By Jeffrey H. Baker, MD, FAAFP, DABMA, DABIHM
Assistant Professor, Department of Family and Community Medicine, Penn State College of Medicine, State College, PA
Dr. Baker reports no financial relationships relevant to this field of study.
SUMMARY POINTS
- Tai chi practice is non-inferior to physical therapy to relieve pain of knee osteoarthritis.
- Tai chi practice is superior to physical therapy to increase physical function and help with mental well-being in people with knee osteoarthritis.
SYNOPSIS: Tai chi is as effective as a standard course of physical therapy in the treatment of pain of osteoarthritis of the knee.
SOURCE: Wang C, Schmid H, Iversen M, et al. Comparative effectiveness of Tai Chi versus physical therapy for knee osteoarthritis. Ann Intern Med 2016;165:77-86.
Osteoarthritis is a major health dysfunction for an aging population. In the National Health Interview Survey 2013-2015, doctor-diagnosed arthritis was reported to affect more than 20% of the working U.S. population, while more than half of the population ≥ 65 years of age suffered from this problem.1 The cost to the nation’s work force is significant; among adults with doctor-diagnosed arthritis in 2012, 12 million people experienced lost work days. This group reported an average of 14.3 work days lost in the previous 12 months, far higher than the 9.9 work days reported by adults with other medical conditions.2
Knee osteoarthritis remains the most common joint disorder in the United States, affecting 10% of men and 13% of women older than 60 years of age.3 With no curative medical treatment available, clinicians focus on controlling pain, minimizing joint damage, and maintaining function and quality of life.
Wang et al investigated the effectiveness of tai chi practice to reduce knee pain, comparing it to a standard treatment practice of physical therapy. This study was funded by the National Institutes of Health’s National Center for Complementary and Integrative Health and was designed as a single-blind, randomized, comparative effectiveness trial. The study included 204 participants who met the American College of Rheumatology criteria for symptomatic knee osteoarthritis, had significant pain scores on the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, and had radiographic evidence of patellofemoral or tibiofemoral osteoarthritis. (See Table 1.) None of the participants had participated in tai chi or physical therapy in the previous year nor had received intra-articular injections of hyaluronic acid or steroids in the previous six months. Participants also were excluded if they had other medical conditions, including dementia, recent stoke, or symptomatic heart or vascular disease that would preclude them from full participation in the study activity.
Table 1: Study Participant Characteristics |
||
Characteristic |
Tai chi
|
Physical therapy (n = 98) |
|
Mean age |
60.3 years |
60.1 years |
|
Male |
31 |
30 |
|
Female |
75 |
68 |
|
Race
|
|
|
|
Self-reported comorbidities
|
|
|
Participants were randomized to tai chi practice or physical therapy. The tai chi participants further were assigned randomly to one of three Yang-style tai chi instructors. The therapeutic activities ran concurrently, and participants were encouraged to maintain usual activities but to refrain from new exercises. All participants received educational materials regarding physical activity and home practice and were encouraged to spend at least 30 minutes on their specific interventional activity daily throughout the initial 12-week follow-up.
The physical therapy group participated in 30-minute, semiweekly sessions for six weeks, following Osteoarthritis Research Society International guidelines for knee osteoarthritis.4 Three trained physical therapists provided treatment, monitored by a supervised physical therapist to ensure consistency. Participants were instructed to continue home exercises for 30 minutes four times a week for another six weeks following their initial treatments.
The tai chi group attended 60-minute, semi-weekly sessions with one of three trained instructors for 12 weeks. The exercises were organized as a protocol based on previous literature,5,6 and included mind-body exercise theory and instruction. After 12 weeks of intervention, the participants were instructed to continue tai chi practice for the remainder of the year-long study period, aided by homework materials provided.
The primary outcome was to measure change in WOMAC pain subscale at the end of 12 weeks (guided therapy) to assess non-inferiority of tai chi therapy vs. traditional physical therapy, and secondary outcomes were to assess at 12, 24, and 52 weeks and to include WOMAC physical and stiffness function scores, Patient Global Assessment score, Beck Depression Inventory-II score, physical and mental components of the 36-item Short Form Health Survey (SF-36), Arthritis Self-Efficacy Scale, and results of the 6-minute walk test and 20-meter walk test.
Attendance rates were 78% for physical therapy and 79% for participation in at least half the sessions. Eighty-two percent of participants completed their evaluations at 12 weeks, while 69% completed their evaluations at 52 weeks. No serious adverse reactions were reported, as they were defined as fatal, life-threatening, permanently disabling, or severely incapacitating events. There were 34 dropouts from the tai chi and 29 dropouts from the physical therapy groups, all included in the analysis using the intention-to-treat principle.
At the 12-week assessment, both groups had improved WOMAC pain scores within their 95% confidence intervals; they did not differ significantly, thereby establishing non-inferiority of the tai chi program. Similar improvements were shown by both groups for most secondary outcomes at 12 weeks and all outcomes at 24 and 52 weeks. However, the tai chi group showed greater improvement than physical therapy in the Beck Depression Inventory-II and SF-36 physical component score at 52 weeks. (See Table 2.)
