elucidation. The three studies, Hsieh et al. [ 26 ], Wang et al. [ 27 ], and Yan et al. [ 28 ], seem to converge on the finding that higher levels of posture are associated with a lower risk of knee pain. The findings highlight the relationship between the height of knee postures and the experience of pain, indicating that variations in knee positioning can influence discomfort levels in individuals. This correlation suggests that knee posture may play a significant role in the management or assessment of knee pain. Furthermore, the studies emphasize the significance of specific knee movements concerning knee pain. Both Wang et al. and Yan et al. note that high knee rotation, along with extensive knee extension and abduction, is associated with an increased risk of knee pain. Thus, practitioners should be cautious with knee movements during activities like Tai Chi to reduce knee pain risk. The analysis of Table 2 indicates that future studies should aim to provide more comprehensive and detailed data, which will facilitate a deeper understanding of the factors contributing to knee pain in relation to posture and movement. Additionally, studies could also include the hip joint in their research because the hip and knee joints function synergistically during Tai Chi movements. The hip joint contributes to the stability and mobility necessary for weight transfer and balance, while the knee joint permits the flexion and extension that enable the characteristic stepping and stance work. Importantly, the movement strategy adopted in Tai Chi often involves a 'coiling' and 'uncoiling' motion, where there is an intentional rotation and counter-rotation of the hip to facilitate fluid continuity in the limbs’ actions. Biomechanically, as the hip engages in a rotational movement within a stance, there is a compensatory action at the knee. For instance, as the hip undergoes external rotation, the knee may concurrently demonstrate a slight internal rotation to maintain alignment and balance, and vice versa. This compensatory mechanism helps to distribute forces more evenly throughout the lower extremity, thus potentially reducing the risk of injury [ 29 ]. Studies has showed that, excessive hip adduction and internal rotation during weight-bearing may significantly alter lower limb kinematics. Specifically, overdoing these movements can lead to a medial shift of the knee joint center relative to the foot. Given that the foot remains stationary on the ground, this medial shift induces outward tibial abduction and foot pronation, culminating in dynamic knee valgus. This condition, excessive knee valgus, has been associated with reduced strength in hip muscles [ 30 , 31 , 32 ] and is recognized in the contribution to a wide array of knee injuries [ 33 ]. Thus, hip and knee of front and rear legs have synchronized movements in opposite directions, leading to the existence of coordination among the hip and knee joints resulting to coupled motion [ 29 ]. 4.2 Important factors for improvement in Tai Chi practice As a martial art, Tai Chi is based on principles of balance and awareness [ 21 ]. It involves a series of slow, continuous movements combined with deep, controlled breathing and focuses on mental relaxation and concentration. Tai Chi practice includes static-stance practice, breathing method, slow movement, single-form practice, combination practice, routine practice, and push-hand moves [ 34 , 35 ]. 4.2.1 Breathing Breathing is a fundamental activity with direct effects on our health and well-being. It is orchestrated by the respiratory, cardiovascular, and nervous systems, all working in concert to maintain optimal oxygen and carbon dioxide levels and ensuring bodily functions [ 36 ]. Adequate breathing benefits the body by supplying oxygen and supports the autonomic nervous system in regulating physiological functions such as heart rate, blood pressure, and digestive processes [ 37 ]. The breathing technique in Tai Chi is called natural breathing, which includes abdominal or diaphragmatic breathing. This style of breathwork not only fosters a mind-body connection, promoting relaxation, balance, and coordination, but also elevates consciousness. Indeed, proper breathing is critical for peak physical and mental performance. Engaging in deep, diaphragmatic breaths can bolster both physical and mental health. Jerath et al. (2016) [ 38 ] found that such breathing techniques can diminish symptom severity, increase oxygen saturation, reduce blood pressure, and enhance lung function and tissue oxygenation. Likewise, Jerath et al. (2015) discovered benefits including regulated blood pressure, diminished stress, and improved mood and cognitive function. Furthermore, Gatts and colleagues (2019) indicated that various Tai Chi breathing methods can substantially improve respiratory function, such as lung capacity and breathing efficiency, as well as balance and coordination [ 39 , 40 ]. Regular Tai Chi has also been noted to augment lung function in the elderly, mitigating respiratory disease risk and promoting general well-being [ 1 ]. Moreover, Tai Chi has been demonstrated to boost cardiovascular fitness and lower blood pressure in those with hypertension [ 14 , 42 ].The correct breathing method is an integral and essential component of Tai Chi practice. The breathing method used in Tai Chi emphasizes slow, deep, and natural breathing that allows the entire body, including the internal organs, to be activated and stimulated. The technique involves inhaling slowly, deeply, and through the nose, while expanding the abdomen to allow a full lung capacity. Which is then followed by a slow, controlled, and natural exhalation, through pursed lips, to release the tension and stress from the body. The breathing methods used in Tai Chi are a crucial component of this traditional Chinese martial art. From promoting relaxation and reducing stress to enhancing martial power and improving overall health and well-being, these breathing techniques offer a wide range of benefits for practitioners. 4.2.2 Static-stance practice Tai Chi's benefits are strongly linked to correct breathing, proper body alignment, and relaxation. These are achieved primarily through an understanding of Zhan Zhuang, the static Tai Chi stance. Standing still for periods often exceeding 15 minutes [ 43 ], practitioners develop an even weight distribution, a stable center of gravity, and optimal body alignment. These practices contribute to stronger muscles, improved balance, flexibility, and functionality while lessening stress [ 44 ]. Studies, such as those by Lee, Kim, and Lim in 2019 [ 45 ], Tang et al. in 2015 [ 46 ], and Knoops, Vermeulen, and Van der Hurk in 2018 [ 47 ], validate the role of the static stance in increasing leg strength and preventing back pain, falls, and injuries by enhancing stability and neuromuscular control. Similarly, Chang, Pan, & Chen in 2014 [ 48 ] demonstrated increased proprioception and reaction times with this practice. Besides physical improvements, Tai Chi is known to foster cardiovascular health and reduce fall risks among the elderly. Oh, Park, and Roh, in their 2015 study [ 49 ], determined that static stance practice could lower blood pressure and improve cardiovascular health by promoting bodily awareness and relaxation. Notably, the immobility involved in Tai Chi sharpens one's sensitivity to bodily, mental, and emotional cues, assisting in tension relief and focus enhancement (Chan & Wong, 2019) [ 50 ]. This state of calm aids stress reduction and bolsters mental well-being. Additionally, it encourages ethical, belief, and character introspection, facilitating moral development and self-actualization (Jin, 2005) [ 51 ]. Ultimately, Tai Chi's static stance is a multifaceted practice that not only improves physical alignment and health [ 48 ] but also contributes to personal growth and holistic well-being. Static stance is also a critical underpinning for more complex Tai Chi techniques, such as defensive applications, Push Hands, and Tai Chi sequences. Without a solid grounding in posture, alignment, and internal energy, these advanced methods are less effective and efficient (Yang, 2005) [ 52 ]. Static stance remains a pivotal element in Tai Chi. It lays the groundwork for movement, cultivates internal strength along with balance, heightens body consciousness, boosts flexibility, doubles as a meditative practice, hones martial proficiency, fosters relaxation, and bolsters overall health. Consequently, can contributing to the reduction of knees injuries. Zhan Zhuang Gong by Marco Lück (copyright 2020/2021) [ 53 ] 4.2.3 Slow movement The slow movement in Tai Chi impacts both physical and mental health significantly, serving as a holistic approach to enhancing overall health by emphasizing the connection between mind and body [ 54 ]. Martínková et al. (2017) demonstrated that slowing down makes us more attentive to changes within our bodies and our surroundings, thus affecting our connection to our own bodies. Tai Chi's slow movements are fundamentally essential for attaining mindfulness, reducing anxiety and depression, and improving the circulatory and vascular systems [ 55 ]. Hedlund (2020) investigated the effects of slow-motion painting, where five participants completed four filmed painting sessions. The research implemented the use of slow, soft, and repetitive painting movements with breaks throughout the painting process [ 56 ]. Results indicated that painting slowly was challenging but also led to an increase in present-moment awareness and immersion; this induced a meditative state of painting, enhancing self-connection and embodiment. The act of being observed and observing was also found to be significant [ 57 ]. Therefore, Tai Chi can be highly effective in improving self-awareness and, consequently, our relationships with ourselves and our surroundings. This is because slowness allows for open-ended thinking, thereby opening ourselves to new experiences and perspectives [ 58 , 59 ]. Such benefits are likely a result of the slow-motion practice that involves slow breathing, movement, and responses to the surrounding environment. 