Current Evidence of the Application of Music in Tai Chi Exercise: Scoping Review

Introduction

Tai Chi, originating in China, is an ancient Chinese martial art that evolved into a sport and mind-body exercise. It is characterized by slow and gentle movements, deep breathing, and meditation. There are various types of Tai Chi such as Chen, Yang, Hao, Wu, and Sun styles [1]. Among these, Chen style is the oldest, characterized by slow and smooth movements with fast and explosive ones; Yang Style is the most widely practiced globally, characterized by slow, gentle, and flowing movements [1]. Each style may include simplified forms, traditional forms, short forms, and long forms. A Tai Chi form is a sequence of movements that are performed in a slow, continuous, and flowing manner, integrating principles of balance, relaxation, and alignment [1,2].

Widely recognized as a valuable therapeutic intervention, Tai Chi is often recommended by health professionals and embraced by the public to complement conventional medical treatments [3]. Its slow and deliberate movements, encompassing aerobic, stretching, balance, and strengthening exercises, have garnered increasing attention among populations with various health statuses and within the scientific community for their potential health benefits [4-6]. Evidence-based research underscores Tai Chi’s health benefits, including but not limited to improvements in balance [7,8], muscle strength [9], cardiovascular and metabolic health [10-13], physical and cognitive function [14-18], mental health [19,20], and quality of life [21-24].

Incorporating music into movement exercises is a common practice to enhance ergogenic effects [25]. In China, Tai Chi practitioners often use soft, relaxing Chinese folk music to promote relaxation and concentration during Tai Chi practice [26,27]. Using music during Tai Chi practice has also been reported in populations outside of China [28,29]. While studies examining Tai Chi’s effects on health outcomes are on the rise, few have explored the use of music during Tai Chi practice in Western populations [30-32]. Previous research has inadequately addressed the application of music in Tai Chi practice [33], and studies assessing Tai Chi with music seldom investigate potential synergistic effects on health outcomes [34,35]. Furthermore, the ongoing debate surrounding the use of music during Tai Chi practice reflects different perspectives on music’s impact [36]. Some argue that Tai Chi is a form of moving meditation, suggesting that engaging in Tai Chi with music may hinder the attainment of “rujing” (the absence of idle thoughts or the cultivation of stillness). Conversely, others indicate that music can aid in reducing distractions and facilitating “rujing” by calming the mind [36]. Scientific evidence is thus imperative to guide best practices in incorporating music into Tai Chi for optimal health benefits.

Therefore, this study aims to explore current evidence regarding the application of music in Tai Chi practice through a scoping review of studies comparing Tai Chi practiced with music to that practiced without. Our objectives include understanding how music has been applied to Tai Chi practice, evaluating what specific outcomes were assessed in the current scientific literature, and exploring whether practicing Tai Chi with music offers advantages over practicing Tai Chi without music.

Methods

Study Design

We used the updated Arksey and O’Malley five-stage framework [37] to guide the conduct of the scoping review. Specifically, we followed these steps: (1) identifying the research question based on the research team’s experience in conducting Tai Chi–related research and reviewing current literature; (2) identifying relevant studies; (3) selecting the studies; (4) charting the data; and (5) collating, summarizing, and reporting results. Steps 2-5 are described in detail below. Additionally, we used the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews) guidelines [38] to draft and report this scoping review. The PRISMA-ScR checklist can be found in Multimedia Appendix 1. We registered this review at the Open Science Framework [39].

Data Search

We searched the electronic databases PubMed and CINAHL in September 2022. Medical Subject Headings terms “Tai Chi” and “music” were used to build the search strategy on PubMed. The search strategies for PubMed are illustrated in Multimedia Appendix 2. Subsequently, the search terms used on CINAHL were constructed based on the PubMed search strategy. Given that Tai Chi originated in China, where the use of music during Tai Chi is common, we also searched Chinese databases CNKI and Weipu. “太极” (Tai Chi) and “音乐” (music) were used to search through Chinese databases. We did not set language or publishing year restrictions in the database searches as we aimed to comprehensively cover this topic in this scoping review.

