Skip Navigation


Rheumatology Advance Access originally published online on July 18, 2007
Rheumatology 2007 46(11):1648-1651; doi:10.1093/rheumatology/kem151
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
46/11/1648    most recent
kem151v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (3)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Lee, M. S.
Right arrow Articles by Ernst, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Lee, M. S.
Right arrow Articles by Ernst, E.
Related Collections
Right arrow Rheumatoid Arthritis
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The Author 2007. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

REVIEWS

Tai chi for rheumatoid arthritis: systematic review

M. S. Lee, M. H. Pittler and E. Ernst

Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK

Correspondence to: Myeong Soo Lee, PhD Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter, EX2 4NT, UK. E-mail: myeong.lee{at}pms.ac.uk; drmslee{at}gmail.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
The objective of this systematic review is to evaluate data from controlled clinical trials testing the effectiveness of tai chi for treating rheumatoid arthritis (RA). Systematic searches were conducted on Medline, Pubmed, AMED, British Nursing Index, CINAHL, EMBASE, PsycInfo, The Cochrane Library 2007, Issue 1, the UK National Research Register and ClinicalTrials.gov, Korean medical databases, Qigong and Energy Medicine Database and Chinese databases up to January 2007. Hand-searches included conference proceedings and our own files. There were no restrictions regarding the language of publication. All controlled trials of tai chi for patients with RA were considered for inclusion. Methodological quality was assessed using the Jadad score. The searches identified 45 potentially relevant studies. Two randomized clinical trials (RCTs) and three non-randomized controlled clinical trials (CCTs) met all inclusion criteria. The included RCTs reported some positive findings for tai chi on disability index, quality of life, depression and mood for RA patients. Two RCTs assessed pain outcomes and did not demonstrate effectiveness on pain reduction compared with education plus stretching exercise and usual activity control. The extent of heterogeneity in these RCTs prevented a meaningful meta-analysis. Currently there are few trials testing the effectiveness of tai chi in the management of RA. The studies that are available are of low methodological quality. Collectively this evidence is not convincing enough to suggest that tai chi is an effective treatment for RA. The value of tai chi for this indication therefore remains unproven.

KEY WORDS: Tai chi, Rheumatoid arthritis, Pain


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Rheumatoid arthritis (RA) has an estimated 1 year prevalence of 0.3% to 1% worldwide [1]. It affects more than 2.9 million Europeans [2] and 2.1 million adults in the USA [3]. Successful treatment of RA requires early diagnosis and timely initiation of disease-modifying agents for limiting joint damage and functional loss [4]. Despite early detection, current treatment medications are limited in their efficacy and are frequently toxic [4]. RA patients therefore often turn towards complementary therapies, including tai chi [5–7].

Tai chi is officially supported by the Arthritis Foundation of Australia [8]. Unlike physiotherapeutic exercise, tai chi combines deep breathing and relaxation with slow and gentle movements [9]. The relaxation and deep breathing components of tai chi may exert effects that differ from those of physiotherapeutic exercise. It is claimed that tai chi is beneficial for cardio-respiratory function, balance control, flexibility and aerobic capacity, and that it improves muscular strength and reduces the risk of falls in the elderly [9].

A Cochrane review included four trials [two randomized clinical trials (RCTs) and two controlled clinical trials (CCTs)] on the effects of tai chi on RA [10]. The review suggested that tai chi does not exacerbate symptoms of RA and has some benefits on range of motion (ROM). However, that review missed several trials and contains other flaws such as inclusion of mixed intervention groups in which some patients received tai chi while others did not [11] and dance programmes incorporating only some principles of tai chi [12]. Also, recent clinical trials reported contradictory results of tai chi for treating RA [13, 14]. Hence, the aim of this systematic review is to update and critically evaluate the clinical trial evidence for the effectiveness of tai chi for patients with RA.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Data sources
Electronic databases were searched from their respective inceptions through January 2007 using the following databases: Medline, Pubmed, AMED, British Nursing Index, CINAHL, EMBASE, PsycInfo, UK National Research Register and the ClinicalTrials.gov of the US National Institute of Health, the Cochrane Library 2007, Issue 1, Korean medical databases (Korean Studies Information, DBPIA, Korea Institute of Science, Technology Information, Research Information Center for Health Database, Korean Medline and National Assembly Library), Qigong and Energy Medicine Database (Qigong Institute, Melon Park, version 7.3) and Chinese databases (China Academic Journal, Century Journal Project, China Doctor/Master Dissertation Full text DB, China Proceedings Conference Full text DB). The search terms used were taichi or tai adj chi or tai chi chun or Korean or Chinese language terms for tai chi and RA, arthritis, reactive arthritis, adjuvant arthritis, infective arthritis, gouty arthritis, juvenile RA, psoriatic arthritis and periarthritis. In addition, our own files and relevant journals (FACT—Focus on Alternative and Complementary Therapies, from 1996 to 2007) were manually searched. Several tai chi associations (n = 10) and experts (n = 4) were contacted and asked to contribute any unpublished trials. In addition, the references of all located articles and the proceedings of the 1st International Conference of Tai Chi for Health (December 2006, Seoul, South Korea) were hand-searched for further relevant articles.

