Tai Chi for Fibromyalgia: Marshalling the Art of Movement Against Pain
Abstract & Commentary
By Nancy J. Selfridge, MD
Dr. Selfridge is Associate Professor, Department of Integrated Medical Education, Ross University School of Medicine, Commonwealth of Dominica, West Indies; she reports no financial relationship to this field of study.
Synopsis: Fibromyalgia patients were randomized to a treatment protocol consisting of 12 weeks of tai chi instruction and practice or a control intervention of wellness education and stretching exercises also of 12 weeks duration. The tai chi treatment group demonstrated clinically significant improvements in pain and quality of life compared to the control group and these improvements were maintained at 24-week follow up.
Source: Wang C, et al. A randomized trial of tai chi for fibromyalgia. N Engl J Med 2010;363:743-54.
The investigators in this nccam-funded study hypothesized that 12 weeks of tai chi training and practice would prove beneficial for fibromyalgia patients at reducing pain, improving sleep quality, and improving physical and psychological function compared to a control intervention of wellness education and stretching exercises. Sixty-six patients who met the 1990 ACR diagnostic criteria for fibromyalgia were randomized into a tai chi group (n = 33) or a control group (n = 33).1 Subjects who had participated in tai chi training or classes within the prior 6 months were excluded as were those with comorbidities known to contribute to fibromyalgia symptoms, e.g., inflammatory arthritides, vasculitides, myositis, or thyroid disease.
The tai chi intervention consisted of twice weekly 60-minute sessions for 12 weeks. A single teacher, a tai chi master, taught all classes at a single venue. Tai chi principles of movement, breathing, and relaxation were preceded by a warm-up and self-massage. For the intervention period, participants also were instructed to practice tai chi at home for at least 20 minutes each day. At the end of the 12-week period, participants were encouraged to continue their tai chi practice on their own using an instructional DVD.
The control intervention also consisted of twice weekly 60-minute sessions for the 12 weeks. Each session was composed of a 40-minute didactic presentation by a health professional on a topic related to fibromyalgia, e.g., optimal nutrition, pain management, sleep problems, exercise, and coping strategies. The final 20 minutes of each class was devoted to practicing supervised stretching. Control group participants were similarly encouraged to practice the stretching exercises at home for 20 minutes each day.
All participants were encouraged to continue their routine medications, activities, and medical care throughout the study period. Adherence to the programs was assessed by monitoring class attendance, providing make-up classes for missed sessions, and having participants complete daily logs documenting their home practice or stretching. To minimize the placebo effect of the tai chi intervention, participants in both groups were told that the purpose of the study was to compare two different exercise programs, one with an educational component and one without.
The primary outcome measure was a change in the Fibromyalgia Impact Questionnaire (FIQ) score from baseline to the end of the 12-week study period. Secondary outcome measures included a weekly FIQ score; global pain status using a visual analog scale (VAS) by the study participant and the study physician who was blinded to the group assignment; and a tender point count by the same physician. Participants' physical performance was measured using a 6-minute walk test (the number of yards walked in 6 minutes). Additional standardized instruments were used to assess sleep quality, depression, outcome expectations for exercise, and self efficacy. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) was used to measure physical and mental quality of life. Any changes in medication use were documented. All measures were repeated at a 24-week follow-up visit to test durability of response. Both groups had similar baseline characteristics and scores except for the Center for Epidemiologic Studies Depression (CES-D) index; the tai chi group had a lower mean score indicating less baseline dysphoria.
All data were subjected to intention-to-treat analyses. Participants who did not complete the follow-up period (tai chi group n = 3; control group n = 4) were considered not to have any changes in scores. Potential interactions between treatment and the covariates of age, sex, BMI, duration of symptoms, pain severity, coexisting illness, and medication use were tested.
Significantly more patients in the tai chi treatment group had clinically meaningful changes in their FIQ scores compared to the control patients: 79% vs. 39% (P = 0.001) at 12 weeks and 82% vs. 51% (P = 0.009) at 24 weeks. Tai chi participants also met standards for clinically meaningful improvement in VAS pain scores, sleep quality, depression, and SF-36 scores more often than controls. These treatment effects remained significant even after adjusting for the group baseline differences in scores for depression. Additionally, more patients in the tai chi group had discontinued medication at 12 weeks compared to the control group, though the difference was not statistically significant.
Studying complex mind-body interventions such as tai chi for equally complex pain conditions such as fibromyalgia is fraught with challenges. A main limitation of this study is that it was single-blinded, as no validated sham tai chi protocol currently exists. However, the investigators may have been successful at de-emphasizing the tai chi intervention (and a potential placebo effect) in the way that participants were informed of the purpose of the study. At least at baseline, both tai chi and control group scores for outcome expectations of benefit from an exercise intervention were similar.
One shortcoming of the study is that although no adverse events were reported, post-exercise delayed muscle soreness was considered an expected outcome and thus was not considered a reportable adverse event. Many fibromyalgia patients cite such soreness as a reason for not being able to exercise. Class attendance was 77% for the tai chi group and 70% for the control group. This level of non-adherence is not atypical for fibromyalgia patients engaged in exercise programs2 but it does beg the question as to whether fibromyalgia patients' post-exercise soreness is as problematic with tai chi as it is for other forms of exercise.
Since 51% of the patients in the control group showed clinically meaningful improvement in FIQ scores at 24 weeks it would be interesting, albeit difficult, to tease out which elements of tai chi created the added advantage. Though double-blind, larger, and longer-term studies are needed to determine the generalizability of this study's positive findings, there is no reason for a practicing clinician not to add tai chi to a growing non-pharmaceutical armamentarium against fibromyalgia pain and debilitation.
1. Wolfe F, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Arthritis Rheum 1990;33:160-172.
2. Busch AJ, et al. Exercise for fibromyalgia: a systematic review. J Rheumatol 2008;35:1130-44.