Eligibility Criteria

Inclusion criteria were (1) studies with comparisons between Tai Chi with music and Tai Chi without music, (2) published journal studies, and (3) at least 1 study group examining Tai Chi with music and 1 group examining Tai Chi without music. Given the broad scope of this scoping review, no age limit was set. Outcomes could encompass any measurements evaluated in the studies such as Tai Chi practice adherence and health outcomes. Exclusion criteria were (1) studies with nonempirical design, such as view paper, review paper, and protocols, and (2) experimental studies without comparisons between Tai Chi with and without music.

Study Selection

First, all search records were merged, and duplicates were removed. The eligibility criteria were then discussed and refined by the study team based on the search processes. YD screened the title and abstract based on the inclusion and exclusion criteria. YD and YH independently screened the full papers according to the eligibility criteria. Any discrepancies were resolved through discussions and consultations with a third researcher (GXW).

Data Extraction

YD drafted the data extraction form. YD and YH tested the extraction by charting 2 studies independently and refined the data extraction form accordingly. The form included study location, study design, sample characteristics, Tai Chi selection, music selection, assessed outcomes, and study findings. YD and YH independently extracted data from each study according to the extraction form. Any discrepancies were resolved through discussions and consultations with a third researcher (GXW). Data were extracted in the original published language, and a bilingual researcher translated the Chinese data into English after synthesis, which was then checked by a native English speaker.

Synthesis

We used a narrative approach to summarize, analyze, and assess the evidence in this review. Specifically, one table charted the characteristics of included studies, and another table summarized the use of Tai Chi and music in each study. A thematic analysis approach [40] was adopted to summarize and categorize the findings of included studies. First, YD created a codebook based on the coding of the extracted data and summarized the findings for each code. Second, YH and GXW reviewed the codes and summary findings against the extracted data. Summary quotes are quotes summarized by the authors but not direct quotes from the studies included. Subsequently, YD, YH, and GXW categorized the codes into subthemes. The study team reviewed the themes, subthemes, codes, and summary quotes. Given the scoping nature of this review, no assessment of study quality was conducted.

Results

A total of 491 papers in English or Chinese were identified, including 260 papers in CNKI, 155 papers in Weipu, 45 papers in PubMed, and 31 papers in CINAHL (Figure 1). We removed 21 duplicated papers, leaving 471 papers for the title and abstract screening. Of those, we considered 20 studies for full-text screening. We further excluded 13 papers after a full-text screening due to reasons of being opinion papers (n=7), lacking a comparison between Tai Chi with and without music (n=5), and involving other components in the Tai Chi with music group (n=1). Figure 1 indicates the reasons and numbers of excluded studies in each screening stage.

All 7 included studies are clinical trials (Table 1); 6 studies were conducted in China and 1 in the United States. Five of the 6 studies in China included only college students, and the rest focused on nurses with impaired mental health. The study conducted in the United States primarily included older adults. Five studies reported gender distributions; 2 reported 100% female, 1 reported 9% female, and the other 2 consisted of 53% and 47% female, respectively. All 7 studies included at least 2 study groups; 1 group for Tai Chi with music and another for Tai Chi without music. For studies with available intervention frequencies, it ranged from 14 to 16 sessions within 7 weeks (about 1 and a half months) to 3 months. The retention rate ranged from 72% to 100%. The sample size included in the final analysis ranged from 13 to 162 participants.

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Table 2 shows the Tai Chi styles or forms, the music type being used, and how the study applied music to Tai Chi practice. Three of the 7 studies specified Tai Chi styles and forms (the 24-form simplified Yang style). There were variations in music selections used for Tai Chi practice. In the study conducted in the United States, a board-certified music therapist selected the music; others did not specify how the music was selected or by whom. Various music types were selected, but the studies in China used Chinese music or Chinese medicine principle-oriented music; while the US study used Western music with instruments familiar to the ethnic groups. Five of the 7 studies described how they used music during Tai Chi practice. Among the 5 studies, 3 studies did not use music during Tai Chi instructions and used music only when practicing Tai Chi routines; 1 study used music throughout the Tai Chi sessions. The remaining study did not provide Tai Chi instructions; however, it assessed body responses to diverse types of music while practicing Tai Chi routines.

