INTRODUCTION:

Hand to eye coordination is defined as the body's capacity to process information acquired by the eyes through coordinated control of eye movement and processing of visual input¹.

Good hand to eye coordination requires numerous brainstem and cerebellum control, as well as certain frontal and parietal regions to cooperate because they play crucial roles in regulating eye movements and hand coordination. The anterior intraparietal cortex (AIP), which is located next to the medial intraparietal cortex (MIP), contains neurons that encode the dimensions, form, and orientation of objects that may be grasped, including plates, cylinders and rings²^,³. These characteristics influence how the hand and fingers are positioned during grasping action. When specific finger or hand postures are made towards targeted items while guided by visual cues, AIP cells are maximally activated. As a result, AIP is concerned with the visualization methods of hand movement, particularly in synchronizing the movement pattern with the spatial features of the item to be controlled. The effectiveness of hand-to-eye coordination has been studied in relation to specific brain regions and their functions, including eye gaze patterns, muscular coordination, and proprioception. According to Battaglia-Mayer & Caminiti, 2018, the use of proprioception of the hands in guiding the eyes is involved in precisely directing movements of the hands to complete a task or skill as it provides the body information of its hand movement, action, and location then this information is sent to the midbrain which two common neural mechanism is believed to interact with the information⁴. The neural networks controlling each effector interacts among each other in the first mechanism to exchange and match information such as movement target position and onset time. The second process entails data passing through independent eye and hand control channels from shared inputs⁵. Finally, the motor actions are carried out by the hand. Therefore, proprioceptive and balance training, which helps improve fine motor function by training the interaction between the constant input of information regarding the body's current location and the output of the following movement, is a crucial aspect of improving hand to eye coordination⁶.

Research done in 2016 shows that academic study can be improved by enhancing motor coordination because it requires interconnecting of the brain structures ⁷. Due to the activation of large areas of the brain when hand to eye coordination is trained, other related functions such as cognitive memory, muscle memory, postural efficiency, and learning ability are likely improved as well ⁸. Research done by Mohammad & Irem (2020) compares hand to eye coordination among university students who do not play volleyball and university students who play volleyball. The results show that university students who do not play volleyball only scored an average of 11.9 in the Alternate hand-wall toss test, which is considered poor. In contrast, university students who play volleyball have an average score of 17.1, which is considered fair. Therefore, it is beneficial to improve hand to eye coordination among university students as it improves not only a student's quality of life but also their academic studies ⁹.

Studies have shown that practicing Tai Chi significantly improves self-esteem ¹⁰, reduces stress ¹¹, balance and hand to eye coordination across various age group including older adults ¹² ^, ¹³ . However, no studies have been conducted to evaluate the effectiveness of balance exercises towards hand to eye coordination, although researchers have shown that static and dynamic balance exercises helps in improving body coordination ¹⁴^, ¹⁵. Research done by Liu et al. (2021) shows that Tai Chi has a significant effect on helping children and adolescents psychologically¹⁶. Tai Chi is mainly divided into two forms which are the Chen form and the Yang form¹⁷. Since previous research which proves that Tai Chi is effective in improving hand to eye coordination and proprioception all incorporates only slow and precisive moves which focus on the flow of the movement, the Yang form is more appropriate to be used as an intervention. Therefore, the Tai Chi used in this research will be based on the Yang form Tai Chi showing that it is effective in improving the physical and psychological components of the participants ¹⁸. On the other hand, balance exercises are exercises that challenge the cognitive, sensory and musculoskeletal systems while handling balance restrictions such orientation in space, changes in direction, and the speed or height of the centre of mass in static and dynamic circumstances. The two main categories of balance exercises are static and dynamic balance exercises. Combining balance control with dual-task, function-focused challenges activate the sensory and neuromuscular control processes ¹⁴.

Tai Chi has been found to be significant in enhancing hand-eye coordination, while balance exercises have been proven to enhance balance and body coordination. These techniques have been widely accepted and practiced by numerous researchers as evidenced in previous literature. However, the impact of balance exercises on improving hand-eye coordination remains uncertain. Currently, there is a lack of studies investigating the efficacy of balance exercises in enhancing hand-eye coordination among university students, despite the fact that balance exercises improve various aspects of hand-eye coordination, including balance, body coordination, and spatial control. Therefore, the purpose of this study is to determine whether the combination of Tai Chi and balance exercises is effective in enhancing hand-eye coordination among university students in Selangor and to assess its efficacy.

