As of 2022, there were 771 million people aged 65 and older, and the proportion of the global population aged 65 and older is projected to increase from 10% in 2022 to 16% in 2050 (1). Age-related decline in balance is associated with an increased risk of falling (2). According to the WHO, one-third of people aged 65 and older fall at least once per year, with 5% of these falls resulting in a fracture (3). In China, the prevalence of falls, single falls, and recurrent falls was 26.4, 19.4, and 4.75%, respectively, among people over 65 years (4). Given China’s aging demographics, it is critical to explore preventive measures for reducing falls in vulnerable populations.

While strategies ranging from psychological counseling to environmental adaptations may be considered, regular exercise continues to be the primary focus of fall-prevention measures (5). The WHO’s 2020 physical activity guideline recommends that older persons pay particular attention to “functional balance and strength training” (6) to prevent falls and functional declines. Among many effective physical activities, Taijiquan—a traditional Chinese exercise—receives less public attention, even in China. According to four national surveys on popular physical activities among Chinese individuals, Taijiquan does not rank among the top 10 activities (7). Yet, available scientific evidence suggests that it is a useful exercise for older persons in terms of its various health benefits (8).

Research into Taijiquan’s benefits on balance control has burgeoned in the past two decades in China and other regions. Evidence to date suggests that Taijiquan appears to be a useful conditioning exercise for improving balance control among older persons experiencing functional decline (9). For this age cohort, exercise prescription should take account into both interventional efficacy and exercise safety. For example, while unilateral exercises or strength training on unstable surfaces are more effective in improving balance than bilateral exercises or training on stable surfaces (10, 11), these exercises are neither viable nor safe for vast majority of aging individuals. Given this consideration, low-aerobic dancing and Taijiquan are valuable in reducing the risk of falling in older persons (12).

Although a growing body of literature supports the efficacy of Taijiquan practice for balance control, there are two shortcomings. First, previous studies selected healthy individuals or those with already impaired physical functions (e.g., participants with knee surgery) to assess the balance control and health benefits of Taijiquan (13, 14). To date, while a few studies have examined Taijiquan’s benefits in reducing recurring falls (15), no study has investigated its effects on a cohort identified as having a high risk of falling but who have not experienced significant falls in the past. In a group of individuals aged 70 years or older who had fallen at least once in the preceding 12 months and had a healthcare practitioner’s referral indicating they were at risk of recurring falls, it was found that the risk of falling was reduced by 31% following 6 months of Taijiquan practice (15). Although this initial finding is encouraging, more evidence is needed to confirm the benefits across different demographics, particularly among those who have no significant fall history. For instance, a two-year longitudinal study indicated that while Taijiquan can prevent a decline in functional balance, its effectiveness in reducing injurious falls remains uncertain (16). In short, there is insufficient evidence to draw a definitive conclusion regarding Taijiquan’s benefits for older persons who are prone to falling. This may be attributed in part to the absence of a common definition of the risk of falling. Nevertheless, given that balance is a predictor of falls (17), those with poorer balance control than their age-matched peers may be categorized as a marginally fall-prone population. Hence, evaluating the effectiveness of Taijiquan practice among older persons at greater risk of falls could have important implications for fall prevention. Second, women, particularly postmenopausal women, tend to engage in less daily physical activity, which exacerbates age-related declines in balance, and the sharpest decline in balance has been seen in women between the ages of 60 and 70 (18). While there may not be a significant difference in the incidence of falls between Chinese males and females (19), it is important to note that postmenopausal women may suffer more severe consequences from accidental falls: postmenopausal women are more susceptible to osteoporosis, and, if they fall, they are more likely to sustain bone fractures (20). To address these concerns, previous research has shown that alternative forms of balance exercises, such as rocker-board and tandem stance activities, may be recommended for reducing falls (21). However, it is important to note that these exercises often require supervised instruction. For widespread promotion, home-based exercises are highly sought after (22). Nonetheless, it remains to be confirmed whether Taijiquan is an effective method for postmenopausal women. For instance, in a group of postmenopausal women with osteoporosis, 6 months of Taijiquan practice showed no significant effect on static balance control (23). Moreover, to date, no previous study has investigated the effects of Taijiquan practice on balance control among healthy postmenopausal women who are prone to falls.

Therefore, this study aimed to establish an evidence-based intervention using Taijiquan practice to improve the balance control of healthy, postmenopausal women prone to falls. We were also interested in if Taijiquan practice could improve functional fitness related to healthy aging. The overall objective was to offer empirical evidence regarding the effectiveness of Taijiquan in enhancing WHO’s call for “functional balance and strength” (6) among at-risk females.

Given that the interpretation of the results could be influenced by the heterogeneity of the sample and the reliability of the measurement, we established the baseline measurement error and the smallest worthwhile change, as shown in Table 2. These study-level benchmark values are useful for determining the magnitude of the study-level effect sizes.

