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SYNOPSIS: In this randomized, controlled trial, researchers found that tai chi shows equal or greater effect than aerobic exercise for addressing symptoms of fibromyalgia, and that more effect is obtained with longer duration of tai chi practice.
SOURCE: Wang C, Schmid CH, Fielding RA, et al. Effect of tai chi versus aerobic exercise for fibromyalgia: Comparative effectiveness randomized controlled trial. BMJ 2018;360:k851
Chronic pain is one of the most frequent presenting symptoms in primary care clinical practice. Because of the difficulty of successful treatment, it is also one of the most frustrating conditions for providers to address.1 According to the International Association for the Study of Pain, 20% of adults worldwide experience chronic pain; the physical, emotional, and financial implications of this often-debilitating health problem affect lives on many levels — from individual patients to families and to society as a whole.2
Fibromyalgia (FM) is a multifaceted disorder and one of the main causes of chronic widespread pain. A hallmark of this disorder is chronic, diffuse musculoskeletal pain; other associated symptoms include disordered sleep, mood changes, and concentration difficulties. Some researchers and clinicians believe FM is a distinct condition, while others place it as part of a spectrum of chronic widespread pain, and still others consider the pain symptoms as part of a psychiatric disorder. Estimates of worldwide prevalence of FM (from 26 epidemiologic studies) are 2.7%, with a higher prevalence in women and in those > 50 years of age.3,4
There is no known cure for FM. Pharmaceutical agents (mostly analgesics) have limited long-term benefit. On the other hand, aerobic exercise is an accepted standard of care in managing this disorder, but is a difficult sell for many patients who report that exercising while in pain is prohibitive.3,4
Tai chi is a traditional Chinese systemic exercise program known for improving balance, flexibility, and endurance. Wang et al reported that several promising small-scale studies examined the effectiveness of tai chi in management of FM prior to this study. Given there were no previous studies comparing tai chi to aerobic exercise in FM patients and no studies regarding optimal “dose” (frequency and duration) of tai chi intervention, Wang et al designed their investigation to elicit this information. To standardize the tai chi intervention, the treatment protocol restricted the tai chi practiced to the Yang type and rotated one set of three instructors among the tai chi groups.
Two hundred and twenty-six adults with FM qualified for this study and were randomized into one of five treatment arms. All were followed up to 52 weeks. The protocol involved six cycles of intervention (12 or 24 weeks each) to control for seasonable variation in response and allow instructors to rotate among groups. Exclusion criteria for participation included recent experience with tai chi, some medical comorbid conditions, and cognitive impairments.
One treatment arm participated in a supervised, hour-long group aerobic exercise program twice weekly for 24 weeks. The other four arms were all tai chi interventions — once or twice weekly and either 12 or 24 weeks. All participants received an additional educational component and encouragement to practice at home. Given this was a head-to-head comparison between the two interventions as well as an inter-group comparison within the tai chi arms, no control or usual-care group was defined.
There were some adverse events reported by participants during this study; none were serious or directly stemmed from any of the interventions.
Every group had improvement in Revised Fibromyalgia Impact Questionnaire (FIQR) scores. (See Table 1.) However, when comparing the FIQR score differences between interventions, tai chi group scores were lowered more significantly than aerobic exercise scores. For example, at 24 weeks, when comparing aerobic exercise and tai chi at matched rate and frequency of intervention, the difference between the scores was 16.2 (P < 0.001).
Secondary outcome results included anxiety and global assessment score, each of which improved more with a tai chi intervention than with aerobic exercise, but with varying degrees of significance. For example, at the same 24-week mark in the groups matched for intensity and frequency of intervention, anxiety score differences were 2.1 favoring the tai chi intervention (P = 0.008) and global assessment score differences were 1.6 (P = 0.0006), also favoring the tai chi arm.
In all categories, the significant differences in outcome measures at 24-week follow-up attenuated at 52 weeks, and in some cases lost significant difference completely at the 52-week mark. This was particularly noticeable when comparing the combined average FIQR score of the tai chi interventions with aerobic exercise. At week 24, the difference in scores was 5.5 (P = 0.03) favoring the tai chi arm, but at the 52-week follow-up, the score difference was no longer significant.
Attendance was higher in the tai chi groups as a whole. The tai chi groups combined had a 62% attendance rate compared with 40% attendance rate in the aerobic group. Wang et al applied several statistical measures to control and account for this difference.