METHODOLOGY:

A randomized control trial, pre and post-test experimental design was used. The independent variable in this study is Tai Chi exercise and combination with balance exercise while the dependent variable in this study is the alternate-hand wall-toss test. This study was done at UTAR Physiotherapy Center, Universiti Tunku Abdul Rahman campus in Sungai Long. This study took place over the course of 4 weeks, which included 2 days of examination of outcome measures during the first and end weeks of the intervention and the 4 weeks of actual intervention. Following acceptance of ethics from ethical committee, data was obtained from June 11, 2022, through December 2, 2022. The entire cost of this research study was self-incurred. Purposive sampling method was employed as there was a limited amount of resource and time to carry out the study. Upon the success of recruiting the subjects, the subjects were allocated into two study group of experimental or control group through the method of drawing lots. Participants were blinded indicating single blinding. The sample size was calculated using G*Power version 3.1.9.2, and with 10% attrition rate the finalized sample size is 44 participants. Male and female aged from 18-25 and studying in universities around Selangor were included. Participants not a university student or studying in university out of Selangor, unable to commit fully to the training program, balancing disorders such as Parkinson’s disease ¹⁹, self-limiting Benign Paroxysmal Positional Vertigo (BPPV) ²⁰, and vestibular neuronitis, history of Traumatic Brain Injury ²¹^, ²², diagnosed musculoskeletal condition on medication ²³^,²⁴ and pregnancy were excluded.

Participants studying in different faculties who met the inclusion criteria were recruited from universities around Selangor. The recruited participants were first given a briefing, and then they were asked to fill in the consent form and demographic data. During the pre-test, the initial hand to eye coordination was measured using the alternate hand wall toss test (AHWT) test. The classification of hand to eye coordination is as shown in the table 1 as below:

Table 1: Rating of AHWT score

Rating	Score (in 30 seconds)
Excellent	>35
Good	30-35
Average	20-29
Fair	15-19
Poor	<15

During the intervention, (control group), with 22 participants, practised Tai Chi. Exercise videos of Tai Chi were downloaded into the video player in advance. The Tai Chi session consists of 10 min of warm-up, 45 min of exercise, and 5 min of cool-down. Coaches from Universiti Tunku Abdul Rahman Wushu Club, Sungai Long campus, conducted the Tai Chi exercise, explaining the movements while the video was being played. Tai Chi exercise movements are listed in table 2 below:

Table 2: Description of Tai Chi move (Wang, 2020)

Descriptions of Tai Chi move

1. Starting and preparation form

2. Slow squat form

3. Bend over form

4. Curled spine form

5. Wrists cross form

6. Go through palms form

7. Standing with one leg

8. Flying form

9. Circulation of Opening and closing hands

10. Closing form

Meanwhile, in group B (intervention group) each of the 22 participants practised Tai Chi with the same procedure as mentioned above and also balancing exercise which also consist of 10 min of warm-up, 45 min of exercise, and 5 min of cool-down. The 45 minutes of balance exercises are listed below:

(1) Exercises in mini trampoline

a. High skipping (on each leg, jump on spot 3 times) then land on the alternative limb every time (2 reps of 45 seconds each leg).

b. Attempts to catch the ball that the researcher is throwing towards them while standing on one leg. (2 reps of 45 seconds each leg)

(2) Exercises in inflated rubber hemisphere attached to a rigid platform (BOSU)

a. Attempts to balance while standing on BOSU's bladder side with one foot. (2 reps of 45 seconds each leg).

b. Attempts to balance while standing on BOSU's bladder side with one foot, while lifting and extending the non-support leg forward and backward (2 reps of 45 seconds each leg).

c. Attempts to balance while standing on BOSU's bladder side with one foot, while trying to catch the ball thrown at them by the experimenter in various directions (2 reps of 45 seconds each leg).

d. Attempts to balance while standing on BOSU's flat hard side with one foot (2 reps of 45 seconds each leg).

e. Attempts to balance while standing on BOSU's flat hard side with one foot, while lifting and extending the non-support leg forward and backward (2 reps of 45 seconds each leg).

f. Attempts to balance while standing on BOSU's flat hard side with one foot, while trying to catch the ball thrown at them by the experimenter in various directions (2 reps of 45 seconds each leg).