As shown in Table 3, there were no notable changes in measurements for the control group after 12 weeks. Conversely, Taijiquan practice exhibited a large effect on the one-leg stand (+61.0%) and sit-and-reach test (+163.2%), a moderate effect on life satisfaction (+7.8%), arm curl (+8.3%), chair stand (+7.2%), and handgrip strength (+8.3%), and a small effect on diastolic blood pressure (−1.8%) and the back scratch (+48.3%). Using stricter criteria that take measurement errors into account, the effect size for the one-leg stand was medium, while the effect sizes for the arm curl and chair stand were small. Nevertheless, the Taijiquan group significantly outperformed the control group in the one-leg stand (g = 0.94), sit-and-reach test (g = 1.00), arm curl (g = 0.79), and handgrip strength (g = 0.86). These findings indicate that the 12-week Taijiquan practice significantly improved balance, flexibility, and upper-body muscular fitness among postmenopausal healthy women.

The recruitment of a group of healthy postmenopausal women prone to falling represents a novel aspect of this research. As aforementioned, there is no consensus on assessing low, medium, or high risk of falling. While the diagnostic precision of the two-step procedures employed in this study may be debatable, the importance of providing training in balance control to individuals with a fear of falling and below-average balance is undeniable. Considering this, the methodology employed to identify the at-risk population in this study may have broader applicability to other research focused on fall prevention. Following a 12-week intervention, the Taijiquan group demonstrated a 61.0% improvement in balance, an 8.3% enhancement in upper-body strength, and a remarkable 163.2% increase in flexibility. These gains not only helped participants achieve the expected goal of balance control but also improved handgrip strength beyond the national norm, potentially leading to long-term benefits for independent living and healthy aging.

Two noteworthy facts should be emphasized regarding the 61.0% improvement in balance control. First, the one-leg stand test serves as a reliable indicator of an individual’s susceptibility to falls (17), thus supporting the evidence-based eligibility criteria for our study’s primary objective. Second, a previous study showed that extending the duration of a one-leg stand by 1 s was associated with a 5% reduction in the risk of hip fractures (33). Our Taijiquan group achieved a noteworthy improvement of 2.5 s in this aspect, which can lead to substantial healthcare advantages. Hence, our study validates previous findings based on a broader population (34) and also contributes new knowledge regarding a target population (i.e., women who self-identified as prone to falling) and a target age range (i.e., 60 to 70 years) for early intervention (18). Additionally, compared to general balance training effects reported in the literature (Cohen’s d = 0.51) (35), our results suggest that Taijiquan is more effective. This reinforces our objective that Taijiquan is particularly valuable for older adults given its efficacy and saftey profiles. The mechanism underlying this improvement may be attributed to Taijiquan’s emphasis on rhythmic trunk rotation, forward-backward weight shifting, and gradual narrowing of the lower extremity stance (refer to Figure 3), which promotes neuromuscular adaptation for coordination and balance (36). Additionally, Taijiquan emphasizes the concept of “rooting with feet,” which involves ensuring heels make initial contact with the ground during all movements, whether circular or explosive (37). This practice is designed to enhance the fluidity of the center of body’s motion. As a result, improved normal gait and postural control can lead to enhancements in balance control.

Promoting appropriate balance exercises is a crucial consideration for long-term exercise participation and adherence (38), especially for older women at a higher risk of osteoporosis. Studies have shown that up to 40% of older persons who experience falls also have a pronounced fear of falling, leading to self-imposed restrictions on daily activities (39). This creates a negative feedback loop (falling-fear-inactivity) that can accelerate the aging process and increase the risk of premature morbidity and mortality. Taijiquan practice, with its few safety concerns and low-intensity physical activity, addresses these issues. Our findings highlight Taijiquan as a valuable exercise for older persons.

Despite the recruited participants having weak balance, their upper-body strength aligned with the national norm (27). Therefore, the gain in upper-body strength, particularly the improvement in handgrip strength [24.9 kg compared to the national norm of 23.6 kg for 60–64 years or 22.8 kg for 65–69 years (27)], was noteworthy and slightly exceeded what previous studies have shown (40). Western resistance theory typically emphasizes weights, repetitions, and volumes (41), whereas Taijiquan stands out as an outlier in this context: it is perceived as a gentle workout that does not require heavy loads, contact, or repetitive motions. The mechanism by which Taijiquan contributes to strength development is rooted in cultural heritage. Originally a martial art known as shadow boxing, Taijiquan was never intended as a relaxing activity but rather as an energy-intensive one. A study on Chen-style 56-form Taijiquan revealed a mean energy expenditure of 61.5 Kcal (42), corresponding to 10 Kcal/min of energy demand in the bare hands state during competitive routines lasting around 6 min. In comparison, a single set in a typical ACSM-style resistance training routine requires an average of 4.52 Kcal/min (43). Research by Hua and colleagues mapped the striking force of Chen-style Taijiquan (44), illustrating its impact on upper-body strength development. The philosophy of Taijiquan revolves around motion within stillness and overcoming hardness with softness. The improvement in upper-body muscular fitness is particularly relevant to aging, as arm curls are essential for daily activities, and low handgrip strength predicts all-cause mortality and cardiovascular disease (45). Therefore, Taijiquan, being an equipment-free form of strength training, is desirable for preserving functional fitness in home environments.

