Running head: USING TAI CHI TO DECREASE REPORTED PAIN 1

Using Tai Chi to Decrease Reported Pain in Adult Fibromyalgia Patients

Michael Sandin & Marc-Allen Dy

University of South Florida

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Abstract

Clinical Problem: Patients with fibromyalgia who follow a prescribed aerobic exercise regimen

continue to report a significant amount of pain which require them to depend on pharmacological

therapy to help control symptoms (Goldenberg et al., 2012).

Objective: The objective is to synthesize evidence comparing Tai Chi and aerobic exercise as

most effective in decreasing reported pain in patients with fibromyalgia. PubMed and CINAHL

were utilized to search for the randomized controlled trials related to decreasing reported pain in

patients with fibromyalgia who performed Tai Chi. The key terms used for the search included

fibromyalgia, pain, Tai Chi, and exercise.

Results: Goldenberg et al. (2012) demonstrated that patients who performed Tai Chi exhibited a

decrease in global pain assessment at 12 weeks (p<.002) and at 24 weeks (p<.001). Bennett et al.

(2012) demonstrated significant changes in BPI severity (p = 0.0008) and FIQ scores (p=0.0002)

when Tai Chi was utilized. Calandre et al. (2009) demonstrated that patients who performed Ai

Chi (water-based Tai Chi) had a substantial change in the pain FIQ score (p<.01). Chernykh et

al. (2017) demonstrated a decrease in the visual analogue scale when patients performed Tai Chi

(p=0.008). Clinical guidelines written by Bennett (2014) recommended Tai Chi as a mindfulness

exercise that can be used to decrease fibromyalgia pain.

Conclusion: Even though Tai Chi can help decrease reported pain in patients with fibromyalgia,

additional research is needed to establish which type of Tai Chi is the most advantageous for

patients. In future studies, both the providers and patients should be blinded to create a double-

blinded study, rather than single-blind studies.

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Using Tai Chi to Decrease Reported Pain in Adult Fibromyalgia Patients

As fibromyalgia progresses, patients become debilitated due to their symptoms. For

example, patients report chronic musculoskeletal pain in the joints, lower back, and neck

(Holleran, Osborn, Watson, & Wraa, 2014). There are also other clinical manifestations such as

depression, headaches, insomnia and generalized weakness (Holleran et al., 2014). According to

Arnold et al. (2008), patients with fibromyalgia had a decreased ability to maintain social

relationships, occupational duties, and activities of daily living due to the severe pain. Aerobic

exercise has been the staple intervention for treating fibromyalgia, but patients still continue to

report limited physical ability due to pain. Exercise that involves moderate to high intensity

decreases compliance in patients with fibromyalgia (Chernykh et al., 2017). Compared to aerobic

exercise, Tai Chi has shown to improve fibromyalgia symptoms and quality of life. Tai Chi is a

slower paced exercise that may be able to reduce reported pain in patients with fibromyalgia. In

patients with fibromyalgia, how does performing Tai Chi compare to aerobic exercise for

decreasing reported pain over a period of 12 weeks?

Literature Search

PubMed and CINAHL were searched for four randomized controlled trials and one

guideline related to the use of Tai Chi to decrease reported pain in adult patients with

fibromyalgia. Key terms that were used included fibromyalgia, pain, Tai Chi, fibromyalgia

management guidelines, and exercise. The search was limited to randomized controlled trials that

were from 2009 to 2017.

Literature Review

Four RCTs and one guideline were used to assess the effect of Tai Chi in decreasing

reported pain in patients with fibromyalgia. Goldenberg et al. (2010) assessed the effect of Tai
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Chi in relation to decreasing musculoskeletal pain in patients with fibromyalgia. Reported pain

was measured by using global pain assessment combined with the visual analogue scale. The

sample size was 66 patients that were above the age of 21. The patients were randomly assigned

to an intervention group (n=33) or a control group (n=33). Patients in the intervention group

performed Tai Chi under a Tai Chi teacher, while the control group was taught stretching

exercises and self-management. Both groups met for 60 minute sessions twice a week. The

patients were instructed to perform their exercise at home 20 minutes every day for 24 weeks.

The intervention group had significant improvements in the global pain assessment at 12 weeks

(p<.002) and after the 24 weeks (p<.001) follow up. The strengths of the study included two

randomly assigned groups, concealed random assignment from those first enrolling in the study,

patients were analyzed in their assigned group, and reasons were given for patients not

completing the study. Additional strengths included an appropriate control group, valid

instruments to measure the outcomes, similar baseline clinical variables, and follow up

appointments were made at the 12th week and 24th week. A weakness found in the study

included the study only being blind to the patients and not the providers.

Bennett et al. (2012) assessed the efficacy of using an 8-form style of Tai Chi specifically

designed to reduce symptoms in patients with fibromyalgia. The total sample size was 101

patients older than 40, and were divided into two groups based on the intervention. The

intervention group (n=51) performed an 8-form style of Tai Chi taught by a Tai Chi master,

while the control group was educated about fibromyalgia management. The interventions were

twice a week for 12 weeks, with each session lasting 90 minutes. The primary measures used to

evaluate the study incorporated the FIQ and the Brief Pain Inventory (BPI). Baseline data were

gathered at the beginning of the study and were compared to results taken after 12 weeks. The
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intervention group demonstrated significant improvements in their FIQ scores (p = .00002) and

BPI severity (p = 0.0008). The strengths of the study included random group assignments,

concealed random assignments, reasons were given for patients not completing the study, and

patients were analyzed in their assigned group. Additional strengths included an appropriate

control group, outcomes found using valid instruments, and similar baseline demographic and

clinical variables. Weaknesses of the study included no follow up assessments, and providers

were not blinded to the study methods.