Between each set of balance exercises participants took 15 second break. (Davis, 2019)

Group A which is the control group, Tai Chi exercises were done two times a week with at least a rest day in between, while in Group B the intervention group, balance exercise and Tai Chi were done two times a week with at least a rest day in between. After the four weeks of intervention, all groups of participants were gathered to perform the post-test. The Alternate-Hand Wall-Toss test was repeated on the participants to measure hand to eye coordination similarly to the pre-test. All the data are recorded in the table, and both groups of results are compared to determine whether there is any improvement in their hand to eye coordination.

RESULTS:

Of the 46 responses collected, there was one duplicate data, and one participant did not consent to process the data; these two data were removed from the data analysis process. So only 44 responses were accepted and recruited into the study. None of these participants falls into the exclusion criteria. However, throughout the study, there was a total of 5 dropouts due to their loss of interest towards the study. This leaves a total of 39 participants who completed to study in the final stage of the study; among the 39 participants, 21 participants completed the study under group A which is the combination intervention of Tai Chi and balance exercise. The remaining 18 participants completed the study under group B, which is Tai Chi intervention only. The characteristics of the participants are explained in table 3. In this study, the Shapiro-Wilk Test is used to find out the normality of the outcome measure because the total sample size of this study is less than 50. From analysis it can be concluded that the sample is equally distributed for all the outcome used but not for the demographics in this study.

Table 3: Demographic data of participants

Demographic data	Frequency (%)	Mean (Std Dev)
Age 17 19 20 21 22 23	1 (6) 3 (7.7) 7 (17.9) 14 (35.9) 10 (25.6) 4 (10.3)	21.03 (1.27)
Gender Male Female	16 (41) 23 (59)
Year of Study 1 2 3 4 5	7 (17.9%) 9 (23.1%) 21 (53.8%) 1 (2.6%) 1 (2.6%)	2.49(0.914)

A split table of the two interventions; Tai Chi and combination of Tai Chi and balance exercise is created to allow comparison of the results between these two groups. As shown in Table 4, the average post-test score in Tai Chi group (M=22.48, SD=1.50) is higher than the average pre-test score (M=18.74, SD=1.34) with a mean difference of 3.74, t value of 5.67 and significance value of less than 0.000. Because the significance value is less than 0.05, this difference is thus statistically significant. Meanwhile, the average post-test score in combination of Tai Chi and balance exercise group (M=23.24, SD=1.46) is also higher than the average pre-test score (M=16.63, SD=1.25) with a mean difference of 6.60, t value of 7.67 and significance value of less than 0.000. Because the significance value is less than 0.05, this difference is thus statistically significant.

Table 4: Pre-post test comparison of average AHWT score among types of interventions

	Variable Mean (SD)		Diff	t	Sig
	Score
	Average post-test score	Average pre-test score
Type of intervention Tai Chi Combination of Tai Chi and balance exercise	22.48 (1.50) 23.24 (1.46)	18.74 (1.34) 16.63 (1.25)	3.74 6.60	5.67 7.67	0.00 0.00

Based on the table 5, it is shown that the Levene's Test for Equality of Variances has a significance value of 0.443, this means that variance in average improvement of hand to eye coordination of Tai Chi group is not significantly different than that of combination of Tai Chi and balance exercise group. This means that the "Equal variances assumed" row should be used for determination the t test results. In the t-test result, the significance value for the equality of means shows the value of 0.720. Since the significance value is more than 0.05, it is concluded that there is no significant difference between the two types of interventions in term of Post-test AHWT score.

Table 5: Comparison of post-post AHWT test between control and intervention group

Independent Sample Test
	Levene's Test for Equality of Variances		t-test for Equality of Means
		Significance	Significance (2-tailed)	Mean difference
Post-test AHWT score	Equal variances assumed	0.443	0.720	0.75624
Post-test AHWT score	Equal variances not assumed		0.719	0.75624

Based on the table 6 it is shown that the Levene's Test for Equality of Variances has a significance value of 0.220, this means that variance in average improvement of hand to eye coordination of Tai Chi group is not significantly different than that of combination of Tai Chi and balance exercise group. This means that the "Equal variances assumed" row should be used for determination the t test results. In the t-test result, the significance value for the equality of means shows the value of 0.013. Since the significance value is less than 0.05, it is concluded that there is a significant difference between the two types of interventions in term of improvement in hand to eye coordination.