4.2.4 Single-form practice and combination practice, routine practice Tai Chi embraces an array of postures such as the empty stance, bow stance, and cross stance. These positions require the practitioner to sustain a stable foundation while transitioning weight and maneuvering limbs. The static stance lays the groundwork for these movements, aiding practitioners in cultivating the balance and stability crucial for their correct execution, thus helping to prevent knee pain (Lam, 2007) [ 60 ]. For precise Tai Chi practice, starting with the forms is important; these are composed of a series of exercises or moves—for instance, the 'Cloud Hands' technique uses the waist as a pivot to coordinate arm movements, exercising the torso and shoulder joints. Other individual moves include 'White Crane Spreads its Wings' and 'Playing the Pipa.' However, a set can also consist of a combination of separate, indispensable moves that together constitute a single form, such as the 'Grasp the Peacock's Tail' posture [ 61 ]. As these combined forms are linked, they formulate a routine. The most well-known variant of Tai Chi is the '24 Forms' routine [ 62 ]. 4.3 Health benefits of Tai Chi The practice of Tai Chi has numerous advantages to our health: cognitive, cardiovascular, organ regulations, fitness, and diseases curing therapy. Presently lots of researches are being carried on the advantages of Tai Chi. These results showed that the constant practice of Tai Chi is very beneficial to the health as indicated below [ 63 ]. 4.3.1 Decreased stress, anxiety, depression, and Enhance quality of sleep According to a World Health Organization (WHO) survey, it is predicted that by 2030, a majority of people will be affected by psychological health issues due to stress, depression, and work pressure. Leng et al. (2021) have shown that Tai Chi practice is very beneficial in controlling stress, anxiety, and depression [ 64 ]. Similarly, Gao M. (2022) demonstrated that practicing Tai Chi at different frequencies for 8 weeks had a significant impact on the physique of college students. It also influenced visual perception threshold ability, effectively reducing paranoia, stress, depression, anxiety, and other psychological states in college students [ 66 ]. These results are attributable to the slow and continuous movements of Tai Chi, which help to improve self-awareness and induce a meditative state during practice sessions. Tai Chi can contribute to the enhancement of self-happiness and self-esteem [ 66 ]. Field T. (2011) experimentally showed that mood changes are also accompanied by decreased cortisol levels [ 67 ], which can directly affect sleep quality. Kannan et al. (2022) demonstrated that decreased stress and anxiety could lead to enhanced sleep quality [ 68 ]. Likewise, Chan et al. (2022) found that regular Tai Chi practice can improve sleep quality [ 69 ]. Therefore, Tai Chi practice has been shown to help overcome sleep disorders and reduce the time it takes to fall asleep [ 70 ]. 4.3.2 Mindful nurturing of well-being Rooted in Chinese philosophy and traditional medicine, Tai Chi practice offers significant health benefits, enhancing practitioners' tranquility [ 71 ]. Achieving this state depends on the complete control of emotions and breathing [ 72 – 74 ]. When breathing is fully controlled, the body naturally responds with slow, continuous, and fluid movements, which in turn help to reduce stress and tension. This process also improves self-awareness and self-esteem [ 77 ]. Thus, consistent practice of Tai Chi is fundamental for fostering physiological well-being. 4.3.3 Cognitive Cognitive impairment is often a concern for the aging population, with a natural decline in certain brain regions like the lateral prefrontal cortex, caudate nucleus, hippocampus, and cerebellar hemispheres [ 77 ]. Tai Chi, well-regarded for its physical benefits, also shows promise in boosting cognitive functions in the elderly, particularly in executive functions and for those with significant impairments [ 77 ]. Research by Li et al. (2022) indicated that 17 weeks of Tai Chi practice led to notable cognitive improvements in participants. Furthermore, Rodrigues et al. (2021) presented findings that illustrate the effectiveness of Tai Chi as a mindful, movement-based cognitive-behavioral therapeutic intervention for cothymia, highlighting its potential for both treatment and clinical prevention of the condition [ 78 ]. Caldwell et al. (2009) also provided evidence of Tai Chi's benefits on mental parameters in a college-aged group [ 79 ]. Consistent, long-term Tai Chi practice appears to hold substantial promise for enhancing cognitive function across various age groups [ 70 ]. 4.3.4 Fitness-enhancement Tai Chi, characterized by its continuous dynamic movements performed mindfully and in a meditative state, holds the potential to enhance fitness [ 81 ]. Kuo et al. (2022) demonstrated that long-term Tai Chi practice can improve posture [ 82 ]. This improvement is facilitated by slow movements that require considerable self-control, coupled with continuous breathing between each movement. Similarly, Cabak et al. (2022) found Tai Chi to be an effective method for improving body balance and physio-prophylaxis. In their study, 64 individuals were assessed, half of whom had at least six years of Tai Chi training, whereas the other half lacked such experience [ 83 ]. Further evidence of Tai Chi's benefits was provided by You et al. (2021) in a meta-analysis that highlighted Tai Chi as an optimal physical training strategy for enhancing walking function and balance in posture control [ 84 , 86 ]. Li et al. (2019) also confirmed the therapeutic advantages of Tai Chi through a randomized clinical trial involving 680 elderly participants with a history of falls. They found that Tai Chi's movement practices were more effective than stretching exercises in improving balance and significantly reducing the incidence of both moderate and severe injury falls [ 86 ]. Moreover, Aras et al. (2022) presented findings in their systematic review and meta-analysis indicating that posture control has a significant impact on functional mobility, balance, and fall rates in patients with Parkinson's disease [ 88 ]. Through these various studies, Tai Chi emerges as a valuable exercise form for individuals seeking to improve their physical wellbeing and balance, particularly among older adults and those with specific health conditions like Parkinson's disease. 4.3.5 Cardio-pulmonary function The cardio-pulmonary function is the interrelation that exist between heart and the pulmonary organs. In the results published by Lan et al [ 88 , 89 ], the practice if Tai Chi in the men group showed 19% higher peak oxygen uptake (V̇ o 2peak ) in comparison with their sedentary counterparts (26.9 ± 4.8mL/kg/min vs 21.8 ± 3.1 mL/kg/min). while women equally showed 18% higher V̇ o 2peak than the sedentary group (20.1 ± 2.9mL/kg/min vs 16.6 ± 2.0mL/kg/min) [90]. The Tai Chi group had higher oxygen uptake at the ventilatory threshold and showed an overall improvement in their fitness [91–93]. Tan et al. (2022) equally showed that regular Tai Chi practice could improve the cardiorespiratory fitness in the elderly person [38]. In their result, the practice of Tai Chi significantly increased the maximum rate of oxygen consumption (VO 2 max ) (weighted mean difference (WMD) = 3.86, 96% CI: 1.26 to 6.26,), leading to an overall reduction in the heart rate (HR) (WMD = − 1.84, 96% CI: −2.04 to − 1.63,) and an increase in the O 2 pulse (WMD = 0.94, 96% CI: 0.60 to 1.28,) in individuals who practiced Tai Chi regularly compared with those who did not. Bayrami et al. (2021) equally observed significant decrease in systolic blood pressure, resting heart rate, and stress in comparison with the control group [94]. Thus, Tai Chi practice will improve the cardiopulmonary functions [95]. 4.3.6 Blood pressure and blood lipids Experiment showed that the practice of Tai Chi could reduce blood pressure and lipid profile changes [ 96 , 97 ]. Tsai et al. (2003) in their experiment, carried within a period of 12-weeks showed significant decrease in systolic blood pressure of 15.6 mm Hg and diastolic blood pressure 8.8 mm Hg. They equally observed a decrease of serum total cholesterol level 15.2 mg/dL and increase high-density lipoprotein cholesterol 4.7 mg/dL [ 98 ]. Tai Chi practice can also influence the level serum glucose and insulin (enhancement of insulin resistance). The practice of Tai Chi equally reduces the blood triglyceride which decreases blood total cholesterol level, thus reducing blood lipid level and blood pressure [ 99 , 100 ]. Tai Chi practice also reduces waist circumference, body mass index, glucose level, insulin resistance, consequently helps in diabetes or obesity control [ 101 , 102 ]. Limitation and Perspective and Outlook and recommendations In the above literature, little has been done to demonstrate the mechanism on how all the beneficial properties of Tai Chi is achieved. Consequently, it presents a lot of limitation at the level theoretical evidence, hence making difficult for its implementation. 