Tai Chi in RA

RA is a chronic inflammatory disease with joint swelling, with a prevalence of 0.5–1% of the population and an incidence of 25–50 cases per 100,000 population . If not treated well, RA may progress to considerable disability and serious joint damage. During the last 10–20 years, large progress in the treatment with synthetic and especially biological disease modifying anti rheumatic drugs (DMARDs) has considerably improved the lives of patients with RA. Further, early arthritis clinics today also help to identify and treat patients early. Non-pharmacological treatment is also important and patients with RA are advised exercise to improve joint mobility, strength and physical fitness. While some decades ago, rest and careful exercise were recommended, new developments advocate a more active approach, also allowing for intensive exercise therapy . As a consequence of improved treatment, we observe better long-term clinical outcomes, with remission of the disease or decreased disease activity .

From a theoretical perspective, Tai Chi exercise would be expected to be beneficial to patients with RA because of its concerted effects on muscle strength, stress reduction and cardiovascular and bone health, thereby improving health-related quality of life. One early publication by Kirsteins et al. from 1991 describes two non-randomised controlled trials where the authors included 47 and 28 RA patients, respectively. Patients exercised with Tai Chi over 10 weeks and outcomes included joint tenderness and swollen joints as measures of disease activity, 50-feet walking time, handgrip strength and exacerbation of joint symptoms was measured. The study did not produce differences in outcomes between the active and control groups in both studies. Importantly, however, the studies showed that Tai Chi seems to be safe for patients with RA, and exercise of two weekly 1-h sessions did not exacerbate joint symptoms. This was important at a time when the intensity of adequate exercise in RA was debated. Tai Chi could thus potentially be used as a weight-bearing exercise with the additional potential advantages.

A first Cochrane review on Tai Chi in RA was published in 2004, including four clinical trials . In these studies, a total of 206 participants were included, two of them were published in one article , also two other studies were reviewed and included because they applied principles of Tai Chi philosophy. As Tai Chi is practised in different forms, it can be debated where to draw the line when studies are to be pooled for the purpose of a meta-analysis. One of two other studies included multi-component programmes that included combinations of exercise and Tai Chi .

With respect to withdrawals, the review found more withdrawals in the control groups, and it was considered uncertain whether this could be due to greater enjoyment or effectiveness among individuals in the experimental groups. The Cochrane collaborators in their review indicated that Tai Chi does not seem to have detrimental effects on disease activity in RA. They suggested for future research to compare Tai Chi to another form of exercise with respect to quality of life. Reporting frequency, intensity and duration of Tai Chi was also recommended. The main conclusion was ‘silver evidence’ that Tai Chi led to improvement in motion in joints of the lower extremities, while grip strength or joint tenderness was not improved.

A systematic review by Lee et al. extended the findings of the Cochrane review by Han et al. , including three more studies. In two additionally included Korean studies referenced in the systematic review , Tai Chi was applied over 6 and 12 weeks. Compared to the control groups, positive effects were seen with respect to affectionate and sleep variables. On the other hand, studies with mixed interventions were not considered . Only two of five studies were randomised trials, and, in general, there was low methodological quality. In summary, the review concluded that evidence is not convincing enough to suggest Tai Chi as an effective treatment for RA.

Since the publication of the reviews on Tai Chi, more studies on health effects of Tai Chi in RA have been performed. In a pilot randomised controlled trial, Wang et al. included 10 patients with established RA and 10 controls in a Tai Chi study where Yang style was taught twice weekly in sessions for 12 weeks. No changes were made for medication and patients maintained ordinary visits to rheumatology care. At 12 weeks, some improvement was seen in the active group with respect to disease activity (American College of Rheumatology (ACR20) response), and physical function improved more than in the control group .