Table 6: Comparison of average improvement of AHWT test between control and intervention group

Independent Sample Test
	Levene's Test for Equality of Variances		t-test for Equality of Means
		Significance	Significance (2-tailed)	Mean difference
Average improvement of hand to eye coordination	Equal variances assumed	0.220	0.013	2.87960
Average improvement of hand to eye coordination	Equal variances not assumed		0.011	2.87960

DISCUSSION:

This study aims to compare the effectiveness of Tai Chi with the combination of Tai Chi and balance exercise in improving hand to eye coordination. Research has shown that Tai Chi is an effective form of exercise and has been shown to improve hand to eye coordination in different age groups ¹²^, ²⁵^, ²⁶. However, to date, there is currently no research to evaluate the effectiveness of balance exercise or the combination of Tai Chi and balance exercise in improving hand to eye coordination. Although balance exercise was shown by Dunsky (2019) to have a positive effect in improving balance, body coordination, spatial memory, body movement control, proprioception, and sensory feedback, which is important aspects of developing a good hand to eye coordination, the direct effect of balance exercise towards hand to eye coordination is not known ¹⁴. This research, therefore, aims to investigate the effectiveness of balance exercise in improving hand to eye coordination by comparing their average improvement in AHWT score after 4 weeks of intervention.

In this particular investigation, both the control group and the intervention group demonstrated a noteworthy outcome in terms of enhancing hand-eye coordination. The control group displayed a rise of 19.90%, whereas the intervention group exhibited a rise of 39.75% in their hand-eye coordination during the AHWT examination. To determine whether the intervention group surpasses the control group, the mean of the average enhancement in AHWT scores is compared between the two. The outcomes indicate a notable distinction between the two groups. The intervention group has demonstrated a 76.47% greater improvement in the average enhancement of AHWT scores in comparison to the control group. Hence, the combination of Tai Chi and balance exercise group is significantly more effective in enhancing hand-eye coordination, with an improvement that is 76.47% superior.

When comparing the Pre-test AHWT score and post-test AHWT score, both the control group (Tai Chi) and the intervention group (Combination of Tai Chi and balance exercise) show statistically significant improvement in AHWT score. The result obtained in Tai Chi group were in accordance with the study done by Lee et al., (2015) ¹². They reported that Tai Chi practitioner has a 17.3% increase in their hand to eye coordination score in a finger pointing accuracy task while the control group has no significant improvement in their hand to eye coordination. While the results in the study done by Lee et al., (2015) has slightly lower improvement compared to this study, it is reasonable as the participants in this study has a mean age of 85.8-years-old compared to a mean of 21.03 years-old in this study. This is due to the fact that adaptive hand to eye coordination deteriorates with age. Adaptive hand to eye coordination is essential in helping us to develop hand to eye coordination, adaptive coordination is activated by error feedback, which uses centrally located, strategically adaptable, short-latency mechanisms to correct for abrupt changes in operational precision that frequently happen with transient changes in coordination tasks. Overtime, these adaption leads to improvement of hand to eye coordination especially in a repeated coordination task ²⁷. Therefore, it is reasonable that although the elderly in the study done by Lee et al., (2015) practiced Tai Chi for over 3 months which is longer than the duration of 4 weeks in this study, the improvement of hand to eye coordination is still relatively lower than of this study.

Although the improvement of hand to eye coordination is in accordance with the studies in the literature, the average AHWT score of the sample before the interventions varies significantly from different literature. In this study, the mean AHWT score before the intervention is 17.61, with a normal distribution that is considered fair. In comparison to the study done by Mohammad & Irem (2020), which has a mean score of 11.9 and is classified as poor in university students who do not play volleyball, this study has an average of 5.71 scores higher ⁹. The results are similar when compared to university students who play volleyball, with a mean score of 17.1. The critical difference that caused the results to vary is that a 2.0m distance was used to evaluate the AHWT test in the study by Mohammad & Irem (2020). In this study, a distance of 1.2m is used to carry out the AHWT test. This is because the results show that 1.2 m is the most reliable as it creates fewer outliers and a most evenly distributed result (Eun-Hyung et al., 2020). This makes a point that the AHWT test score in both the pre and post-test are normally distributed. However, because participants stand at a shorter distance when carrying out the test, less effort and difficulty are required to carry out the test, thus, resulting in a much higher score in the sample of this study.