Calandre et al. (2009) evaluated the impact of Ai Chi (water-based Tai Chi) on

fibromyalgia pain in a randomized controlled trial that lasted for 22 weeks. The study lasted for 6

for weeks, and patients were instructed to have follow-up assessments 4 weeks and 12 weeks

after the study ended. After the 6 week period, no guided exercises were given to the participants

during the follow-up period. The sample consisted of 81 patients who were 18 and older. The

patients in the intervention group participated in Ai Chi (n=41), while the control group (n=39)

performed stretching exercises. Both groups participated in 18 sessions during the study period.

Each session lasted 60 minutes, and were held three times a week for 6 weeks. The results

demonstrated that the Ai Chi group had better FIQ scores at the end of the study (p<0.01) and at

the 4 week follow-up (p<0.05). The strengths of the study included two groups assigned by

randomly generated numbers, follow up assessments were conducted, and subjects were

analyzed in their assigned group. Additional strengths of the study included an appropriate

control group, valid instruments used to measure the outcomes, patients were similar in baseline

demographics, and reasons were given for patients not completing the study. Weaknesses of the

study included neither the providers or patients were blinded in the study, and the random

assignment was not concealed from patients.

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Chernykh et al. (2017) studied the effect of Tai Chi on fibromyalgia pain in women with

fibromyalgia. The patients were randomly assigned to an intervention group (n= 18) or a control

group (n=19). Baseline assessments were taken at the beginning of the study and were compared

to results taken after 12 weeks. The patients in the intervention group practiced Tai Chi under a

Tai chi master three times a week in 55-minute sessions for 12 weeks. The control group was not

taught any exercises and was instructed to continue their everyday lifestyle routines. The results

of the study demonstrated substantial improvements in reported pain per the visual analogue

scale (p=0.006). Strengths of the study included random group assignments, subjects analyzed in

their assigned group, valid instruments were used to measure the outcomes, similar demographic

and clinical variables, and valid reasons for participants not completing the study, and an

appropriate control group. Weaknesses of the study included follow up assessments not

conducted, patients not being blinded to the study design, and random assignment was not

concealed from those first enrolled in the study.

Bennett (2014) synthesized guidelines for managing fibromyalgia symptoms.

Management consisted of fibromyalgia education, pharmacological and physical modalities. The

guidelines also incorporate self-help modalities which include pacing, distraction, heat

modalities, aerobic exercise, and mindfulness exercise. The guidelines recommend Tai Chi as a

mindfulness exercise that can be used to treat fibromyalgia pain.

Synthesis

Goldenberg et al. (2012) showed that patients in the Tai Chi group had a significant

decrease in the global pain assessment at 12 weeks (p<0.002), and at 24 weeks (p<.001). Bennett

et al. (2010) demonstrated that patients had a decrease in reported pain according to BPI severity

(p=0.0008) and FIQ scores (p=0.0002). Calandre et. al (2009) demonstrated a significant
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improvement in FIQ pain (p<0.01) when patients performed Ai Chi, the water-based Tai Chi.

Chernykh et al. (2017) demonstrated that reported pain had decreased by using the visual

analogue scale (p=0.008). Current guidelines written by Bennett (2014) recommend Tai Chi as a

supplementary self-help modality to help treat fibromyalgia pain.

Three of the studies included a major weakness of participants dropping out of the study.

Another weakness identified in two studies included the studies not being double-blinded

studies. Further research needs to be conducted that include both the provider and patients being

blinded in the study. The research conducted by the four RCTs conclude that using Tai Chi as a

form of treatment to reduce pain in adults may be effective among patients with fibromyalgia.

Current guidelines suggest that a mindfulness exercise such as Tai Chi could be used to reduce

fibromyalgia pain (Bennett, 2014). However, the research does not seem to be conclusive on the

form of Tai Chi, the amount of sessions, and time needed for each session to attain maximum

therapeutic benefits. Research confirms that using Tai Chi in 55 to 90 minute sessions, 2 to 3

times a week, for 6 to 12 weeks can decrease pain in adult patients with fibromyalgia (Bennett et

al., 2012; Calandre et al., 2009; Chernykh et al., 2017; Goldberg et al., 2010). While other

improvements regarding quality of life were reported, further studies need to be conducted to

assess the efficacy of Tai Chi with other symptoms of fibromyalgia.

Clinical Recommendations

Based on the synthesis of the literature and clinical guidelines, clinicians should

recommend Tai Chi as an adjunct non-pharmacological method to help decrease reported pain in

patients with fibromyalgia. Tai Chi is already recommended as a self-help modality to decrease

fibromyalgia pain according to current guidelines (Bennett, 2014). Tai Chi is a non-invasive

intervention that can be implemented by nurses without a physician’s order.

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