In an uncontrolled pilot study from Norway, Tai Chi was taught twice weekly over an 8-week period to patients with RA who had been recruited from the Oslo Rheumatoid Arthritis Register . No clear effects of Tai Chi could be observed on disease activity, muscle strength, flexibility, balance and health status, whereas there were no concerns for possible injuries or difficult movements when an adapted exercise form for Tai Chi was used. Considering lack of observed health benefits in this pilot study, the authors hypothesised they had probably been too careful and slow in increasing the pace of instruction for this non-Western form of exercise, an exercise which may initially have been considered as unfamiliar to a patient with RA. Further, there was a clear floor effect for scoring instruments selected to detect health-care effects, thus making it difficult to detect improvement. Measuring outcomes already after 8 weeks may in retrospect also be seen as ambitious and impatient, not giving the patient time to fully practice the full form of six movements. However, patients became enthusiastic about Tai Chi during the supervised session and rated it more joyful and useful than the previously practised exercise form .

To improve methodology applied in the first study , we then studied the patient perspective in a qualitative study. We further increased the intervention to 12 weeks duration to give more time for the manifestation of an exercise effect. Another change was to include measures which we thought would be especially sensitive for change when individuals exercise with Tai Chi. After 12 weeks, the group improved statistically significantly in the timed-stands test, and this improvement was sustained at 3 months follow-up . The timed-stands test measures in seconds the time used to rise up and sit down and could be sensitive to change when patients during Tai Chi exercise strengthen their quadriceps muscles. Muscle strength and endurance are important to patients and the observed improvement in muscle function of the lower limbs was also supported by patient experience of improved walking ability and increased confidence while moving . Even if this was no randomised controlled trial, this study gives clues on what to expect and measure in future Tai Chi trial in patients with RA.

Although existing evidence regarding Tai Chi on RA remains limited and inconclusive , these promising results suggest that Tai Chi may be a safe adjunctive therapy for RA and warrants further investigation.

Tai Chi in OA

OA is the most frequent joint disease and is considered a growing problem not only in the United States , but also in Europe with a large impact on the individual and on society . There is a clear increase in the incidence with age, and among females. With an ageing population and increasing obesity, a search for suitable exercise methods is important. A large proportion of individuals will during their lifetime be affected by OA in the hip, knee or hands. Among general strategies for the prevention of OA, modifiable risk factors are obesity and the lack of exercise.

No disease-modifying drug therapies exist as of today, and symptom relief by non-steroidal anti-inflammatory drugs and analgesic are widely applied. However, anti-inflammatory drugs have limitations when treating the elderly . As a consequence, exercise remains a core recommendation in patients with hip, knee and possibly also for hand OA , and Tai Chi with its gentle movements may thus constitute a potential treatment modality.

There are a little more than a handful of randomised controlled studies in the English literature which have examined the effect of Tai Chi in OA. Most studies have been performed in knee OA and most with a limited number of individuals as well as short follow-up time. The first randomised controlled study was published by Hartmann et al. with patients affected by OA with a wide array of localisations; they could be included with radiographic or symptomatic OA in the lumbar spine, hips, knee, ankle and foot joints. Patients randomised to Tai Chi trained 9-form Yang style for 12 weeks while the control group was instructed to continue with usual physical activities. Tai Chi sessions lasted about 60 min twice weekly. After the intervention, Tai Chi compared to the control group led to greater improvement in self-efficacy for arthritis symptoms, tension and satisfaction with health according to the arthritis impact measurement scales (AIMS), but not lower extremity function.

In a Korean study by Song et al. , 43 patients with knee OA completed an intervention and evaluation after randomisation to Tai Chi. There was considerable drop-out among patients included. Patients in the Tai Chi group performing Sun style over 12 weeks experienced, after the intervention, less pain and stiffness than patients receiving routine treatment. In addition, physical functioning as measured by the Korean version of the Western Ontario and McMaster Universities (WOMAC) questionnaire, balance and abdominal muscle strength were significantly improved compared to the control group where participants were expected not to take part in other exercise modalities .