5.1 Limitation The primary challenge encountered in many studies on Tai Chi is the absence of theoretical evidence that can elucidate the mechanisms by which Tai Chi impacts overall health [ 103 ]. This deficiency has been a significant obstacle to the advancement of Tai Chi. The benefits to health derived from Tai Chi are primarily supported by experimental evidence which does not clearly delineate the processes through which these benefits are achieved. Additionally, the lack of specificity is due to the high degree of variation in Tai Chi styles, with each style having its own distinctive form of practice. The lack of well-trained masters to improve and reduce the risk of knee pain and potential investors remains a barrier to promoting Tai Chi as a form of physical fitness. 5.2 Perspective The aforementioned meta-analysis demonstrates the significance of Tai Chi's impact on health and its influence on the knee. To gain a better understanding of Tai Chi's effect on knee injuries, future studies should consider including the hip in their research, as the hip and knee joints work together during Tai Chi movements. The hip joint plays a role in providing stability and mobility necessary for weight transfer and balance, while the knee joint enables the flexion and extension needed for characteristic stepping and stance work. Notably, the movement strategy used in Tai Chi often involves deliberate rotation and counter-rotation of the hip to facilitate fluid continuity in the limbs' actions. From a biomechanical perspective, as the hip engages in rotational movement within a stance, there is a compensatory action at the knee. For example, as the hip undergoes external rotation, the knee may concurrently exhibit slight internal rotation to maintain alignment and balance, and vice versa. This compensatory mechanism assists in more evenly distributing forces throughout the lower extremity, potentially reducing the risk of injury. Additionally, the static stance is a crucial aspect of Tai Chi practice, as it teaches individuals to maintain a stable posture for an extended period. This helps practitioners develop balance, centering, and precise positioning of the body. It serves as the foundation for movement, fosters both internal strength and balance, increases body awareness, enhances flexibility, and also functions as a form of meditation. Furthermore, it contributes to the development of martial arts skills, promotes relaxation, and improves overall health. In particular, the Zhan Zhuang static stance plays a key role in reaping these health benefits and promoting physical well-being. Zhan Zhuang can help alleviate knee discomfort and can be customized to suit individual skill levels through its three primary upright postures, which are known as low, intermediate, and high levels. This flexibility allows practitioners to easily find a suitable posture level, reducing the risk of knee pain. 5.3 Outlook and recommendations of Tai Chi implementation. The effective implementation of Tai Chi as a beneficial physical practice can be markedly improved through deeper research into its biomechanical intricacies. By dissecting Tai Chi movements through posture capture technologies, researchers and practitioners can pinpoint and correct stance aberrations, refining the practice for individuals. [ 104 ] This personalized correction can lay the groundwork for the development of artificial Tai Chi coaching systems—which may employ advanced algorithms and sensor-based feedback to guide users in real-time, much like having a personal instructor [ 106 , 107 ]. The prospects for these innovations require a careful examination of the types of equipment that can best support Tai Chi routines without impeding the natural flow of movement. Future research should thus focus on the design and evaluation of such equipment to ensure that it complements the gentle, yet precise nature of Tai Chi, enabling practitioners to reap maximum physical and mental health benefits from their workouts. Furthermore, the incorporation of virtual reality (VR) technology into Tai Chi education and physical conditioning can be a game-changer, particularly for enhancing cognitive attributes. By immersing practitioners in a simulated environment, VR can amplify focus and retention, accelerating the mastery of Tai Chi's martial applications. This immersive approach offers a dynamic and engaging learning experience, potentially bolstering the speed and depth with which students grasp the subtleties of Tai Chi's defensive and offensive maneuvers [ 108 ]. Finally, investigation Slow-motion technology, novel equipment like slow treadmills, can greatly enhance the learning curve in practices like Tai Chi by emphasizing the significance of measured movements. This equipment can serve as a tactile reminder of the power of deceleration, reinforcing the concept that slower motion can improve stability, control, and mental clarity. By slowing the pace, practitioners can more effectively dissect and appreciate each nuance of their form, deepening their understanding of the discipline's fundamentals. This hands-on approach to learning the virtues of slowness could be especially illuminating for those used to the fast pace of modern life, offering a tangible pathway to mastering the art of moving deliberately. Conclusion This review starts with a meta-analysis which provides valuable insights into the potential relationship between posture level, knee pain, and knee movements, Form the above, Knee pain after Tai Chi practice ranged from 48.20% to 52.78% across studies, suggesting a consistent prevalence of knee pain among practitioners. Which is caused by movements involving high knee rotation and high knee extension/abduction. This indicates the need for practitioners to be mindful of their knee movements during activities like Tai Chi in order to minimize the risk of knee pain. From the above knowledge Tai Chi has essentially beneficial to the whole body. The correct practice of Tai Chi is a perfect start to acquire all its beneficial properties. Static stance being the fundamental of Tai Chi not only builds the strength of the legs and hips, but also helps to establish a solid foundation to learn and practice more complicated forms / movements. Therefore, adopting the right posture can help in many ways such as pain reduction and injury prevention. Good posture maintains joints and bones in the right configuration so that the muscles are used efficiently. Hence, enhancing the physical fitness, the quality of life making suitable for all age group. Declarations Conflicts of interest: No conflicts of interest Ethical statement Ethical approval was not sought for the present study because it is a review paper. Funding: No funding was received for this study. Author Contribution: We thank our group members for technical support and thanks the Wushu Collage of Henan University. Darrin Sime Nkemeni, Hao Hong wrote and design the review. 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04:46:09","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":186372,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8566281/v1/d5097b36bbba56f4f8473653.html"},{"id":100365483,"identity":"bdcaff36-f595-4d9e-b0bd-be816014186f","added_by":"auto","created_at":"2026-01-16 07:55:14","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":284517,"visible":true,"origin":"","legend":"\u003cp\u003eindicates the Prisma diagram of the meta-analysis\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8566281/v1/0c57ad850e82cdd78ac0fb68.jpeg"},{"id":100105251,"identity":"cc105933-e3a2-427f-a0bd-dcd815063956","added_by":"auto","created_at":"2026-01-13 04:46:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":47653,"visible":true,"origin":"","legend":"\u003cp\u003estructural organization\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8566281/v1/ae561cca033d84cba3f5c15a.png"},{"id":100382292,"identity":"7cadbf57-67cb-4501-88c0-ccf19222b649","added_by":"auto","created_at":"2026-01-16 10:41:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1189317,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8566281/v1/54d33410-fbe5-48de-b2df-dcfbb3c18ade.pdf"},{"id":100105254,"identity":"ea704592-8ba7-4ad5-b36f-6421358b6483","added_by":"auto","created_at":"2026-01-13 04:46:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":108262,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8566281/v1/76c80be4057417a832453112.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAn Analysis of Tai Chi Posture Effects on Knee pains: An approach for improving the Implementation Tai Chi.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccording to the WHO, 1.4\u0026nbsp;billion adults, representing more than a quarter of the global adult population, are not engaging in enough physical activity. About 33% of women and 25% of men fail to do enough physical activity to stay healthy. [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Physical fitness has a multitude of impacts on one's overall health, encompassing health-related attributes such as body balance, flexibility, muscular endurance, coordination, body composition, and cardio-vascular endurance, as well as skill-related attributes like speed, strength, response time, agility, and power [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe decrease in physical activity is exacerbated by a troubling increase in sedentary behavior, reaching alarming levels. With more people embracing inactive lifestyles influenced by technology and urban living, the adverse health effects are increasingly clear. This inactivity leads to various physical and mental health problems, including obesity, cardiovascular diseases, and anxiety disorders. Tackling this issue is essential for enhancing overall well-being. Promoting active lifestyles through community initiatives, accessible recreation options, and health education can help counteract this trend, fostering a healthier and more engaged population.