Th improvement when combining Tai Chi with balance exercise could be due to a few factors. The first possible factor is that balance exercise is directly helping in improve hand to eye coordination. As balance exercise has shown to improve multiple aspects of hand to eye coordination such as balance, body coordination, spatial memory, body movement control, proprioception, and sensory feedback ¹⁴. Therefore, there is a high chance that balance exercise alone is effective in improving hand to eye coordination. The next possible factor explaining the improvement in hand to eye coordination is that exercise alone is sufficient in helping improve hand to eye coordination. According to Pointer (2016), exercise generally helps in improving hand to eye coordination especially when it is aerobic exercise, these exercises include a high variety of exercises such as swimming and playing catch. This explains the reason in which Combination of Tai Chi and balance exercise is better in improving hand to eye coordination compared to that of Tai Chi because the total exercise time in the intervention group is 2 times higher than that of control group.

According to Pointer (2016), hand to eye coordination declines with age, this is due to the decrease in time of reaction and dexterity which is the two important factors of hand-eye coordination. Research done by Seidler et al. (2010) found that decreases in motor function in older persons appear to be brought on by problems with the neuromuscular, central, and peripheral nervous systems. In contrast to young adults, older people exhibit motor performance deficits such as difficulty with coordination ²⁸, increased movement variations ²⁹, movement slowing ³⁰, and issues with gait and balance ³¹. The ability of elderly to motor function essentially in everyday tasks is negatively impacted by these deficiencies. Hence an early intervention and strategies trained during early adulthood or adolescents can delay the secondary complications. Additionally, compared to younger individuals, older adults shows greater spatial and temporal movements variability, which leads to less consistent actions. Postural stability is also frequently affected as people get older. The addition of these factors results in the big difference of hand to eye coordination between young adults and elderly ²⁸. Research done by Van Halewyck et al. (2014) compares the hand to eye coordination among elderly and young adults in a pointing task ³². During the study, the elderly group in the study spent a greater proportion of time homing in on the target during the pointing task, an outcome that is directly related to a person's hand-eye coordination. The percentage of target strikes also indicates that the elderly group performed at lower accuracy levels than young adults (p.005). This idea is further supported by the fact that older individuals made more targeting errors than younger adults (p .0001), indicating that they often completed their movement more from the centre of the target. Therefore, this study proves that age is a factor that can affect hand to eye coordination, as hand to eye coordination tends to decline with age.

Another factor that can affect hand to eye coordination is gender, according to research done by Chraif & Aniţei, (2013), young males had statistically significantly stronger hand-eye coordination compared to young females ³³. However, results show that young female students have a statistically significant stronger capacity to calibrate, correct, and learn from errors than young male students (t = 2.77, p = 0.007). Therefore, gender could be a factor that changes the hand to eye coordination results in this study. Lastly, physical activity level is also a factor that can affect a person’s hand to eye coordination. Research done by Van Halewyck et al. (2014) also proves that physical activity level clearly impacted hand to eye coordination during discrete manual aiming as participants who has a higher level of physical activity tends to do better in the discrete manual aiming task ³². This can be explained by the fact that exercise itself is effective in improving hand to eye coordination especially when it is aerobic exercise.

CONCLUSION:

In conclusion, the findings suggest that while both interventions led to improvements in performance, the combination of Tai Chi and balance exercises resulted in significantly greater gains. These results underscore the potential benefits of integrating complementary exercises to optimize outcomes in interventions aimed at enhancing specific skills or abilities.

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Received on 30.04.2024 Revised on 24.08.2024

Accepted on 26.12.2024 Published on 28.01.2025

Available online from February 27, 2025

Research J. Pharmacy and Technology. 2025;18(2):684-690.

DOI: 10.52711/0974-360X.2025.00101

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.