To conduct a comprehensive and systematic review of the relevant literature, we will search the PubMed, Web of Science, and EMbase databases, covering the period from the inception of each database until August 2024. The search strategy will employ a combination of controlled vocabulary (e.g., MeSH terms) and free-text keywords, including: Tai-ji, Tai Chi, Tai Chi Chuan, T’ai Chi, Age, Older, Elderly, Senior, Fall, Falling, Falls, Accidental Fall, Physical Functional Ability, Physical Functional Performance, Functional Performance, Random, Randomized Controlled Trial, and RCT. The search terms will be refined iteratively based on the initial results to optimize retrieval accuracy. In addition to electronic database searches, manual searches will be conducted to identify relevant studies, and reference lists of included articles will be scrutinized to ensure comprehensive coverage of the field. The specific search strategy for PubMed is detailed in Table 2.

The quality of the studies included in this review will be independently evaluated by two researchers, following the guidelines recommended by the Cochrane Handbook version 5.1.0 for assessing risk of bias. The evaluation will address six key criteria:

The risk of bias in the RCTs was rigorously evaluated using the revised Cochrane Risk of Bias tool (RoB2), which examines several critical domains: the randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and the selection of reported results. To ensure accuracy and objectivity, discrepancies in assessment were addressed through discussions between two authors to reach a consensus; if consensus was not achieved, a third author was consulted. Each domain was classified into one of three categories: “low,” “some concerns,” or “high” risk of bias. The overall risk of bias for each trial was determined by the highest level of risk observed in any domain. Additionally, the quality of evidence supporting our outcomes was systematically appraised using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, ensuring a robust evaluation of the evidence base. This comprehensive assessment process aligns with the stringent standards required for evidence-based practice, particularly in the fields of sports and elderly rehabilitation, where precise and reliable data interpretation is critical for clinical decision-making.

Data extraction will be independently performed by two researchers, who will review the literature according to the pre-defined inclusion and exclusion criteria. A standardized data extraction form will be utilized to systematically collect the following information:

Any discrepancies identified during the data extraction process will be resolved through discussion between the researchers until consensus is achieved. For studies with incomplete reporting, the researchers will attempt to contact the original authors to request the missing data. If the required information cannot be obtained, the study will be excluded from the analysis.

Meta-analysis will be performed using RevMan 5.4 software. The primary effect parameter will be the difference between post-intervention values and baseline measurements (referred to as the difference score). This will be calculated using the following formula:

where M represents the effect mean, M₁ is the baseline mean, M₂ is the post-intervention mean, S is the effect standard deviation, S₁ is the baseline standard deviation, S₂ is the post-intervention standard deviation, and R is a constant (either 0.4 or 0.5) used for the calculation.

For categorical data, the risk ratio (RR) will be used as the effect size, with each effect size reported as an RR with a 95% confidence interval (CI).

For continuous variables, the weighted mean difference (WMD) will be used as the summary statistic if all studies measure the same outcome using identical scales. If different scales are used across studies to assess the same outcome, the standardized mean difference (SMD) will be employed. All analyses will include a 95% confidence interval (95% CI).

Statistical heterogeneity will be assessed using the chi-square test and quantified with the I² statistic and p value. If p > 0.1 and I² < 50%, a fixed-effect model will be applied. If p < 0.1 or I² ≥ 50%, and the studies are considered clinically homogeneous, a random-effects model will be used. If heterogeneity is substantial, a descriptive analysis will be conducted.

The quality of evidence was systematically evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework, a widely recognized tool in evidence-based practice (27). The GRADE approach examines five critical domains: risk of bias, publication bias, indirectness, imprecision, and inconsistency. Each domain is rigorously analyzed to determine its impact on the overall confidence in the evidence. Following this comprehensive assessment, each outcome is categorized into one of four levels: high, moderate, low, or very low quality. This structured evaluation ensures a robust and transparent appraisal of the evidence, which is crucial for making informed clinical decisions, particularly in the fields of sports and elderly rehabilitation, where the precision of evidence directly influences patient care and therapeutic outcomes.

The literature screening process and its outcomes are illustrated in Figure 1. An initial search identified 180 studies. After removing duplicates, 84 studies remained. Of these, 45 studies were excluded for the following reasons: they were non-randomized controlled trials, duplicate publications, lacked access to full-text versions, or did not provide usable data. Consequently, 22 studies, encompassing a total of 2,170 participants, were included in the final analysis. The basic characteristics of these included studies are summarized in Table 3. Details of the excluded references are provided in Supplementary material.

All 22 included RCTs reported baseline characteristics of participants and explicitly stated the use of randomization (28–49). Seven RCTs provided details on allocation concealment, and 11 RCTs reported the implementation of blinding. Data reporting was complete across all 22 RCTs, with adequate descriptions of any missing data or the reasons for their absence. Furthermore, all 22 RCTs demonstrated selective outcome reporting, and no additional sources of bias were identified in these studies. The detailed results of the quality assessment are illustrated in Figure 2.