Some secondary outcome measures, including sleep quality and a six-minute walk test score, did not show significant differences between interventions. Likewise, although every group showed a reduction in the use of analgesics, there was no significant difference in this measure among the interventions. There were no significant differences found in outcome measures when tai chi once weekly was compared to twice weekly.
Tai chi is an ancient Chinese martial art with a long-standing role in Chinese traditional medicine.5 In discussing tai chi in 2017, Peter Wayne, research director of the Osher Center for Integrative Medicine in Boston, remarked, “I think of it as meditation on wheels. You’re getting all the cognitive pieces you might get from meditation — mental clarity and focus and positive thoughts and lower stress — but you’re also getting physical exercise.”6
There are five major styles of tai chi. The Yang style is the most popular worldwide, and most likely to be the type of tai chi seen practiced in parks or large group settings. Movements tend to be slow, steady, and deliberate as opposed to the older Chen style, which is characterized by more energetic and faster movements interspersed with slower movements. On the other hand, the Sun style concentrates on internal movements and stillness.5
One of the strengths of the Wang et al study is the standardization of the type of tai chi taught to Yang style and the use of three instructors rotating among all groups. Past investigations of tai chi have suffered in credibility because of lack of these controls. Additional strengths are the relatively long-term follow-up to 52 weeks, as well as the head-to-head testing of two different “doses” or frequencies of tai chi weekly and two different durations (12 or 24 weeks.)
In essence, Wang et al studied two non-pharmaceutical approaches to manage FM and found tai chi weekly (for 24 weeks) delivered a more robust intervention than aerobic exercise delivered at the same frequency and duration. According to Wang et al, the minimally clinical noticeable difference in FIQR scores is 8.1. Thus, the differences at weeks 12, 24, and 52 (10.9, 16.2, and 11.1, respectively) between FIQR scores when comparing tai chi and aerobic exercise matched for rate and frequency should hold clinical significance. However, many of the other FIQR differences among the compared groups were < 8.1 and while significant, may not hold clinical relevance.
By week 52, the significance of the differences between most groups had diminished. This may mean that the tai chi intervention needs to be maintained for a longer period, but there are no direct data to support this without longer-term studies. The drop-in use of analgesics from all interventions is a notable caveat for providers managing patients with FM.
It is interesting that attendance rate for the tai chi classes was higher than for the aerobic exercise classes. Wang et al explained that this could mean that patients with FM are more likely to practice and continue a tai chi intervention as opposed to aerobic exercise. However, this attendance difference could also have affected the results, although there were statistical measures, including intention-to-treat analysis, to control for this possibility.
It may be difficult to find a high-quality tai chi program in more isolated communities. Wang et al studied on-site group tai chi instruction with home practice. Future studies with remote or virtual tai chi instruction would be useful to understand if this individual modality is also effective in easing the symptoms of FM. There is no obvious path in the Wang et al study to account for the effect of group dynamics on interventions in addressing FM symptoms, and it may be that the group setting itself accounts for a portion of the response rate seen with both types of interventions.
Clearly, future studies aimed at understanding the nuances of response to specific mind-body and exercise interventions are needed. Perhaps there are predisposing factors, such as age, gender, body mass index, or even socioeconomic factors, that allow prediction of response to specific interventions; knowing such factors can lead to development of individually tailored management programs for patients with FM.
The Wang et al study gives providers exciting and encouraging news for patients with FM. Notably, there were few adverse effects in the study and none related specifically to tai chi. Telling patients that tai chi practice may help in management of FM symptoms, reduce their dependence or use of analgesics, and positively affect quality of life can give hope to those who feel current efforts and interventions are less than adequate. The ability to provide concrete information, recommending a tai chi dose of one hour of practice once weekly for 12 weeks with increased benefits after 24 weeks, may be reassuring and conducive to incorporating this ancient Chinese form of exercise into a 21st century multimodality treatment strategy aimed at control of FM.
Financial Disclosure: Integrative Medicine Alert’s Executive Editor David Kiefer, MD; Peer Reviewer Suhani Bora, MD; AHC Media Executive Editor Leslie Coplin; Editor Jonathan Springston; and Editorial Group Manager Terrey L. Hatcher report no financial relationships relevant to this field of study.