Chenchen Wang

A Randomized Trial of Tai Chi for Fibromyalgia

BACKGROUNDnPrevious research has suggested that tai chi offers a therapeutic benefit in patients with fibromyalgia.nnnMETHODSnWe conducted a single-blind, randomized trial of classic Yang-style tai chi as compared with a control intervention consisting of wellness education and stretching for the treatment of fibromyalgia (defined by American College of Rheumatology 1990 criteria). Sessions lasted 60 minutes each and took place twice a week for 12 weeks for each of the study groups. The primary end point was a change in the Fibromyalgia Impact Questionnaire (FIQ) score (ranging from 0 to 100, with higher scores indicating more severe symptoms) at the end of 12 weeks. Secondary end points included summary scores on the physical and mental components of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). All assessments were repeated at 24 weeks to test the durability of the response.nnnRESULTSnOf the 66 randomly assigned patients, the 33 in the tai chi group had clinically important improvements in the FIQ total score and quality of life. Mean (+/-SD) baseline and 12-week FIQ scores for the tai chi group were 62.9+/-15.5 and 35.1+/-18.8, respectively, versus 68.0+/-11 and 58.6+/-17.6, respectively, for the control group (change from baseline in the tai chi group vs. change from baseline in the control group, -18.4 points; P<0.001). The corresponding SF-36 physical-component scores were 28.5+/-8.4 and 37.0+/-10.5 for the tai chi group versus 28.0+/-7.8 and 29.4+/-7.4 for the control group (between-group difference, 7.1 points; P=0.001), and the mental-component scores were 42.6+/-12.2 and 50.3+/-10.2 for the tai chi group versus 37.8+/-10.5 and 39.4+/-11.9 for the control group (between-group difference, 6.1 points; P=0.03). Improvements were maintained at 24 weeks (between-group difference in the FIQ score, -18.3 points; P<0.001). No adverse events were observed.nnnCONCLUSIONSnTai chi may be a useful treatment for fibromyalgia and merits long-term study in larger study populations. (Funded by the National Center for Complementary and Alternative Medicine and others; ClinicalTrials.gov number, NCT00515008.)

Tai Chi on psychological well-being: systematic review and meta-analysis

BackgroundPhysical activity and exercise appear to improve psychological health. However, the quantitative effects of Tai Chi on psychological well-being have rarely been examined. We systematically reviewed the effects of Tai Chi on stress, anxiety, depression and mood disturbance in eastern and western populations.MethodsEight English and 3 Chinese databases were searched through March 2009. Randomized controlled trials, non-randomized controlled studies and observational studies reporting at least 1 psychological health outcome were examined. Data were extracted and verified by 2 reviewers. The randomized trials in each subcategory of health outcomes were meta-analyzed using a random-effects model. The quality of each study was assessed.ResultsForty studies totaling 3817 subjects were identified. Approximately 29 psychological measurements were assessed. Twenty-one of 33 randomized and nonrandomized trials reported that 1 hour to 1 year of regular Tai Chi significantly increased psychological well-being including reduction of stress (effect size [ES], 0.66; 95% confidence interval [CI], 0.23 to 1.09), anxiety (ES, 0.66; 95% CI, 0.29 to 1.03), and depression (ES, 0.56; 95% CI, 0.31 to 0.80), and enhanced mood (ES, 0.45; 95% CI, 0.20 to 0.69) in community-dwelling healthy participants and in patients with chronic conditions. Seven observational studies with relatively large sample sizes reinforced the beneficial association between Tai Chi practice and psychological health.ConclusionsTai Chi appears to be associated with improvements in psychological well-being including reduced stress, anxiety, depression and mood disturbance, and increased self-esteem. Definitive conclusions were limited due to variation in designs, comparisons, heterogeneous outcomes and inadequate controls. High-quality, well-controlled, longer randomized trials are needed to better inform clinical decisions.