The ability of older persons to live independently is directly affected by age-related reductions in flexibility (46). In the Taijiquan group, participants increased their sit-and-reach distance from 3.8 cm to 10.0 cm, marking a significant improvement of 163.2%. Despite a baseline effect, Taijiquan improved this measurement from poor to well above the national norm (7.9 cm for 60–64 years and 7.1 cm for 65–69 years) (27), showcasing another remarkable outcome of this study. A previous cross-sectional study revealed that Taijiquan practitioners exhibited faster reflex reaction times in their hamstrings and gastrocnemius muscles, along with reduced knee joint angle repositioning errors (47). The forward and backward movements of the center of gravity during Taijiquan practice primarily involve increasing and decreasing the joint angles of the bilateral lower limbs, thereby strengthening the lower limb muscles (48). Contemporary Taijiquan, characterized by alternating slow motion and bursts of power, stimulates lumbar muscles (48) and enhances lower back flexibility and muscular strength (49). Consequently, improvements in hamstrings and lower back from Taijiquan practice are often accompanied by increased trunk flexibility. However, the absence of improvement in the back scratch test contradicts previous research findings (50). Given that the group means showed a significant difference in the single-arm portion of this study, it is likely that sample variation or study duration complicated the interpretation of results.

There were several insignificant outcomes that warrant attention. Firstly, the lack of development in lower-body strength may be attributed to baseline chair stand measurements being comparable to the national norm (27), which could have influenced subsequent lower-body strength gains in this medium-term study. However, a meta-analysis on the effect of exercise on NAD+ regulation suggests that multi-component training is more effective for healthy aging than a single form of exercise (51). In line with the WHO’s recommendation (6), we advocate for older persons to engage in various forms of physical activity alongside Taijiquan. For instance, incorporating walking into a Taijiquan session can target whole-body muscle groups and enhance overall physical fitness, especially beneficial for older persons with concurrent chronic conditions (52). Secondly, traditional Chinese cuisine is often rich in carbohydrates such as rice and noodles. With a steady rise in GDP per capita, modern Chinese households tend to consume excess calories, contributing to overweight (53). Therefore, sustained improvements in body composition require lifestyle modifications that include increased physical activity and consumption of nutrient-dense foods. Thirdly, although our findings contradict a previous study that reported Yang-style 24-form Taijiquan improved life satisfaction in healthy older persons (mean age 71.6 years) (54), we recommend that future studies continue to assess mental health outcomes. Interventions like Taijiquan may show greater sensitivity in assessment when mobility improves for individuals with existing movement impairments.

The absence of 24-h activity monitoring may have obscured the overall results. While participants were not allowed to engage in any exercise outside of the prescribed schedule during the study, they were permitted to walk freely. Unlike Western populations, Chinese individuals, especially the older adult, prioritize walking as their primary daily activity. Therefore, the lack of verification of step counts is a major drawback in interpreting the data. In addition, we only evaluated static balance as a measure of balance control. As we pointed out, the one-leg stand test is a proven reliable indicator of an individual’s susceptibility to falls (17). However, it would be valuable for future researchers to extend our findings by using other types of balance indicators, such as dynamic balance, reactive balance, and gait speed.

In conclusion, this study shows Taijiquan practice as a suitable exercise for postmenopausal women aiming to reduce their risk of falls. Considering the safety profile of Taijiquan, this conditioning exercise holds great relevance for aging societies in China. Moving forward, we contend that the research community has sufficiently demonstrated the modern health and fitness benefits of Taijiquan. However, despite its traditional roots, Taijiquan does not rank among the top 10 physical activities in China. We argue that the primary barrier to promoting this exercise lies in the lack of clear instructional guidance. Therefore, we recommend that Chinese policymakers prioritize the training of qualified social sports instructors and regularly introduce Taijiquan classes into communities. This approach will enable people to learn and experience the various benefits of Taijiquan. Meanwhile, Taijiquan has been endorsed by the United Nations as an intangible cultural heritage in 2020, highlighting its potential as a universal exercise practice that transcends cultural, linguistic, and geographical barriers. To overcome the main operational barrier of learning to practice this exercise, the Yang-style 24-form Taijiquan used in this study may be ideal for promotion in other nations. This form is simplified for easier practice and has demonstrated general efficacy in improving balance control compared to other forms of Taijiquan (55). Overall, our study contributes to the literature concerning a growing target population in China, and along with numerous other studies, it provides broader context of promoting Taijiquan as an aging-friendly exercise.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by this study was reviewed and approved by Ethics Committee of Universiti Putra Malaysia, with the approval number: JKEUPM 2020-296. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

XB: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. WX: Conceptualization, Data curation, Formal analysis, Writing – original draft. KS: Supervision, Writing – review & editing. YZ: Writing – review & editing.