\u003c/p\u003e \u003cp\u003ePertinently, the practice of physical activities that involve an organized regimen of exercise such as Tai Chi and Ba Duan Jin, has been shown to have good benefit on both mental and physical health across all age demographics [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These exercises such as Tai Chi; a traditional Chinese martial art that integrates physical activity with mindfulness, facilitating harmony, synchronization, and tranquility [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The practice is based on the foundational concepts of Yin and Yang, which encompass a sequence of deliberate, continuous movements paired with mindful, regulated breathing techniques [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Yin and Yang are qualified by the fundamental rhythm that animates Qi, while Qi represents life energy. Tai Chi practice can improve Qi, which animates the human organs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Adherence to Tai Chi has been shown to ameliorate various aspects of an individual's health, including posture, balance, coordination, relaxation, cardiovascular health, fitness levels, and it may contribute to a reduced incidence of falls, as well as diminished levels of depression, anxiety, and stress [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Given its low to moderate exercise intensity, reflecting metabolic equivalents ranging from 2.5 to 6.5, Tai Chi is deemed appropriate for individuals of varying ages [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, certain studies have illuminated concerns regarding the potential of Tai Chi to induce strain or injury specifically in the knees of some practitioners. This issue is becoming a considerable factor that not only affects the uptake of Tai Chi but also contributes to some practitioners leaving the discipline. The movements involved in Tai Chi, particularly those that require bending and supporting body weight, may place strain on the knee. Consequently, this has brought the safety of the practice into question, especially for people with existing knee conditions or those who might not be accustomed to regular physical activity. As Tai Chi gains in popularity, it is important that individuals receive proper guidance and adequate exercises to suit their personal capabilities to reduce the risk of injury. Therefore, balancing the positive aspects of Tai Chi with these emerging concerns about knee health is crucial for both new and experienced practitioners.\u003c/p\u003e \u003cp\u003eThe aim of this research is to highlight the significance importance of the fundamental components of Tai Chi practice, such as static-stance exercise, breathing, slow movement single-form and combination practice, and routine practice. It also aims to conduct a meta-analysis to explore the statistics and reasons behind knee injuries in Tai Chi practitioners. Furthermore, this review provides\u003c/p\u003e \u003cp\u003eThe aim is to systematically evaluate and synthesize existing research on how Tai Chi postures influence knee pain. This study seeks to identify effective techniques that can improve the application of Tai Chi in managing knee pain, thereby offering insights into best practices for practitioners and enhancing patient outcomes. By reviewing modern methodologies, the analysis aims to provide recommendations for optimizing Tai Chi interventions for individuals suffering from knee pain.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Meta-Analysis\u003c/h2\u003e \u003cp\u003eSearch Strategy and Study Selection Criteria: A comprehensive search was conducted across five major databases: PUBMED, Web of Science, EMBASE, CNKI, and Google Scholar, with no restrictions on language. The search terms used covered numerous variations and related phrases of Tai Chi, arranged in the following manner: (Tai Ji OR Tai Chi OR Tai Ji Quan OR Tai Chi Chuan OR Tai Chi Quan) AND (injuries OR knee pain). Studies were considered eligible for this meta-analysis if they met the following criteria: 1) they investigated the issue of knee pains in relation to Tai Chi; and 2) they included an intervention that specifically involved Tai Chi exercise training causing knee pian.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Screening process\u003c/h2\u003e \u003cp\u003eThe screening process and data extraction were done in four parts, with the first step's basic screening criterion being the title and abstract. Second, research-related papers that did not fall under this category were not included. Third, any search results that included Tai Chi alongside another sort of exercise (for example, yoga, qigong, etc.) were also removed. At a later time, full-text eligibility was implemented. Using a pre-piloted form, data from the selected studies were gathered. The obtained data comprised study design, sample size, and results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Data extraction\u003c/h2\u003e \u003cp\u003ePotential papers were screened for inclusion. We retrieved potentially relevant studies and determined their eligibility. Discrepancies were resolved through consensus. The extracted information included the following categories: 1) Publication details, such as the last name of the first author and the year of publication; 2) Characteristics of the study participants, including sample size; 3) Details of the interventions, for example, type of intervention, and the effect on knee, and posture level.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e3.1.3 Quality assessment\u003c/h2\u003e \u003cp\u003eThe quality assessment was based on Prisma technique [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The papers included in this study were critically analyzed. Classifications in the following areas were assigned based on perceived low value, ambiguity, or elevated risk of bias: the randomness of sequence generation, allocation concealment, blinding methods, instances of incomplete outcome data, potential for selective reporting of outcomes, and other sources of bias.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Characteristics of Tai Chi Practice and Impart on health\u003c/h2\u003e \u003cp\u003eThe literature search was conducted in PUBMED, Web of Science, CNKI, and Google Scholar. The search was restricted to English only and had no restriction on the publication date from its inception to the end of 2022. The search was examined based on three major categories: the fundamentals of Tai Chi practice, the health benefits of Tai Chi, and the implementation of Tai Chi. The keywords used were Tai Ji OR Tai Chi OR Tai Ji Quan OR Tai Chi OR Tai Chi Chuan OR Tai Chi Quan. Data from the study was uploaded into Endnote for structured organization. The software assisted in categorizing the findings into three distinct themes and streamlined the deletion of any repetitive entries. To enhance accuracy, specific keywords were utilized within each classification.\u003c/p\u003e \u003cp\u003eFor the fundamentals of Tai Chi practice, the search was conducted using the slow movement, static stance, posture, breathing, single form, self-defense, and routine.\u003c/p\u003e \u003cp\u003eFor the health benefits of Tai Chi, the keywords were stress, anxiety, depression, sleep, well-being, mental health, cognitive fitness, cardiopulmonary and vascular, blood pressure, and lipids. In this section, the result was subjected to a meta-analysis, where a Prisma diagram was derived. In addition, in this category, studies that did not have anything in common with the health benefits of Tai Chi were excluded.\u003c/p\u003e \u003cp\u003eFinally, for the implementation of Tai Chi, the keywords used were application, modern technology, motion capture, implementation, and therapy. For this part, the papers were selected directly from the research database and included another form of exercises such as yoga. A condensed structure of the work is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results and Discursion","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Meta-Analysis of Tai Chi posture difference on the health.\u003c/h2\u003e \u003cp\u003eTai Chi is known around the world for its ability to rehabilitate and provide health benefits. However, recent studies have suggested that certain Tai Chi movements could potentially harm the joints in the lower body. While various research points to Tai Chi as a potential therapeutic approach for knee pain and injuries, the full extent of its benefits and the impact on overall health remain somewhat unclear. This meta-analysis aims to raise awareness about the risks of performing incorrect Tai Chi movements and to emphasize the importance of further research into injury occurrence within Tai Chi practice, as it is a critical aspect that can influence Tai Chi practitioners.