Tai Chi is Effective in Treating Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVEnTo evaluate the effectiveness of Tai Chi in the treatment of knee osteoarthritis (OA) symptoms.nnnMETHODSnWe conducted a prospective, single-blind, randomized controlled trial of 40 individuals with symptomatic tibiofemoral OA. Patients were randomly assigned to 60 minutes of Tai Chi (10 modified forms from classic Yang style) or attention control (wellness education and stretching) twice weekly for 12 weeks. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at 12 weeks. Secondary outcomes included WOMAC function, patient and physician global assessments, timed chair stand, depression index, self-efficacy scale, and quality of life. We repeated these assessments at 24 and 48 weeks. Analyses were compared by intent-to-treat principles.nnnRESULTSnThe 40 patients had a mean age of 65 years and a mean body mass index of 30.0 kg/m(2). Compared with the controls, patients assigned to Tai Chi exhibited significantly greater improvement in WOMAC pain (mean difference at 12 weeks -118.80 mm [95% confidence interval (95% CI) -183.66, -53.94; P = 0.0005]), WOMAC physical function (-324.60 mm [95% CI -513.98, -135.22; P = 0.001]), patient global visual analog scale (VAS; -2.15 cm [95% CI -3.82, -0.49; P = 0.01]), physician global VAS (-1.71 cm [95% CI -2.75, -0.66; P = 0.002]), chair stand time (-10.88 seconds [95% CI -15.91, -5.84; P = 0.00005]), Center for Epidemiologic Studies Depression Scale (-6.70 [95% CI -11.63, -1.77; P = 0.009]), self-efficacy score (0.71 [95% CI 0.03, 1.39; P = 0.04]), and Short Form 36 physical component summary (7.43 [95% CI 2.50, 12.36; P = 0.004]). No severe adverse events were observed.nnnCONCLUSIONnTai Chi reduces pain and improves physical function, self-efficacy, depression, and health-related quality of life for knee OA.

Tai Chi improves pain and functional status in adults with rheumatoid arthritis: results of a pilot single-blinded randomized controlled trial.

BACKGROUND/AIMSnRheumatoid arthritis (RA) is a serious health problem resulting in significant morbidity and disability. Tai Chi may be beneficial to patients with RA as a result of effects on muscle strength and mind-body interactions. To obtain preliminary data on the effects of Tai Chi on RA, we conducted a pilot randomized controlled trial. Twenty patients with functional class I or II RA were randomly assigned to Tai Chi or attention control in twice-weekly sessions for 12 weeks. The American College of Rheumatology (ACR) 20 response criterion, functional capacity, health-related quality of life and the depression index were assessed.nnnRESULTSnAt 12 weeks, 5/10 patients (50%) randomized to Tai Chi achieved an ACR 20% response compared with 0/10 (0%) in the control (p = 0.03). Tai Chi had greater improvement in the disability index (p = 0.01), vitality subscale of the Medical Outcome Study Short Form 36 (p = 0.01) and the depression index (p = 0.003). Similar trends to improvement were also observed for disease activity, functional capacity and health-related quality of life. No adverse events were observed and no patients withdrew from the study.nnnCONCLUSIONnTai Chi appears safe and may be beneficial for functional class I or II RA. These promising results warrant further investigation into the potential complementary role of Tai Chi for treatment of RA.

Acupuncture for pain relief in patients with rheumatoid arthritis: a systematic review

OBJECTIVEnTo systematically review the efficacy of acupuncture on pain relief in patients with rheumatoid arthritis (RA).nnnMETHODSnWe performed a comprehensive search of 12 western and Chinese databases and reference lists through March 2008. We included randomized controlled trials with pain as an end point, measured by tender joint count (TJC) or a pain scale. We also reviewed the effect of acupuncture on morning stiffness, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level. Study quality was assessed by Jadad score. Differences between treatment groups were pooled as mean or median change (P value).nnnRESULTSnEight studies met eligibility criteria with a total of 536 subjects. There were 4 placebo-controlled trials and 4 active-controlled trials. Average study duration was 11 weeks. Mean +/- SD acupuncture points and sessions were 11 +/- 8 and 42 +/- 62, respectively. Average duration of needle insertion was 24 minutes. Six studies reported a decrease in pain for acupuncture versus controls; the mean or median changes of acupuncture-decreased TJC pain ranged from 1.5 to 6.5. In addition, 4 studies reported a significant reduction in morning stiffness (mean change -29 minutes), but the difference was nonsignificant versus controls. With regard to inflammatory markers, 5 studies observed a reduction in ESR (mean change -3.9 mm/hour) and 3 observed a CRP level reduction (mean change -2.9 mg/dl); only 1 study showed a significant difference for both ESR and CRP.nnnCONCLUSIONnDespite some favorable results in active-controlled trials, conflicting evidence exists in placebo-controlled trials concerning the efficacy of acupuncture for RA. Rigorous and well-controlled randomized trials are warranted.