The largest trial on Tai Chi in OA was performed in a three-armed design among individuals with hip or knee OA. In this study by Fransen et al. , an exercise group with modified Sun style Tai Chi practised 1 h twice weekly for 12 weeks as well as a group receiving hydrotherapy were compared with a waiting list control group. The magnitude of the treatment effect for physical function (WOMAC) was moderate for both hydrotherapy and Tai Chi classes with standardised response means (SRM) of 0.62 and 0.63, respectively, when comparing with the control group, and low for physical function measured by SF-12, up-and-go test as well as stair climb test, and moderate for physical function (measured by WOMAC). These improvements were sustained also at 24 weeks.

A more intensive but shorter Tai Chi intervention was reported by Brismée and colleagues where Tai Chi was taught three times a week but only over a 6-week period and then maintained by home video instruction. The 41 patients with knee OA were randomised and in a control group lectures were given with health education also on other medical conditions not related to rheumatologic diseases. While some benefits for knee pain and physical function (visual analogue scale) and WOMAC were observed at weeks 6 and 9 compared to the control group, these differences in improvements were no longer present after follow-up through week 18.

The best evidence for Tai Chi in OA has been researched by Wang et al. in a large and well-performed Tai Chi study on patients with knee OA. Tai Chi with Yang style was performed after randomisation of 40 symptomatic OA patients. Patients also satisfied the American College of Rheumatology (ACR) criteria for knee OA with radiographic changes according to the Kellgren and Lawrence classification. The study was a single-blind randomised controlled trial and tested the effectiveness of Tai Chi modified Yang style with two weekly sessions over 12 weeks against an attention control. Outcomes were assessed at baseline, 12, 24 and long-term follow-up at 48 weeks. Measures were WOMAC pain, WOMAC function, patient and physician global assessments, timed chair stand, depression index, self-efficacy scale and health-related quality of life. The results showed that participants in the Tai Chi arm had greater improvements in pain, physical function, depression and self-efficacy than controls and effects were sustained with statistically significant differences present until 48 weeks.

A randomised study in women with OA examined the effects of Tai Chi on muscle strength, bone mineral density (BMD) and fear of falling . The intervention with Tai Chi lasted for 6 months and 65 patients were randomised to Tai Chi or to a control group receiving self-help education and completing a 24-week follow-up. The Tai Chi group hat at week 24 significantly greater knee extensor strength within the Tai Chi group, but knee extensor and flexor strength did not differ significantly between the groups.

In a study by Lee et al. , 44 elderly knee OA patients were randomised (2:1) to an 8-week Tai Chi Qigong training programme given 1 h twice weekly, or to a waiting list. Quality of life as measured by SF-36 was the primary outcome and improved more than in the control group, while WOMAC scores were non-significantly improved.

The above-reviewed evidence suggests that Tai Chi training may provide a useful form of exercise for older individuals with OA, improving muscle strength, coordination and balance, and thus enhancing the physical capacity and activities of daily life.

Tai Chi in other conditions

As Tai Chi could be beneficial against poor balance, falls and non-vertebral fractures, a systematic review evaluated the effectiveness of Tai Chi in osteoporosis and included five randomised controlled trials, and two controlled clinical trials. The systematic review found a wide range of Tai Chi sessions applied, ranging from 32 to almost 300, with exercise from twice to daily sessions of up to 1 h. In postmenopausal women, one trial found Tai Chi to be superior for loss of BMD compared with sedentary lifestyle. The meta-analysis showed no significant effect of Tai Chi on BMD change at the spine compared with no treatment in postmenopausal women. One randomised controlled trial did not show superiority of Tai Chi on BMD as compared to resistance training. Another randomised controlled trial demonstrated a higher increase in markers of bone formation in the Tai Chi than in the resistance training group. The review did not impose any language restriction for published studies, but found considerable limitations in the quality of reviewed studies. On the whole, there was no impressive or convincing evidence for usefulness of Tai Chi in the prevention or treatment of osteoporosis.