Table 2: Study Outcomes |
||
Variable (at week 52) |
Between-group Difference |
P Value |
|
WOMAC pain score |
-17.8 (-58.1 to 22.4) |
0.22 |
|
WOMAC physical function score |
-88.3 (-223.4 to 46.7) |
0.160 |
|
WOMAC stiffness score |
-1.4 (-19.3 to16.6) |
0.74 |
|
Beck Depression Inventory-II |
-1.1 (-.34 to 1.2) |
0.049 |
|
SF-36 score physical component |
2.0 (-0.8 to 4.8) |
0.034 |
|
SF-36 mental component |
1.4 (-1.3 to 4.1) |
0.59 |
COMMENTARY
Based on ancient Taoist practices, Tai Chi Chuan (often abbreviated tai chi) is a form of meditative movement, often practiced in slow, flowing, dance-like moves involving the mind, body, and breath. It is believed to balance the internal and external energies of the body and mind for healing, stress reduction, and mental tranquility. Yang-style is the most modern and popular of the four schools (Chen, Hao, Wu, and Yang) of Tai Chi Chuan practice.
After their previous study found that tai chi was superior to an attention control of wellness education and stretching,8 Wang et al took the bold step to compare this therapeutic practice to a known accepted therapy to establish its usefulness. The current study included 204 people with osteoarthritis, a reasonable sample size to address the study hypothesis. In a 2013 systemic review, Lauche et al previously concluded that more RCTs were needed to confirm the likely effectiveness of tai chi for osteoarthritis pain relief;9 Wang et al have accomplished this.
An inherent limitation of the study is in its single-blind design, but Wang et al stated this up front in their discussion, noting that “for a study involving complex, multicomponent mind-body therapy, searching and finding a feasible, useful, and valid sham comparison group remains challenging, with no accepted solution.”7 Prior to randomization, the participants were told that they would participate in one of two exercise programs without mentioning either one specifically. Once assigned, their preconceived notions of treatment benefit may have affected their willingness to continue with tai chi practice and the outcome of the study. Similarly, this study was conducted in an academic setting, not the community, perhaps influencing the outcome.
Wang et al also demonstrated that tai chi improved some measures of physical functionality and perceived mental health in superior fashion to traditional physical therapy. They included participants with older age, obesity, and comorbidities in both groups to negate the criticism that the exclusion criteria might not make this study “real world.” The tai chi arm emphasized regular home practice and included education on meditation practice as a part of its inherent mind-body therapy. That likely led to the difference of the Beck Depression Inventory-II and SF-36 scores.
The treatment of osteoarthritis is arguably a long-term tolerance rather than a short-term fix. This study has brought more credence to the evidence of lifestyle medicine as a modality for assisting patients in their daily living as well as dysfunction. A recent study of the effects of an eight-week meditation program to aid the pain and functioning of knee arthritis also showed promise.10
It is unfortunate that insurance reimbursement remains nonexistent or minimal for lifestyle interventions and complementary techniques. Tai chi practice recommendations for patients coping with arthritic knees can help their functional well-being. It is reasonable to expect that tai chi practice will help with arthritis pain elsewhere in the body; further research will clarify that.
Of note, the National Center for Complementary and Integrative Health has announced a new series of funding opportunities that will involve mind-body interventions, paving the way for more knowledge in this field in the future.11
REFERENCES
- Barbour KE, Helmick CG, Boring M, Brady TJ. Vital Signs: Prevalence of Doctor-Diagnoses Arthritis and Arthritis-Attributable Activity Limitation – United States 2013-2015. MMWR Morb Mortal Wkly Rep 2017;66:246-253.
- United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), Third Edition, 2014. Rosemont, IL. Available at: http://www.boneandjointburden.org. Accessed March 19, 2017.
- Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatric Med 2010;26:355-369.
- McAlindon TE, Basnnuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014;22:363-388.
- Wang C, Collet JP, Lau J. The effect of Tai Chi on health outcomes in patients with chronic conditions: A systematic review. Arch Intern Med 2004;164;493-501.
- Hartman CA, Manos TM, Winter C. Effects of T’ai Chi training on function and quality of life indicators in older adults with osteoarthritis. J Am Geriatr Soc 2000;48:1553-1559.
- Wang C, Goldenberg D, McAlindon T. Correspondence: A randomized trial of tai chi for fibromyalgia. N Engl J Med 2010;363:2266-2267.
- Wang C, Schmid CH, Hibberd PL, et al. Tai Chi is effective in treating knee osteoarthritis: A randomized controlled trial. Arthritis Rheumatism 2009;61;11:1545-1553.
- Lauche R, Langhorst J, Dobos, G. A systematic review and meta-analysis of Tai Chi for osteoarthritis of the knee. Complement Ther Med 2013;21:396-406.
- Selfe KT, Innes KE. Effects of meditation on symptoms of knee osteoarthritis. Altern Complement Ther 2013;19:139-146.
- Briggs JP. NCCIH’s New Approach to Clinical Trials. NCCIH Research Blog Available at: https://nccih.nih.gov/research/blog/clinical-trial-FOAs. Accessed April 10, 2017.
- Lauche R, et al. A systematic review and meta-analysis of Tai Chi for osteoarthritis of the knee. Complement Ther Med 2013;21:396-406.
- Selfe KT, Innes KE. Effects of meditation on symptoms of knee osteoarthritis. Altern Complement Ther 2013;19:139-146.
- Briggs JP. NCCIH’s New Approach to Clinical Trials. NCCIH Research Blog Available at: https://nccih.nih.gov/research/blog/clinical-trial-FOAs. Accessed April 10, 2017.
Tai chi is as effective as a standard course of physical therapy in the treatment of pain of osteoarthritis of the knee.
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