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents data collected from four studies (HE et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], Zhu et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Hou et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Xing et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]) focusing on the relationship between practicing Tai Chi and the incidence of knee pain. The table is organized with authors of the studies in the first column, followed by the research method they used, the number of participants in their studies, and various statistics related to knee pain before, during, or after practicing Tai Chi. The studies involve a large number of participants of 3148 individuals and used questionnaires to investigate knee pain in relation to Tai Chi practice.\u003c/p\u003e \u003cp\u003eFrom Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, In all the study, a majority of participants experienced knee pain after Tai Chi practice. Zhu et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] provided detailed percentages of participants at different Tai Chi levels, showing a relationship between participants' Tai Chi practice level and the impact on knee pain. A majority (57%) of participants in the \"Initial Stage\" experienced knee pain, while fewer participants reported as their Tai Chi practice level progressed. At the \"High Level,\" only 3.4% reported knee pain. This shows that as the proficiency of Tai Chi increase the probability of having knee pain equally decreases. Additionally, Zhu et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] indicate that a large portion (48.20%) of participants still had knee pain after practicing Tai Chi. And for those who had knee pain before taken Tai Chi, 60.8% still indicate knee pain and 39.2% were found their pian relived. Xing et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] also reported a significant percentage of participants (49.09%) having knee pain after practicing Tai Chi. Meanwhile in HE et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and Hou et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] indicate that, the percentage of participants having knee pain after practicing Tai Chi was 49.03% and 52.78%, respectively. Xing et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] also reported a significant percentage of participants (49.09%) having knee pain after practicing Tai Chi.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e present the summary of findings from three different studies that investigated the relationship between posture level, knee pain, and knee movement. The studies appear to have focused particularly on knee pain associated with various postures and movements potentially occurring during activities like Tai Chi. Below is an analysis of the information provided for each study:\u003c/p\u003e \u003cp\u003eIn interpreting the information presented in the Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, it is evident that the relationship between posture level, knee pain, and knee movements is complex and requires further elucidation. The three studies, Hsieh et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], Wang et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], and Yan et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], seem to converge on the finding that higher levels of posture are associated with a lower risk of knee pain. The findings highlight the relationship between the height of knee postures and the experience of pain, indicating that variations in knee positioning can influence discomfort levels in individuals. This correlation suggests that knee posture may play a significant role in the management or assessment of knee pain.\u003c/p\u003e \u003cp\u003eFurthermore, the studies emphasize the significance of specific knee movements concerning knee pain. Both Wang et al. and Yan et al. note that high knee rotation, along with extensive knee extension and abduction, is associated with an increased risk of knee pain. Thus, practitioners should be cautious with knee movements during activities like Tai Chi to reduce knee pain risk.\u003c/p\u003e \u003cp\u003eThe analysis of Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e indicates that future studies should aim to provide more comprehensive and detailed data, which will facilitate a deeper understanding of the factors contributing to knee pain in relation to posture and movement. Additionally, studies could also include the hip joint in their research because the hip and knee joints function synergistically during Tai Chi movements. The hip joint contributes to the stability and mobility necessary for weight transfer and balance, while the knee joint permits the flexion and extension that enable the characteristic stepping and stance work. Importantly, the movement strategy adopted in Tai Chi often involves a 'coiling' and 'uncoiling' motion, where there is an intentional rotation and counter-rotation of the hip to facilitate fluid continuity in the limbs\u0026rsquo; actions. Biomechanically, as the hip engages in a rotational movement within a stance, there is a compensatory action at the knee. For instance, as the hip undergoes external rotation, the knee may concurrently demonstrate a slight internal rotation to maintain alignment and balance, and vice versa. This compensatory mechanism helps to distribute forces more evenly throughout the lower extremity, thus potentially reducing the risk of injury [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies has showed that, excessive hip adduction and internal rotation during weight-bearing may significantly alter lower limb kinematics. Specifically, overdoing these movements can lead to a medial shift of the knee joint center relative to the foot. Given that the foot remains stationary on the ground, this medial shift induces outward tibial abduction and foot pronation, culminating in dynamic knee valgus. This condition, excessive knee valgus, has been associated with reduced strength in hip muscles [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and is recognized in the contribution to a wide array of knee injuries [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, hip and knee of front and rear legs have synchronized movements in opposite directions, leading to the existence of coordination among the hip and knee joints resulting to coupled motion [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Important factors for improvement in Tai Chi practice\u003c/h2\u003e \u003cp\u003eAs a martial art, Tai Chi is based on principles of balance and awareness [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. It involves a series of slow, continuous movements combined with deep, controlled breathing and focuses on mental relaxation and concentration. Tai Chi practice includes static-stance practice, breathing method, slow movement, single-form practice, combination practice, routine practice, and push-hand moves [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e4.2.1 Breathing\u003c/h2\u003e \u003cp\u003eBreathing is a fundamental activity with direct effects on our health and well-being. It is orchestrated by the respiratory, cardiovascular, and nervous systems, all working in concert to maintain optimal oxygen and carbon dioxide levels and ensuring bodily functions [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Adequate breathing benefits the body by supplying oxygen and supports the autonomic nervous system in regulating physiological functions such as heart rate, blood pressure, and digestive processes [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe breathing technique in Tai Chi is called natural breathing, which includes abdominal or diaphragmatic breathing. This style of breathwork not only fosters a mind-body connection, promoting relaxation, balance, and coordination, but also elevates consciousness. Indeed, proper breathing is critical for peak physical and mental performance. Engaging in deep, diaphragmatic breaths can bolster both physical and mental health. Jerath et al. (2016) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] found that such breathing techniques can diminish symptom severity, increase oxygen saturation, reduce blood pressure, and enhance lung function and tissue oxygenation. Likewise, Jerath et al. (2015) discovered benefits including regulated blood pressure, diminished stress, and improved mood and cognitive function.\u003c/p\u003e \u003cp\u003eFurthermore, Gatts and colleagues (2019) indicated that various Tai Chi breathing methods can substantially improve respiratory function, such as lung capacity and breathing efficiency, as well as balance and coordination [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Regular Tai Chi has also been noted to augment lung function in the elderly, mitigating respiratory disease risk and promoting general well-being [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moreover, Tai Chi has been demonstrated to boost cardiovascular fitness and lower blood pressure in those with hypertension [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].The correct breathing method is an integral and essential component of Tai Chi practice. The breathing method used in Tai Chi emphasizes slow, deep, and natural breathing that allows the entire body, including the internal organs, to be activated and stimulated. The technique involves inhaling slowly, deeply, and through the nose, while expanding the abdomen to allow a full lung capacity. Which is then followed by a slow, controlled, and natural exhalation, through pursed lips, to release the tension and stress from the body. The breathing methods used in Tai Chi are a crucial component of this traditional Chinese martial art. From promoting relaxation and reducing stress to enhancing martial power and improving overall health and well-being, these breathing techniques offer a wide range of benefits for practitioners.