The effects of mind-body therapies on the immune system: meta-analysis.

Importance Psychological and health-restorative benefits of mind-body therapies have been investigated, but their impact on the immune system remain less defined. Objective To conduct the first comprehensive review of available controlled trial evidence to evaluate the effects of mind-body therapies on the immune system, focusing on markers of inflammation and anti-viral related immune responses. Methods Data sources included MEDLINE, CINAHL, SPORTDiscus, and PsycINFO through September 1, 2013. Randomized controlled trials published in English evaluating at least four weeks of Tai Chi, Qi Gong, meditation, or Yoga that reported immune outcome measures were selected. Studies were synthesized separately by inflammatory (nu200a=u200a18), anti-viral related immunity (nu200a=u200a7), and enumerative (nu200a=u200a14) outcomes measures. We performed random-effects meta-analyses using standardized mean difference when appropriate. Results Thirty-four studies published in 39 articles (total 2, 219 participants) met inclusion criteria. For inflammatory measures, after 7 to 16 weeks of mind-body intervention, there was a moderate effect on reduction of C-reactive protein (effect size [ES], 0.58; 95% confidence interval [CI], 0.04 to 1.12), a small but not statistically significant reduction of interleukin-6 (ES, 0.35; 95% CI, −0.04 to 0.75), and negligible effect on tumor necrosis factor-α (ES, 0.21; 95% CI, −0.15 to 0.58). For anti-viral related immune and enumerative measures, there were negligible effects on CD4 counts (ES, 0.15; 95% CI, −0.04 to 0.34) and natural killer cell counts (ES, 0.12, 95% CI −0.21 to 0.45). Some evidence indicated mind-body therapies increase immune responses to vaccination. Conclusions Mind-body therapies reduce markers of inflammation and influence virus-specific immune responses to vaccination despite minimal evidence suggesting effects on resting anti-viral or enumerative measures. These immunomodulatory effects, albeit incomplete, warrant further methodologically rigorous studies to determine the clinical implications of these findings for inflammatory and infectious disease outcomes.

Tai Chi and Rheumatic Diseases

Tai chi is a complex multicomponent mind-body exercise. Many studies have provided evidence that tai chi benefits patients with a variety of chronic disorders. This form of mind-body exercise enhances cardiovascular fitness, muscular strength, balance, and physical function and seems to be associated with reduced stress, anxiety, and depression and improved quality of life. Thus, despite certain limitations in the evidence, tai chi can be recommended to patients with osteoarthritis, rheumatoid arthritis, and fibromyalgia as a complementary and alternative medical approach. This article overviews the current knowledge about tai chi to better inform clinical decision making for rheumatic patients.

Tai Chi for treating knee osteoarthritis: Designing a long-term follow up randomized controlled trial

BackgroundKnee Osteoarthritis (KOA) is a major cause of pain and functional impairment among elders. Currently, there are neither feasible preventive intervention strategies nor effective medical remedies for the management of KOA. Tai Chi, an ancient Chinese mind-body exercise that is reported to enhance muscle function, balance and flexibility, and to reduce pain, depression and anxiety, may safely and effectively be used to treat KOA. However, current evidence is inconclusive. Our study examines the effects of a 12-week Tai Chi program compared with an attention control (wellness education and stretching) on pain, functional capacity, psychosocial variables, joint proprioception and health status in elderly people with KOA. The study will be completed by July 2009.Methods/DesignForty eligible patients, age > 55 yr, BMI ≤ 40 kg/m2 with tibiofemoral osteoarthritis (American College of Rheumatology criteria) are identified and randomly allocated to either Tai Chi (10 modified forms from classical Yang style Tai Chi) or attention control (wellness education and stretching). The 60-minute intervention sessions take place twice weekly for 12 weeks. The study is conducted at an urban tertiary medical center in Boston, Massachusetts. The primary outcome measure is the Western Ontario and McMaster Universities (WOMAC) pain subscale at 12 weeks. Secondary outcomes include weekly WOMAC pain, function and stiffness scores, patient and physician global assessments, lower-extremity function, knee proprioception, depression, self-efficacy, social support, health-related quality of life, adherence and occurrence of adverse events after 12, 24 and 48 weeks.DiscussionIn this article, we present the challenges of designing a randomized controlled trial with long-term follow up. The challenges encountered in this design are: strategies for recruitment, avoidance of selection bias, the actual practice of Tai Chi, and the maximization of adherence/follow-up while conducting the clinical trial for the evaluation of the effectiveness of Tai Chi on KOA.Trial registrationClinicalTrials.gov identifier: NCT00362453

Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial

Knee osteoarthritis is a major age-related public health problem and a leading cause of long-term pain and disability (1, 2). No effective medical treatments for the disease currently exist. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used to treat osteoarthritis but often fail to relieve symptoms and may cause serious adverse effects (3). Physical therapy, a globally recommended element of the standard care regimen for knee osteoarthritis, produces moderate benefits for pain and physical functioning, but data on psychological well-being and durability effects are limited (4, 5). Identifying new and effective treatments for patients with knee osteoarthritis is an urgent clinical and public health priority. Tai Chi is a multicomponent traditional Chinese mindbody practice that combines meditation with slow, gentle, graceful movements; deep diaphragmatic breathing; and relaxation (6). Previous studies have indicated that Tai Chi can reduce pain and improve physical and psychological health among patients with chronic rheumatic disorders, such as rheumatoid arthritis and fibromyalgia (713). In our previous randomized trial, participants with knee osteoarthritis who completed 12 weeks of Tai Chi showed greater improvements in pain, physical function, depression, and health status compared with an attention control group (12). A 2013 updated meta-analysis of 7 studies that included 348 participants with osteoarthritis showed significant reductions in pain and improvements in physical function after 8 to 24 weeks of Tai Chi training compared with a waiting list, attention control, or usual physical activity (14). Those prior trials suggested that Tai Chi could provide a practical exercise regimen with an integrative mindbody approach to manage knee osteoarthritis. The physical component provides exercise benefits that are consistent with recommendations for knee osteoarthritis (physical function, balance, and muscle strength) (15), and the mind component promotes psychological well-being, life satisfaction, and improved perceptions of health (9, 16). To date, however, no randomized trials have directly compared Tai Chi and standard care treatments. The primary goal of this study was to compare the effectiveness of Tai Chi versus a physical therapy regimen among a large sample of patients with symptomatic and radiographic knee osteoarthritis who were seen in the clinical setting and followed for 12 months. Supplement. Study Protocol Methods Design Overview This 52-week, single-blind, randomized, comparative effectiveness trial recruited participants with symptomatic and radiographic knee osteoarthritis. Patients were randomly assigned to either Tai Chi (2 times per week for 12 weeks) or physical therapy in a clinical setting (2 times per week for 6 weeks, followed by 6 weeks of rigorously monitored home exercise). Details of the trial design and conduct have been published (17) and registered at ClinicalTrials.gov (NCT01258985). The study was approved by the Tufts Health Sciences Institutional Review Board and overseen by an independent data and safety monitoring board. Setting and Participants The trial was conducted at Tufts Medical Center in Boston, Massachusetts, between October 2010 and September 2014. Participants were recruited through multimodal strategies, including print advertisements, online media, a booth at a senior exposition, and a clinical patient database. We obtained informed consent before baseline assessments for eligibility. We enrolled persons aged 40 years or older who met American College of Rheumatology criteria for symptomatic knee osteoarthritis and had radiographic evidence of tibiofemoral or patellofemoral osteoarthritis (defined as the presence of a definite osteophyte in the tibiofemoral compartment and/or the patellofemoral compartment, as assessed on standing anteriorposterior and lateral or sunrise views) (18). All participants were required to have a score of 40 or greater on at least 1 of the 5 questions in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale (range of 0 to 100, with higher scores indicating greater pain) at baseline. A study rheumatologist (W.H.) confirmed eligibility of applicants. We excluded persons who had participated in Tai Chi or physical therapy in the past year; those with current serious medical conditions, such as dementia, symptomatic heart or vascular disease, or recent stroke, that would limit full participation; those with intra-articular steroid or intra-articular hyaluronic acid injections in the past 3 or 6 months or reconstructive surgery before baseline screening on the most severely affected knee; and those with a score less than 24 on the Mini-Mental State Examination (19). Participants who satisfied eligibility criteria were offered enrollment. Randomization Participants were randomly assigned in a 1:1 ratio to Tai Chi or physical therapy after the baseline evaluation. Randomization was done in 9 consecutive cycles, comprising about 20 participants each. Within each block of patients randomly