EXETER, England—Tai chi exercise is often recommended for patients with arthritis, including rheumatoid arthritis (RA), and is even officially supported by the Arthritis Foundation of Australia. A systematic review by Myeong Lee, PhD, and colleagues raises doubts about both the efficacy and the safety of this form of exercise for patients with RA.

"Collectively this evidence is not convincing enough to suggest that tai chi is an effective treatment for RA," Dr. Lee reported in Rheumatology.¹

Dr. Lee and colleagues from the complementary medicine department at Peninsula Medical School, Universities of Exeter and Plymouth in England evaluated data from controlled clinical trials testing the effectiveness of tai chi for treating RA. They exhaustively combed PubMed, EMBASE, other online databases, clinical trials registries, Korean medical databases, and Qigong files for controlled trials of tai chi for patients with RA.

Forty-five potential studies were identified, but only five met all inclusion criteria (two randomized clinical trials (RCTs), with 62 patients, and 3 nonrandomized controlled clinical trials (CCTs) with 155 patients). [Table 1] The researchers included trials comparing tai chi with any type of control intervention but excluded any trials with tai chi as part of a complex intervention.  The two RCTs reported "some positive findings for tai chi on disability index, quality of life, depression and mood for RA patients," Dr. Lee said. The effects on pain in the RCTs were uniformly insignificantly different from either education plus stretching or control subjects just going about their usual daily activities. "The methodological quality of the included RCTs was low," Dr. Lee said. "None of the included RCTs reported details on randomization, blinding, and allocation."

For specific outcomes

• One of the CCTs reported significant pain reduction with tai chi compared with a usual-activity control group
• One RCT assessed the effects of tai chi on fatigue and found no improvement versus usual activity
• One CCT suggested some effectiveness for fatigue
• Two CCTs assessed and found no effect of tai chi on range of motion, joint function, joint tenderness, and number of swollen joints
• One RCT reported significant improvement in depression with tai chi versus education and stretching exercise, and one RCT reported improvement of mood versus usual-activity controls
• One RCT reported favorable effects on the disability index with tai chi versus education and stretching
• One CCT found no effect on ability to perform activities of daily living
• One RCT found improvement in the vitality subscale of the SF36 Quality of Life Measurement compared with education plus stretching

"The evidence from RCTs assessing pain reduction is not favorable for tai chi. However, some positive findings exist for the effects of tai chi on disability index, quality of life, depression, and mood," Dr. Lee concluded.

Tai chi safety issue need more study

Although tai chi is usually thought of as a mild and risk-free form of exercise, the reviewers question this assumption. "One of the included trials reported several adverse events such as soreness in the knee, shoulder and lower back," Dr. Lee said. Although these effects may be trivial compared with serious adverse drug effects, "the safety of tai chi is an important issue and needs to be addressed in future studies," the authors conclude.

Till Uhlig, MD, PhD, who had also studied tai chi exercise in RA,² told CIAOMed, "The study by Lee and coworkers reminds us of the difficulty of demonstrating effects in exercise approaches in the treatment of rheumatic diseases, and in this case especially rheumatoid arthritis. Many of the tai chi studies reviewed were very small, and it is thus conceivable that only limited conclusions can be drawn from the studies performed." [Table 2]

Dr. Uhlig, rheumatologist and senior researcher at the national resource center for rehabilitation in rheumatology at Diakonhjemmet Hospital in Oslo, Norway, added, "We know that patients with rheumatoid arthritis highly cherish tai chi once they have been instructed in it. Practicing tai chi increases the independence of patients, as it can be performed independently from healthcare providers."

Dr. Uhlig agreed that more studies are needed and pointed out that this will require innovative research design. "Traditional health status measures are unlikely to be modified by tai chi, which is likely to also influence pychological aspects of health."

Paul Lam, MD, who designed the Tai Chi for Arthritis program endorsed by the Arthritis Foundation of Australia agreed that the Lee study is "a very good, multilinguistic study" that highlights the potential cost-effectiveness of tai chi and the lack of good tai chi studies in RA. Dr. Lam, a family physician and lecturer at the University of New South Wales said, "Clinicians should be aware that there are many forms of tai chi with very significant differences between them. Studies without clearly defined forms of tai chi would not necessarily show whether another form of tai chi would have been effective."

Dr. Lam warned that most traditional tai chi forms contain some high risk movements for people with RA. "Risk depends on the type of tai chi. Many have high risk, and traditional teachers don't necessarily understand how to adapt the forms for people with RA," he told CIAOMed. "That is why a specifically designed tai chi in collaboration with rheumatologists, physical therapists, family physicians, and tai chi professionals was designed for people with arthritis—together with training in how to teach it safely and effectively."

Table 1. Summary of Randomized Controlled Trials of Tai Chi for Treating RA

First author (year)	N ranomized/N analyzed	Intervention vs control	Outcomes	P
Wang (2005)	20/20	Tai chi 60 min, twice weekly, for 12 weeks vs Education on nutrition and RA and stretching, 20 min twice weekly for 12 weeks	Pain (VAS)	NS
			Disability Index	.01
			Quality of Life (Vitality)	.01
Lee (2005)	42/31	Tai chi 60 min, once weekly for 6 weeks vs Usual activity	Pain (VAS)	NS
			Mood (Profile of Mood State)	.02
			Fatigue	NS

Source: Adapted from Lee et al¹


Table 2. Nonrandomized Controlled Clinical Trials of Tai Chi for RA

First author (year)	N randomized/N analyzed	Intervention vs Control	Outcomes	P
Kirsteins (1991)	47/31	Tai chi 60 min, once weekly, 10 weeks vs Usual activity	Joint tenderness	NS
			Functional assessment	NS
			Swollen joint count	NS
			50-foot walk	NS
Kirsteins (1991)	28/22	Tai chi 60 min, twice weekly, 10 weeks vs Usual activity	Joint tenderness	NS
			Functional assessment	NS
			Swollen joint count	NS
			50-foot walk	.01
Lee (2006)	80/61	Tai chi 50 min, once weekly, 12 weeks vs Usual activity	Pain (VAS)	<.01
			Fatigue	.002

Source: Adapted from Lee et al.¹

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