Study selection
Prospective controlled clinical trials of tai chi for treating RA were included. Trials comparing tai chi with any type of control intervention were included. Any trials with tai chi as a part of a complex intervention were excluded. No language restrictions were imposed. Dissertations and abstracts were also included. Hardcopies of all articles were obtained and read in full.

Data extraction and quality assessment
All articles were read by two independent reviewers (M.S.L., M.H.P.) and data from the articles were extracted according to pre-defined criteria. The Jadad score [15] was calculated by assessing three criteria: description of randomization, blinding and withdrawals; the score ranges from a minimum of 0 to a maximum of 5 points. Taking into account that patients and therapist are impossible to blind to tai chi, one point was given for blinding if the outcome assessor was blinded. Discrepancies were resolved by discussion between the two reviewers (M.S.L., M.H.P.) and if needed, by seeking the opinion of the third reviewer (E.E.). The heterogeneity of studies prevented a meta-analysis.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
The literature search identified 45 articles. We contacted 10 tai chi associations and four tai chi experts. No additional published or unpublished trials were identified through these contacts. Forty studies were excluded (Fig. 1). Among these, two RCTs were excluded [12, 16] because it was not possible to extract data for tai chi alone. Five trials, two RCTs and three CCTs (Table 1) met the inclusion criteria and were reviewed. Two ongoing RCTs funded by NCCAM were located from ClinicalTrials.gov (at http://clinicaltrials.gov). One trial is a two-armed single-blind RCT over a 12-week treatment period that assesses the effectiveness of tai chi compared with relaxation on RA-related disability and health functioning in RA patients at the University of California, LA Medical Center, USA. Another ongoing RCT conducted at the University of California, LA, USA is investigating the effectiveness of tai chi compared with cognitive-behavioural therapy and health education on disease activity, health functioning, inflammation and other immunological variables.


Figure 1
View larger version (12K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		FIG. 1. Flowchart of trial selection process.

 

View this table:
[in this window]
[in a new window]

  		TABLE 1. Summary of controlled clinical studies of tai chi for treating rheumatoid arthritis

 
Study quality
The methodological quality of the included RCTs was low. None of the included RCTs reported details on randomization, blinding and allocation. Sufficient details of drop-outs and withdrawals were described in four of the included studies [14, 17, 19].

Outcomes
Pain
Two RCTs tested tai chi for pain in RA [14, 17]. Both suggested no significant pain reduction compared with education plus stretching exercise [14] and usual activity [17]. The heterogeneity of studies prevented a meta-analysis. One CCT, however, suggested significant pain reduction compared with usual activity control group [18].

Fatigue
One RCT assessed the effects of tai chi on fatigue [17] and showed no improvement compared with usual activity. One CCT compared tai chi with usual activity and suggested effectiveness of tai chi for fatigue [18].

Range of motion and joint functions
Two CCTs, reported in one article, tested tai chi for joint tenderness and the number of swollen joints [19]. Both trials failed to show intergroup differences for joint tenderness and the number of swollen joints compared with usual activity.

Depression and mood
One RCT tested tai chi for depression and reported significant intergroup differences compared with education plus stretching exercise [14]. Another RCT compared tai chi with usual activity and suggested improvement of mood on the Profile of Mood State inventory [17].

Functional index
One RCT compared tai chi with education plus stretching exercise and reported data favourable to tai chi on the disability index [14]. One CCT reported no improvement for the ability of daily life performance [18].

Quality of life
One RCT tested the effectiveness of tai chi on quality of life and reported intergroup differences for vitality subscale of SF36 compared with education plus stretching exercise [14].


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Only few controlled trials have tested tai chi for RA. The evidence from RCTs assessing pain reduction is not favourable for tai chi. However, some positive findings exist for the effects of tai chi on disability index, quality of life, depression and mood. One of the included trials reported several adverse events such as soreness in the knee, shoulder and lower back [19]. Overall our findings provide no convincing evidence that tai chi is beneficial for treating patients with RA.