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e4.2.2 Static-stance practice\u003c/h2\u003e \u003cp\u003eTai Chi's benefits are strongly linked to correct breathing, proper body alignment, and relaxation. These are achieved primarily through an understanding of Zhan Zhuang, the static Tai Chi stance. Standing still for periods often exceeding 15 minutes [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], practitioners develop an even weight distribution, a stable center of gravity, and optimal body alignment. These practices contribute to stronger muscles, improved balance, flexibility, and functionality while lessening stress [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies, such as those by Lee, Kim, and Lim in 2019 [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], Tang et al. in 2015 [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], and Knoops, Vermeulen, and Van der Hurk in 2018 [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], validate the role of the static stance in increasing leg strength and preventing back pain, falls, and injuries by enhancing stability and neuromuscular control. Similarly, Chang, Pan, \u0026amp; Chen in 2014 [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] demonstrated increased proprioception and reaction times with this practice.\u003c/p\u003e \u003cp\u003eBesides physical improvements, Tai Chi is known to foster cardiovascular health and reduce fall risks among the elderly. Oh, Park, and Roh, in their 2015 study [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], determined that static stance practice could lower blood pressure and improve cardiovascular health by promoting bodily awareness and relaxation. Notably, the immobility involved in Tai Chi sharpens one's sensitivity to bodily, mental, and emotional cues, assisting in tension relief and focus enhancement (Chan \u0026amp; Wong, 2019) [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. This state of calm aids stress reduction and bolsters mental well-being. Additionally, it encourages ethical, belief, and character introspection, facilitating moral development and self-actualization (Jin, 2005) [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUltimately, Tai Chi's static stance is a multifaceted practice that not only improves physical alignment and health [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] but also contributes to personal growth and holistic well-being. Static stance is also a critical underpinning for more complex Tai Chi techniques, such as defensive applications, Push Hands, and Tai Chi sequences. Without a solid grounding in posture, alignment, and internal energy, these advanced methods are less effective and efficient (Yang, 2005) [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Static stance remains a pivotal element in Tai Chi. It lays the groundwork for movement, cultivates internal strength along with balance, heightens body consciousness, boosts flexibility, doubles as a meditative practice, hones martial proficiency, fosters relaxation, and bolsters overall health. Consequently, can contributing to the reduction of knees injuries.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eZhan Zhuang Gong by Marco L\u0026uuml;ck (copyright 2020/2021) [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e4.2.3 Slow movement\u003c/h2\u003e \u003cp\u003eThe slow movement in Tai Chi impacts both physical and mental health significantly, serving as a holistic approach to enhancing overall health by emphasizing the connection between mind and body [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Mart\u0026iacute;nkov\u0026aacute; et al. (2017) demonstrated that slowing down makes us more attentive to changes within our bodies and our surroundings, thus affecting our connection to our own bodies. Tai Chi's slow movements are fundamentally essential for attaining mindfulness, reducing anxiety and depression, and improving the circulatory and vascular systems [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Hedlund (2020) investigated the effects of slow-motion painting, where five participants completed four filmed painting sessions. The research implemented the use of slow, soft, and repetitive painting movements with breaks throughout the painting process [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Results indicated that painting slowly was challenging but also led to an increase in present-moment awareness and immersion; this induced a meditative state of painting, enhancing self-connection and embodiment. The act of being observed and observing was also found to be significant [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Therefore, Tai Chi can be highly effective in improving self-awareness and, consequently, our relationships with ourselves and our surroundings. This is because slowness allows for open-ended thinking, thereby opening ourselves to new experiences and perspectives [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Such benefits are likely a result of the slow-motion practice that involves slow breathing, movement, and responses to the surrounding environment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e4.2.4 Single-form practice and combination practice, routine practice\u003c/h2\u003e \u003cp\u003eTai Chi embraces an array of postures such as the empty stance, bow stance, and cross stance. These positions require the practitioner to sustain a stable foundation while transitioning weight and maneuvering limbs. The static stance lays the groundwork for these movements, aiding practitioners in cultivating the balance and stability crucial for their correct execution, thus helping to prevent knee pain (Lam, 2007) [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor precise Tai Chi practice, starting with the forms is important; these are composed of a series of exercises or moves\u0026mdash;for instance, the 'Cloud Hands' technique uses the waist as a pivot to coordinate arm movements, exercising the torso and shoulder joints. Other individual moves include 'White Crane Spreads its Wings' and 'Playing the Pipa.' However, a set can also consist of a combination of separate, indispensable moves that together constitute a single form, such as the 'Grasp the Peacock's Tail' posture [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. As these combined forms are linked, they formulate a routine. The most well-known variant of Tai Chi is the '24 Forms' routine [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Health benefits of Tai Chi\u003c/h2\u003e \u003cp\u003eThe practice of Tai Chi has numerous advantages to our health: cognitive, cardiovascular, organ regulations, fitness, and diseases curing therapy. Presently lots of researches are being carried on the advantages of Tai Chi. These results showed that the constant practice of Tai Chi is very beneficial to the health as indicated below [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e4.3.1 Decreased stress, anxiety, depression, and Enhance quality of sleep\u003c/h2\u003e \u003cp\u003eAccording to a World Health Organization (WHO) survey, it is predicted that by 2030, a majority of people will be affected by psychological health issues due to stress, depression, and work pressure. Leng et al. (2021) have shown that Tai Chi practice is very beneficial in controlling stress, anxiety, and depression [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Similarly, Gao M. (2022) demonstrated that practicing Tai Chi at different frequencies for 8 weeks had a significant impact on the physique of college students. It also influenced visual perception threshold ability, effectively reducing paranoia, stress, depression, anxiety, and other psychological states in college students [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. These results are attributable to the slow and continuous movements of Tai Chi, which help to improve self-awareness and induce a meditative state during practice sessions. Tai Chi can contribute to the enhancement of self-happiness and self-esteem [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Field T. (2011) experimentally showed that mood changes are also accompanied by decreased cortisol levels [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], which can directly affect sleep quality. Kannan et al. (2022) demonstrated that decreased stress and anxiety could lead to enhanced sleep quality [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Likewise, Chan et al. (2022) found that regular Tai Chi practice can improve sleep quality [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Therefore, Tai Chi practice has been shown to help overcome sleep disorders and reduce the time it takes to fall asleep [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e4.3.2 Mindful nurturing of well-being\u003c/h2\u003e \u003cp\u003eRooted in Chinese philosophy and traditional medicine, Tai Chi practice offers significant health benefits, enhancing practitioners' tranquility [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. Achieving