Thematic analysis revealed two major themes with corresponding subthemes: health outcomes including (1) physical health and (2) mental and emotional health; and experience of Tai Chi practice including (1) Tai Chi practice and (2) perceived instruction quality (Table 3). Included studies assessed various outcomes to compare the efficacy of Tai Chi with and without music. First, the assessed health outcomes included but were not limited to physical and mental health. Overall, practicing Tai Chi with music led to significantly better balance (dynamic gait index); and a trend of better physical health indicators and better mental health (depression and coping), which were not significant. Tai Chi beginners had significantly higher skin response to Tai Chi with slow, gentle music or relaxing, joyful music than advanced practitioners; higher skin response was found in advanced practitioners compared to those beginners when practicing Tai Chi without music. Second, for the experience of Tai Chi practice, at least 1 study showed that practicing Tai Chi with music led to multiple outcomes such as higher adherence in and outside of class [31,44], more confidence in learning and mastering Tai Chi [44,45], better concentration and enjoyment [41], less perceived difficulties [45], and better performance [41,43-45]. Third, instruction quality was assessed in 3 studies, 2 of which reported a higher satisfaction rate in the Tai Chi with music groups [41,44], and more participants rated the instruction high quality in the Tai Chi with music group compared to the control group [43].

Discussion

Principal Findings

This scoping review aimed to map out the application of music in Tai Chi practice. We identified 7 studies published in either Chinese or English using controlled trials to compare the differences between practicing Tai Chi with and without music on various outcome measures. Most studies were conducted in China, and the selection and use of music for Tai Chi practice were heterogeneous. There is clear positive evidence supporting the beneficial effects of applying music to Tai Chi practice to improve the perceived quality of Tai Chi instructions and promote Tai Chi learning experience, enjoyment, concentration, adherence, and movement performance. However, further investigations are needed regarding how music should be selected in Western culture, its benefits in beginners versus advanced practitioners, and whether listening to music alone would lead to similar health benefits compared to practicing Tai Chi with music.

The studies included in this review used various types of music for Tai Chi practice, and music was used either throughout the instruction and routine practice or only for routine practice but not during instruction. In general, the music selected was soothing, soft, and relaxing [31,44,45]; aligned well with the soft, gentle, slow, and graceful movements of Tai Chi; and suitable to participant culture [31,45]. The finding is consistent with another study reviewing the psychophysical effects of music in sports and exercise [46]. The review indicated that the keys to selecting music should include considering not only the sociocultural background of the practitioners but also the nature of the physical activity and coordination with the physical activity task [46]. Therefore, music was often used in sports for pre-event preparations, warm-ups, and training sessions. In this review, music was played either throughout the Tai Chi class session or only during practicing the Tai Chi routines, both of which formats showed favorable effects [31,45]. However, since most of the included studies were conducted in China, further investigation is needed to determine the generalizability of these findings to other regions. In addition, Tai Chi has been strongly recommended to improve balance and promote health in the aging populations; while most included studies focused on Chinese college students, studies assessing to what extent the findings may apply to older populations are warranted.

Evidence from many studies suggests that music could promote positive effects during exercise, such as increasing motivation, happiness, confidence, relaxation, and performance levels [47,48]. Similarly, we found that practicing Tai Chi with music could yield higher learning motivation [41], concentration [41], enjoyment [42], confidence [43,45], performance and compliance [31,41,43-45], and lower perceived difficulties in learning Tai Chi [45]. Previous studies reported that many people who do not habitually engage in exercises often find it difficult to initiate an exercise routine, and some well-documented barriers to regular exercise engagement include a lack of motivation and enjoyment and feeling bored and physically uncomfortable [49]. The findings from the included studies may suggest that adding music to Tai Chi practice could help alleviate the barriers to engaging in Tai Chi exercise, especially for beginners. For example, among the included studies, one study found that Tai Chi beginners had a stronger positive influence from music than advanced practitioners assessed by galvanic skin responses (a signal for capturing the autonomic nerve responses) and subjective enjoyment [50]; this may indicate that Tai Chi beginners may benefit more from using music when practicing Tai Chi in comparison to more advanced users [42]. Music could likely help beginners feel relaxed and focused, and promote Tai Chi exercise in those who are new to learning Tai Chi. For more advanced Tai Chi practitioners, this may vary depending on various factors such as the practitioner’s mood and environment [36]. As an exercise that originated in Asian culture, adding music affiliated with Western populations may help promote its instruction, implementation, and dissemination. However, further investigations are needed to confirm this assumption.