Among the five studies we included, only two were randomized [14, 17]. Non-randomized trials are open to selection bias and likely to generate false positive results [18, 19]. The results from RCTs [14, 17] do not suggest beneficial effects for pain reduction compared with education plus exercise control (n = 20) [14] and usual activity (n = 42). One RCT suggested positive effects for depression, disability index and quality of life [14].

Considering tai chi as part of a mixed intervention, two further RCTs were identified. One RCT (n = 46) tested the effectiveness of tai chi on ROM and reported intergroup differences for ankle plantar flexion and lower extremity flexion compared with traditional exercise [12]. Another RCT (n = 218) suggested significant pain reduction and reduction of fatigue compared to an arthritis education programme [16].

No cost-effectiveness studies of tai chi for RA are available. The average direct cost of treating RA is approximately US$ 1503 to US$ 16514 per year per patient [20–22] and the total mean annual costs are approximately US$1702 to US$ 25211 [20, 21, 23]. Several tai chi experts estimate that 36–48 sessions (two times weekly for 24 weeks or three times weekly for 12 weeks) are required for treating RA. Each session would cost up to $20. This would amount to total direct costs of about $960. Thus the direct costs for tai chi might turn out to be competitive, but reliable data are required.

One argument for using tai chi in the management of RA is that it is safer than conventional treatment. Several adverse effects of tai chi have been reported in one trial [19], although others did not report any [14, 17, 18]. Compared to those of standard drug treatment, soreness in the knee, shoulder or lower back may be infrequent or even negligible. Adverse effects were not the focus of this review but the safety of tai chi is an important issue and needs to be addressed in future studies.

This systematic review has several limitations. Although strong efforts were made to retrieve all RCTs on the subject, it is conceivable that some were not found. In this review there were no restrictions in terms of publication language and a large number of different databases were searched. It is conceivable that several negative RCTs remained unpublished and thus distorted the overall picture [24–27]. Further limitations include the paucity and the often suboptimal quality of the primary data. One should note, however, that design features such as placebo or blinding are difficult to incorporate in studies of tai chi. These are factors that evidently influence both quality and the quantity of research.

In conclusion, currently there are few trials testing the effectiveness of tai chi in the management of RA. The studies that are available are of low methodological quality. Collectively this evidence is not convincing enough to suggest that tai chi is an effective treatment for RA. The value of tai chi for this indication therefore remains unproven.

Formula


   Acknowledgments
 
The authors specially thank Kate Boddy for editing this manuscript and Ruling Guo for translation from Chinese to English.