this state depends on the complete control of emotions and breathing [\u003cspan additionalcitationids=\"CR73\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. When breathing is fully controlled, the body naturally responds with slow, continuous, and fluid movements, which in turn help to reduce stress and tension. This process also improves self-awareness and self-esteem [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Thus, consistent practice of Tai Chi is fundamental for fostering physiological well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e4.3.3 Cognitive\u003c/h2\u003e \u003cp\u003eCognitive impairment is often a concern for the aging population, with a natural decline in certain brain regions like the lateral prefrontal cortex, caudate nucleus, hippocampus, and cerebellar hemispheres [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Tai Chi, well-regarded for its physical benefits, also shows promise in boosting cognitive functions in the elderly, particularly in executive functions and for those with significant impairments [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Research by Li et al. (2022) indicated that 17 weeks of Tai Chi practice led to notable cognitive improvements in participants. Furthermore, Rodrigues et al. (2021) presented findings that illustrate the effectiveness of Tai Chi as a mindful, movement-based cognitive-behavioral therapeutic intervention for cothymia, highlighting its potential for both treatment and clinical prevention of the condition [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. Caldwell et al. (2009) also provided evidence of Tai Chi's benefits on mental parameters in a college-aged group [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. Consistent, long-term Tai Chi practice appears to hold substantial promise for enhancing cognitive function across various age groups [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e4.3.4 Fitness-enhancement\u003c/h2\u003e \u003cp\u003eTai Chi, characterized by its continuous dynamic movements performed mindfully and in a meditative state, holds the potential to enhance fitness [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]. Kuo et al. (2022) demonstrated that long-term Tai Chi practice can improve posture [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. This improvement is facilitated by slow movements that require considerable self-control, coupled with continuous breathing between each movement. Similarly, Cabak et al. (2022) found Tai Chi to be an effective method for improving body balance and physio-prophylaxis. In their study, 64 individuals were assessed, half of whom had at least six years of Tai Chi training, whereas the other half lacked such experience [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. Further evidence of Tai Chi's benefits was provided by You et al. (2021) in a meta-analysis that highlighted Tai Chi as an optimal physical training strategy for enhancing walking function and balance in posture control [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]. Li et al. (2019) also confirmed the therapeutic advantages of Tai Chi through a randomized clinical trial involving 680 elderly participants with a history of falls. They found that Tai Chi's movement practices were more effective than stretching exercises in improving balance and significantly reducing the incidence of both moderate and severe injury falls [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]. Moreover, Aras et al. (2022) presented findings in their systematic review and meta-analysis indicating that posture control has a significant impact on functional mobility, balance, and fall rates in patients with Parkinson's disease [\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e]. Through these various studies, Tai Chi emerges as a valuable exercise form for individuals seeking to improve their physical wellbeing and balance, particularly among older adults and those with specific health conditions like Parkinson's disease.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e4.3.5 Cardio-pulmonary function\u003c/h2\u003e \u003cp\u003eThe cardio-pulmonary function is the interrelation that exist between heart and the pulmonary organs. In the results published by Lan et al [\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e], the practice if Tai Chi in the men group showed 19% higher peak oxygen uptake (V̇\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eo\u003c/span\u003e\u003csub\u003e2peak\u003c/sub\u003e) in comparison with their sedentary counterparts (26.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8mL/kg/min vs 21.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 mL/kg/min). while women equally showed 18% higher V̇\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eo\u003c/span\u003e\u003csub\u003e2peak\u003c/sub\u003e than the sedentary group (20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9mL/kg/min vs 16.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0mL/kg/min) [90]. The Tai Chi group had higher oxygen uptake at the ventilatory threshold and showed an overall improvement in their fitness [91\u0026ndash;93]. Tan et al. (2022) equally showed that regular Tai Chi practice could improve the cardiorespiratory fitness in the elderly person [38]. In their result, the practice of Tai Chi significantly increased the maximum rate of oxygen consumption (VO\u003csub\u003e2 max\u003c/sub\u003e) (weighted mean difference (WMD)\u0026thinsp;=\u0026thinsp;3.86, 96% CI: 1.26 to 6.26,), leading to an overall reduction in the heart rate (HR) (WMD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.84, 96% CI: \u0026minus;2.04 to \u0026minus;\u0026thinsp;1.63,) and an increase in the O\u003csub\u003e2 pulse\u003c/sub\u003e (WMD\u0026thinsp;=\u0026thinsp;0.94, 96% CI: 0.60 to 1.28,) in individuals who practiced Tai Chi regularly compared with those who did not. Bayrami et al. (2021) equally observed significant decrease in systolic blood pressure, resting heart rate, and stress in comparison with the control group [94]. Thus, Tai Chi practice will improve the cardiopulmonary functions [95].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e4.3.6 Blood pressure and blood lipids\u003c/h2\u003e \u003cp\u003eExperiment showed that the practice of Tai Chi could reduce blood pressure and lipid profile changes [\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e, \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e]. Tsai et al. (2003) in their experiment, carried within a period of 12-weeks showed significant decrease in systolic blood pressure of 15.6 mm Hg and diastolic blood pressure 8.8 mm Hg. They equally observed a decrease of serum total cholesterol level 15.2 mg/dL and increase high-density lipoprotein cholesterol 4.7 mg/dL [\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e]. Tai Chi practice can also influence the level serum glucose and insulin (enhancement of insulin resistance). The practice of Tai Chi equally reduces the blood triglyceride which decreases blood total cholesterol level, thus reducing blood lipid level and blood pressure [\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e, \u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e]. Tai Chi practice also reduces waist circumference, body mass index, glucose level, insulin resistance, consequently helps in diabetes or obesity control [\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e, \u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Limitation and Perspective and Outlook and recommendations","content":"\u003cp\u003eIn the above literature, little has been done to demonstrate the mechanism on how all the beneficial properties of Tai Chi is achieved. Consequently, it presents a lot of limitation at the level theoretical evidence, hence making difficult for its implementation.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Limitation\u003c/h2\u003e \u003cp\u003eThe primary challenge encountered in many studies on Tai Chi is the absence of theoretical evidence that can elucidate the mechanisms by which Tai Chi impacts overall health [\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e]. This deficiency has been a significant obstacle to the advancement of Tai Chi. The benefits to health derived from Tai Chi are primarily supported by experimental evidence which does not clearly delineate the processes through which these benefits are achieved. Additionally, the lack of specificity is due to the high degree of variation in Tai Chi styles, with each style having its own distinctive form of practice. The lack of well-trained masters to improve and reduce the risk of knee pain and potential investors remains a barrier to promoting Tai Chi as a form of physical fitness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Perspective\u003c/h2\u003e \u003cp\u003eThe aforementioned meta-analysis demonstrates the significance of Tai Chi's impact on health and its influence on the knee. To gain a better understanding of Tai Chi's effect on knee injuries, future studies should consider including the hip in their research, as the hip and knee joints work together during Tai Chi movements. The hip joint plays a role in providing stability and mobility necessary for weight transfer and balance, while the knee joint enables the flexion and extension needed for characteristic stepping and stance work. Notably, the movement strategy used in Tai Chi often involves deliberate rotation and counter-rotation of the hip to facilitate fluid continuity in the limbs' actions. From a biomechanical perspective, as the hip engages in rotational movement within a stance, there is a compensatory action at the knee. For example, as the hip undergoes external rotation, the knee may concurrently exhibit slight internal rotation to maintain alignment and balance, and vice versa. This compensatory mechanism assists in more evenly distributing forces throughout the lower extremity, potentially reducing the risk of injury.