assigned in each cycle, those assigned to Tai Chi were further randomly assigned to 1 of 3 instructors so that each instructor treated 1 group every 3 blocks. This design allowed for assessment of instructor-level effects. Pseudorandom numbers were generated in advance by the statistician (C.S.) using the R statistical package (20). Assignments were concealed in sealed, opaque envelopes with date and signature labels. The study coordinator opened the consecutive envelopes individually after obtaining consent and confirming eligibility. Research study nurses, physical function assessors, and sponsor personnel were blinded to the treatment assignments during enrollment. The blinded assessors did not have access to the data until data collection was complete. Interventions Tai Chi and physical therapy ran concurrently to minimize seasonal influences on disease activity. We encouraged participants to maintain routine activities but refrain from new exercises outside the study. Both groups received educational information about the importance of physical activity and home practice. We tracked reasons for missed sessions and asked participants to complete daily logs indicating duration of practice. Participants were encouraged to integrate at least 30 minutes of Tai Chi or physical therapy into their daily routine throughout follow-up. Attendance was monitored during each in-person session by using attendance forms and sign-in sheets. Study staff made monthly calls to monitor adherence throughout the 1-year follow-up. Tai Chi The 60-minute Tai Chi sessions occurred twice per week for 12 weeks. We recruited 3 experienced Tai Chi instructors from the greater Boston area. We developed a standardized classical Yang style Tai Chi protocol for knee osteoarthritis that was based on the literature (13). Before study initiation, the principal investigator (C.W.) and the Tai Chi master (R.R., who was also 1 of the 3 instructors) reviewed the concepts of knee osteoarthritis and trained the other instructors (17, 21). In the first session, participants received printed materials on Tai Chi principles, practice techniques, and safety precautions. The instructor explained mindbody exercise theory and procedures. Subsequent sessions started with a warm-up and a review of Tai Chi principles and movement, breathing techniques, and relaxation methods. Participants were instructed to practice Tai Chi at home for at least 20 minutes per day. The principal investigator monitored all sessions by regularly reviewing video recordings and providing feedback throughout the study. After completing the 12-week intervention (24 sessions), participants were instructed to continue Tai Chi practice for 52 weeks with the aid of provided homework materials. Physical Therapy The physical therapy protocol followed U.S. guidelines for knee osteoarthritis treatment (15) and consisted of two 30-minute outpatient sessions per week for 6 weeks. Before enrollment, the supervising physical therapist (M.I.) trained the 3 physical therapists. She observed evaluations and interventions during each treatment cycle to ensure consistency in documentation and provided feedback for program progression (17). Depending on the diagnostic findings in the initial musculoskeletal examination, the therapist targeted physical therapy regimens to address specific treatment goals developed collaboratively with the participant. At each session, the physical therapist examined the participant for adverse signs and symptoms before proceeding with manual therapy or exercise. Patients were encouraged to also perform exercises at home. After 6 weeks, participants were instructed to continue exercises in 30-minute sessions 4 times per week for 6 weeks. These were monitored weekly by telephone by using standardized forms to ascertain frequency, exercises completed, adverse events, and adherence. Outcomes and Follow-up Knee osteoarthritis outcomes, which were measured at baseline and 12, 24, and 52 weeks, were drawn from the core set recommended by the Osteoarthritis Research Society International (OARSI) and focused on pain, physical function, and patients overall assessment of their disease severity (22). Primary Outcome The primary outcome was the change in WOMAC pain subscale score between baseline and 12 weeks. The WOMAC is a validated, self-administered visual analogue scale designed specifically to evaluate osteoarthritis symptoms (23). Secondary Outcomes Secondary outcomes were measured at baseline and 12, 24, and 52 weeks and included WOMAC physical function and stiffness scores, Patient Global Assessment score, Beck Depression Inventory-II score (24), scores on the physical and mental components of the 36-item Short Form Health Survey (SF-36) (25), Arthritis Self-Efficacy Scale score (26), and results of the 6-minute walk test (27) and the 20-mete

Assessing the comparative effectiveness of Tai Chi versus physical therapy for knee osteoarthritis: design and rationale for a randomized trial

BackgroundKnee osteoarthritis (OA) causes pain and long-term disability with annual healthcare costs exceeding