The quality of evidence for the outcomes analyzed in this study was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework. The assessment indicated that the evidence quality for each outcome was rated as low. Several factors likely contributed to this rating, including the risk of bias inherent in the study designs, inconsistency in results across studies, imprecision due to small sample sizes, and concerns related to indirectness or publication bias. Additionally, the observed variability in the incidence and progression of falls, balance issues, and physical functioning among the elderly population further exacerbates these inconsistencies. For a detailed summary of the evidence quality assessed in this meta-analysis, please refer to Table 4 (27).

This meta-analysis systematically assessed the effects of Tai Chi on improving balance, reducing fear of falling, and enhancing physical function in older adults. The findings indicate that Tai Chi significantly improved scores on the BBS and extended the duration of OLS-Close, demonstrating its positive impact on balance enhancement in this population. Furthermore, Tai Chi was associated with significant improvements in the TUG test and Fall Efficacy test, underscoring its potential to enhance physical function and reduce fall risk among older adults. However, the results for the TBT, FES, FOF, and SPPB did not achieve statistical significance, suggesting that Tai Chi’s effects may vary depending on the specific balance and functional measures used.

Tai Chi supports postural control by reinforcing the visual, proprioceptive, and vestibular systems, all of which are vital for maintaining balance. As individuals age, reduced visual acuity and environmental sensitivity impair balance (58). Tai Chi enhances visual feedback through controlled gaze adjustments, which helps stabilize posture (59). The proprioceptive system, which monitors muscle and joint positions, is strengthened by Tai Chi’s slow, continuous motions, improving coordination and dynamic balance (60). This is particularly beneficial for older adults, allowing better responses to sudden balance disruptions. The vestibular system, responsible for sensing head position and acceleration, is also activated through Tai Chi’s rotational movements and footwork, boosting adaptability and response to balance challenges. Furthermore, Tai Chi exercises enhance lower limb strength by engaging the quadriceps and stabilizing knee joints, which helps reduce gait instability (24). These improvements support older adults in maintaining postural balance during daily activities, thereby lowering fall risks significantly.

Assessing the feasibility of incorporating Tai Chi into healthcare requires considering various factors. First, qualified Tai Chi instructors need a solid background in exercise physiology and geriatrics, as well as specialized teaching skills, which could strain finances for resource-limited institutions. However, as Tai Chi requires minimal equipment, institutions could train existing staff or collaborate with local practitioners to reduce costs and facilitate integration. Second, Tai Chi’s low-impact, gentle nature is ideal for elderly patients who prioritize safety and comfort, making it feasible as a long-term intervention. Its adaptable frequency and duration enhance patient adherence and reduce the burdens of intense exercise. Finally, while Tai Chi does not require large equipment, it does need spacious, level areas for safe practice. For facilities with limited indoor space, using outdoor or public areas with appropriate safety measures can meet these spatial needs without extra costs.

Tai Chi, an exercise regimen characterized by low-intensity movements and restorative attention practices, has demonstrated significant benefits in enhancing cognitive function and physical flexibility among older adults. Additionally, it fosters improved mental health and social connectedness. The slow, deliberate motions integral to Tai Chi practice promote attentional restoration, making this exercise particularly beneficial for individuals frequently engaged in multitasking or subjected to high-stress environments. This practice is supported by Attention Restoration Theory (ART), which suggests that alternating between rest and focused activities helps replenish cognitive resources and reduce psychological fatigue (61). Tai Chi’s benefits extend well beyond physical health, encompassing improvements in mental and emotional well-being. Engagement in group-based Tai Chi activities provides older adults with beneficial social interactions, which have been shown to foster emotional resilience and psychological flexibility (62). In contrast to traditional treatment-centered approaches, Tai Chi emphasizes a preventative and health-promoting perspective within elderly care. This integrated approach, which simultaneously addresses physical and mental health needs through communal exercises, underscores Tai Chi’s essential role in contemporary elderly care. It provides a holistic support system that is both preventive and rehabilitative, thus offering comprehensive health benefits to the aging population (61).

A key strength of our research lies in the integration of recent RCTs into our analysis, supported by a comprehensive sensitivity assessment. Nevertheless, our study presents several limitations. First, the reliance on predominantly English-language publications selected according to specific criteria may have introduced selection bias. Second, our findings are confined to standard Tai Chi programs and do not encompass personalized program variations. This limitation underscores the necessity for further research into the efficacy of individualized Tai Chi programs in the context of elderly rehabilitation. Additionally, our study population was restricted to healthy older adults, thereby excluding those with significant comorbidities. While sensitivity and subgroup analyses were conducted, potential heterogeneity might still influence the robustness of our findings. To broaden the applicability of future research, it would be advantageous to include elderly individuals with diverse health conditions. Finally, although our study compared Tai Chi to traditional, non-Tai Chi exercise modalities, various emerging interventions and technologies may also have implications for improving the quality of life among older adults. Future studies should consider examining the distinctive advantages and limitations of Tai Chi through comparative analyses with other innovative interventions. Such studies could provide a more nuanced understanding of Tai Chi’s role within the broader spectrum of rehabilitation strategies for the elderly.