\u003c/p\u003e \u003cp\u003eAdditionally, the static stance is a crucial aspect of Tai Chi practice, as it teaches individuals to maintain a stable posture for an extended period. This helps practitioners develop balance, centering, and precise positioning of the body. It serves as the foundation for movement, fosters both internal strength and balance, increases body awareness, enhances flexibility, and also functions as a form of meditation. Furthermore, it contributes to the development of martial arts skills, promotes relaxation, and improves overall health. In particular, the Zhan Zhuang static stance plays a key role in reaping these health benefits and promoting physical well-being. Zhan Zhuang can help alleviate knee discomfort and can be customized to suit individual skill levels through its three primary upright postures, which are known as low, intermediate, and high levels. This flexibility allows practitioners to easily find a suitable posture level, reducing the risk of knee pain.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e5.3 Outlook and recommendations of Tai Chi implementation.\u003c/h2\u003e \u003cp\u003eThe effective implementation of Tai Chi as a beneficial physical practice can be markedly improved through deeper research into its biomechanical intricacies. By dissecting Tai Chi movements through posture capture technologies, researchers and practitioners can pinpoint and correct stance aberrations, refining the practice for individuals. [\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e] This personalized correction can lay the groundwork for the development of artificial Tai Chi coaching systems\u0026mdash;which may employ advanced algorithms and sensor-based feedback to guide users in real-time, much like having a personal instructor [\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e, \u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e]. The prospects for these innovations require a careful examination of the types of equipment that can best support Tai Chi routines without impeding the natural flow of movement. Future research should thus focus on the design and evaluation of such equipment to ensure that it complements the gentle, yet precise nature of Tai Chi, enabling practitioners to reap maximum physical and mental health benefits from their workouts.\u003c/p\u003e \u003cp\u003eFurthermore, the incorporation of virtual reality (VR) technology into Tai Chi education and physical conditioning can be a game-changer, particularly for enhancing cognitive attributes. By immersing practitioners in a simulated environment, VR can amplify focus and retention, accelerating the mastery of Tai Chi's martial applications. This immersive approach offers a dynamic and engaging learning experience, potentially bolstering the speed and depth with which students grasp the subtleties of Tai Chi's defensive and offensive maneuvers [\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, investigation Slow-motion technology, novel equipment like slow treadmills, can greatly enhance the learning curve in practices like Tai Chi by emphasizing the significance of measured movements. This equipment can serve as a tactile reminder of the power of deceleration, reinforcing the concept that slower motion can improve stability, control, and mental clarity. By slowing the pace, practitioners can more effectively dissect and appreciate each nuance of their form, deepening their understanding of the discipline's fundamentals. This hands-on approach to learning the virtues of slowness could be especially illuminating for those used to the fast pace of modern life, offering a tangible pathway to mastering the art of moving deliberately.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis review starts with a meta-analysis which provides valuable insights into the potential relationship between posture level, knee pain, and knee movements, Form the above, Knee pain after Tai Chi practice ranged from 48.20% to 52.78% across studies, suggesting a consistent prevalence of knee pain among practitioners. Which is caused by movements involving high knee rotation and high knee extension/abduction. This indicates the need for practitioners to be mindful of their knee movements during activities like Tai Chi in order to minimize the risk of knee pain.\u003c/p\u003e \u003cp\u003eFrom the above knowledge Tai Chi has essentially beneficial to the whole body. The correct practice of Tai Chi is a perfect start to acquire all its beneficial properties. Static stance being the fundamental of Tai Chi not only builds the strength of the legs and hips, but also helps to establish a solid foundation to learn and practice more complicated forms / movements. Therefore, adopting the right posture can help in many ways such as pain reduction and injury prevention. Good posture maintains joints and bones in the right configuration so that the muscles are used efficiently. Hence, enhancing the physical fitness, the quality of life making suitable for all age group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest:\u003c/h2\u003e \u003cp\u003eNo conflicts of interest\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical statement\u003c/strong\u003e \u003cp\u003eEthical approval was not sought for the present study because it is a review paper.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution:\u003c/h2\u003e \u003cp\u003eWe thank our group members for technical support and thanks the Wushu Collage of Henan University. Darrin Sime Nkemeni, Hao Hong wrote and design the review.\u003c/p\u003e\u003ch2\u003eAcknowledgments:\u003c/h2\u003e \u003cp\u003eWe thank our group members for technical support and thanks the Wushu Collage of Henan University.\u003c/p\u003e\u003ch2\u003eData availability statement:\u003c/h2\u003e \u003cp\u003eAll data will be made available on requested.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFalk-Rafael A (2006) Globalization and global health: Toward nursing praxis in the global community. Adv Nurs Sci 29(1):2\u0026ndash;14\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenatar S, Brock G (eds) (2011) Global health and global health ethics. 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Mobile Information Systems, 2022\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Henan University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"knee pain, Tai Chi, health benefits, physical fitness, implementation","lastPublishedDoi":"10.21203/rs.3.rs-8566281/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8566281/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTai Chi is a form of physical activity characterized by slow movements that induce a state of meditation synchronized with breathing, to achieve spiritual tranquility. This kind of training exercise has a light-to-moderate-intensity with a metabolic activity varying between 2.5 and 6.5 METs, is suitable for all age groups. This review begins with a compelling meta-analysis that sheds light on the significant relationship between posture, knee pain, and knee movements. Prepare to uncover valuable insights that could transform our understanding and management of knee health during Tai Chi practice. Additionally, it investigates the proportion of knee pain between Tai Chi practitioners, and the findings suggest that there is a notable prevalence of knee pain among Tai Chi practitioners, with reported rates ranging from 48% to 57% in different research studies. This knee pain is caused by movements involving high knee rotation and high knee extension/abduction, owning to the posture level. This indicates the need for practitioners to be mindful of their knee movements during Tai Chi practice in order to minimize the risk of knee pain. Furthermore, it outlines the role of the hip in knee pain and indicates the need for further research. In the review part, the selected results were analyzed based on three primary categories: characteristics of Tai Chi practice, health benefits of Tai Chi, and its implementation. The findings revealed that Tai Chi greatly enhances both physical and psychological well-being. It similarly proposes how the implementation of Tai Chi can be beneficial to private and public sector and further outlines some limitation faced by Tai Chi.\u003c/p\u003e","manuscriptTitle":"An Analysis of Tai Chi Posture Effects on Knee pains: An approach for improving the Implementation Tai Chi.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 04:46:04","doi":"10.21203/rs.3.rs-8566281/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2057961-83be-4a1d-a1b4-da7459f548f4","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":60915622,"name":"Educational Psychology"},{"id":60915623,"name":"Physical Medicine \u0026 Rehab"}],"tags":[],"updatedAt":"2026-01-13T04:46:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-13 04:46:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8566281","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8566281","identity":"rs-8566281","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}