Disclosure statement: The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. World Health Organization. Chronic rheumatic conditions. (available at: www.who.int/chp/topics/rheumatic/en/print.html). Accessibility verified April 20, 2007.
  2. Markenson JA. Worldwide trends in the socioeconomic impact and long-term prognosis of rheumatoid arthritis. Semin Arthritis Rheum (1991) 21:4–12.[CrossRef][Web of Science][Medline]
  3. Gabriel SE, Crowson CS, O'Fallon WM. The epidemiology of rheumatoid arthritis in Rochester, Minnesota, 1955–1985. Arthritis Rheum (1999) 42:415–20.[CrossRef][Web of Science][Medline]
  4. American College of Rheumatology. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum (2002) 46:328–46.[CrossRef][Web of Science][Medline]
  5. Barnes PM, Powell-Griner E, MacFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. In: Advance data from vital and health statistics; no 343 (2004) Hyattsville, Maryland: National Centre for Health Statistics. (available at http://www.cdc.gov/nchs/data/ad/ad343.pdf). Accessibility verified April 20, 2007.
  6. Herman CJ, Allen P, Hunt WC, Prasad A, Brady TJ. Use of complementary therapies among primary care clinic patients with arthritis. Prev Chronic Dis (2004) 1:A12.[Medline]
  7. National Center for Complentary and Alternative Medicine. Rheumatoid arthritis and complementary and alternative medicine. (available at: http://nccam.nih.gov/health/RA/). Accessibility verified April 20, 2007.
  8. Lam P. A specially designed tai chi program for arthritis. Arthritis Rheum (1999) 42:S329.
  9. National Center for Complentary and Alternative Medicine. Tai chi for health purposes. (avaiable at http://nccam.nih.gov/health/taichi/). Accessibility verified April 20, 2007.
  10. Han A, Robinson V, Judd M, Taixiang W, Wells G, Tugwell P. Tai chi for treating rheumatoid arthritis. Cochrane Database Syst Rev (2004) CD004849.
  11. Zhu JJ, Guo WY, Qian HQ. [Shan Pi Tang with exercise program in the treatment of rheumatoid arthritis]. Zhong Guo Zhong Xi Yi Jie He Za Zhi (1999) 19:588. (in Chinese).
  12. Van Deusen J, Harlowe D. The efficacy of the ROM Dance Program for adults with rheumatoid arthritis. Am J Occup Ther (1987) 41:90–5.[Web of Science][Medline]
  13. Uhlig T, Larsson C, Hjorth AG, Odegard S, Kvien TK. No improvement in a pilot study of tai chi exercise in rheumatoid arthritis. Ann Rheum Dis (2005) 64:507–9.[Free Full Text]
  14. Wang C, Roubenoff R, Lau J, et al. Effect of Tai Chi in adults with rheumatoid arthritis. Rheumatology (Oxford) (2005) 44:685–7.[CrossRef][Medline]
  15. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials (1996) 17:1–12.[CrossRef][Web of Science][Medline]
  16. Hammond A, Bryan J, Hardy A. A lifestyle management for arthritis programme: short-term outcomes for people with inflammatory arthritis. Rheumatology (2004) 43:ii147. (abstract).
  17. Lee EN. [Effects of a tai-chi program on pain, sleep disturbance, mood and fatigue in rheumtoid arthritis patients]. J Rheumatol Health (2005) 12:57–68. (in Korean).
  18. Lee KY, Jeong OY. [The effect of Tai Chi movement in patients with rheumatoid arthritis]. Taehan Kanho Hakhoe Chi (2006) 36:278–85. (in Korean).[Medline]
  19. Kirsteins AE, Dietz F, Hwang SM. Evaluating the safety and potential use of a weight-bearing exercise, Tai-Chi Chuan, for rheumatoid arthritis patients. Am J Phys Med Rehabil (1991) 70:136–41.[CrossRef][Web of Science][Medline]
  20. Cooper NJ. Economic burden of rheumatoid arthritis: a systematic review. Rheumatology (Oxford) (2000) 39:28–33.[CrossRef][Medline]
  21. Rosery H, Bergemann R, Maxion-Bergemann S. International variation in resource utilisation and treatment costs for rheumatoid arthritis: a systematic literature review. Pharmacoeconomics (2005) 23:243–57.[CrossRef][Web of Science][Medline]
  22. Verstappen SM, Jacobs JW, van der Heijde DM, et al. Utility and direct costs:ankylosing spondylitis compared with rheumatoid arthritis. Ann Rheum Dis (2007) 66:727–31.[Abstract/Free Full Text]
  23. Fautrel B, Clarke AE, Guillemin F, et al. Costs of rheumatoid arthritis: new estimates from the human capital method and comparison to the willingness-to-pay method. Med Decis Making (2007) 27:138–50.[Abstract/Free Full Text]
  24. Dickersin K. The existence of publication bias and risk factors for its occurrence. JAMA (1990) 263:1385–9.[Abstract/Free Full Text]
  25. Egger M, Smith GD. Bias in location and selection of studies. Br Med J (1998) 316:61–6.[Free Full Text]
  26. Ernst E, Pittler MH. Alternative therapy bias. Nature (1997) 385:480.[Medline]
  27. Pittler MH, Abbot NC, Harkness EF, Ernst E. Location bias in controlled clinical trials of complementary/alternative therapies. J Clin Epidemiol (2000) 53:485–9.[CrossRef][Web of Science][Medline]
Submitted 19 February 2007; revised version accepted 4 May 2007.
Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Nutr Clin PractHome page
D. Kiefer, J. Pitluk, and K. Klunk
An Overview of CAM: Components and Clinical Uses
Nutr Clin Pract, October 1, 2009; 24(5): 549 - 559.
[Abstract] [Full Text] [PDF]

Home page
 West J Nurs ResHome page
C. E. Rogers, L. K. Larkey, and C. Keller
A Review of Clinical Trials of Tai Chi and Qigong in Older Adults
West J Nurs Res, March 1, 2009; 31(2): 245 - 279.
[Abstract] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
46/11/1648    most recent
kem151v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (3)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Lee, M. S.
Right arrow Articles by Ernst, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Lee, M. S.
Right arrow Articles by Ernst, E.
Related Collections
Right arrow Rheumatoid Arthritis
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?