The findings differ when assessing improvements in health outcomes through adding music. Balance, as measured by the dynamic gait index, was found to be significantly improved in the study participants incorporating music, but not in their counterparts practicing Tai Chi without music after a 15-week Tai Chi intervention. Balance is a frequently studied measurement of Tai Chi’s effects on health [51], and the Centers for Disease Control and Prevention also highly recommends that older adults practice Tai Chi to improve balance [52]. For other assessed health measurements, although not significant, trends showed better outcomes in the Tai Chi with music group such as physical symptoms and depression. For other health measurements, no significant improvements were detected, which could be due to the relatively short intervention lengths. Further research with longer interventions and a larger sample size is warranted to explore the possible symbiotic effect of Tai Chi and music on health outcomes.

Integrating music into Tai Chi practice may offer a promising avenue for enhancing its benefits on health outcomes in a holistic approach. First, based on the findings of this review, the health benefits could be through the pathway of a positive influence of added music on perceived enjoyment and concentration, improved adherence or compliance, and overall positive experience. In addition, as evidenced in the literature, listening to music alone could improve a variety of health outcomes including but not limited to mental health, cognitive function, and cardiovascular health [53-58]. Therefore, we hypothesized a theoretical framework of adding music to Tai Chi practice to increase its benefits on health outcomes (Figure 2). Future research could focus on whether the application of music to Tai Chi practice leads to synergistic effects on health outcomes. This includes both physical (eg, mobility, balance, and metabolic health), cognitive (eg, orientation and memory), and mental health (eg, stress and depression symptoms). Studies could also aim to quantify these outcomes and understand the underlying mechanisms driving these potential benefits. It is also warranted to investigate which music (such as type of music, its tempo, and rhythm) is appropriate to maximize health benefits, and how these factors might influence different populations such as various age groups and health conditions. These investigations may provide insights into how to improve health through a holistic approach. Last, but not least, qualitative studies to gather in-depth insights from participants on their experiences, preferences, and perceptions of Tai Chi practice with music may provide valuable information to guide the development of tailored and effective Tai Chi exercise programs. Tools and recommendations could be developed to guide interventions using music to Tai Chi practice for health benefits.

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Limitations

The findings of this scoping review should be interpreted with caution due to the majority of included studies being conducted in China among college students. Even though music has been used during Tai Chi practice in other populations as reported in prior studies [26], the mechanisms of using music in Tai Chi practice in various populations have been understudied. Further research is needed to explore the mechanisms and the potential harms or benefits and establish the practicality of using music for Tai Chi practice in other regions and populations. In addition, the heterogeneous interventions, lengths, and frequencies of the included studies may further limit the application of the findings.

Conclusions

Based on the findings of the included studies, Tai Chi style or form selection, the music used during Tai Chi practice, and the studied populations were heterogeneous. Various outcomes, such as differences in Tai Chi practice experience, instruction quality, and health outcomes, were assessed. There is positive evidence supporting the beneficial effects of applying music to Tai Chi practice to improve the perceived quality of Tai Chi instructions and promote Tai Chi learning experience, enjoyment, concentration, adherence, and movement performance. Particularly, including music in Tai Chi practice may promote Tai Chi among individuals new to Tai Chi practice through perceived better instruction and learning experience. Therefore, applying music to Tai Chi learning and practice might help promote the implementation of Tai Chi in the general population. However, further study with a rigorous study design is needed to clarify if there are synergistic effects of Tai Chi and music on health outcomes.