A Korean study examined whether Tai Chi had effect on disease activity, flexibility and depression in patients with ankylosing spondylitis. In this chronic, inflammatory rheumatologic disease primarily the sacroiliac joint and the spine are affected, leading to reduced physical activity and flexibility, pain, sleep disturbance and fatigue. In this study, 40 patients were randomised to either Tai Chi exercise twice weekly for 8 weeks or to a control group. Disease activity was measured by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), flexibility as finger-to-floor distance and depression using the Center for Epidemiologic Studies Depression Scale (CES-D). At the end of the 8-week intervention, disease activity and flexibility improved with statistically significant improvements as compared to the control group, while only numerical improvement was seen for depression.

Recently, a randomised study found an effect of Tai Chi in fibromyalgia . The treatment response was exceptional and much higher than in other therapeutical trials in fibromyalgia. The study has however been criticised for methodological issues , and the implications of the study results are unclear.

Further, a specific systematic search was performed for the effect of Tai Chi in chronic musculoskeletal pain conditions . Of seven randomised controlled trials, six studies were performed in patients with chronic arthritis. The quality of the studies was generally rated as low. This review also took the approach of a meta-analysis and estimated pooled effect sizes of about 10 for pain reduction and improvement in disability on a 0–100 scale. Thus, small though positive effects were found with respect to two dimensions important to health-related quality of life. It needs to be kept in mind that due to the low methodological quality of trials, also results with effect sizes need to be interpreted with caution.

Tai Chi in RA

RA is a chronic inflammatory disease with joint swelling, with a prevalence of 0.5–1% of the population and an incidence of 25–50 cases per 100,000 population . If not treated well, RA may progress to considerable disability and serious joint damage. During the last 10–20 years, large progress in the treatment with synthetic and especially biological disease modifying anti rheumatic drugs (DMARDs) has considerably improved the lives of patients with RA. Further, early arthritis clinics today also help to identify and treat patients early. Non-pharmacological treatment is also important and patients with RA are advised exercise to improve joint mobility, strength and physical fitness. While some decades ago, rest and careful exercise were recommended, new developments advocate a more active approach, also allowing for intensive exercise therapy . As a consequence of improved treatment, we observe better long-term clinical outcomes, with remission of the disease or decreased disease activity .

From a theoretical perspective, Tai Chi exercise would be expected to be beneficial to patients with RA because of its concerted effects on muscle strength, stress reduction and cardiovascular and bone health, thereby improving health-related quality of life. One early publication by Kirsteins et al. from 1991 describes two non-randomised controlled trials where the authors included 47 and 28 RA patients, respectively. Patients exercised with Tai Chi over 10 weeks and outcomes included joint tenderness and swollen joints as measures of disease activity, 50-feet walking time, handgrip strength and exacerbation of joint symptoms was measured. The study did not produce differences in outcomes between the active and control groups in both studies. Importantly, however, the studies showed that Tai Chi seems to be safe for patients with RA, and exercise of two weekly 1-h sessions did not exacerbate joint symptoms. This was important at a time when the intensity of adequate exercise in RA was debated. Tai Chi could thus potentially be used as a weight-bearing exercise with the additional potential advantages.

A first Cochrane review on Tai Chi in RA was published in 2004, including four clinical trials . In these studies, a total of 206 participants were included, two of them were published in one article , also two other studies were reviewed and included because they applied principles of Tai Chi philosophy. As Tai Chi is practised in different forms, it can be debated where to draw the line when studies are to be pooled for the purpose of a meta-analysis. One of two other studies included multi-component programmes that included combinations of exercise and Tai Chi .

With respect to withdrawals, the review found more withdrawals in the control groups, and it was considered uncertain whether this could be due to greater enjoyment or effectiveness among individuals in the experimental groups. The Cochrane collaborators in their review indicated that Tai Chi does not seem to have detrimental effects on disease activity in RA. They suggested for future research to compare Tai Chi to another form of exercise with respect to quality of life. Reporting frequency, intensity and duration of Tai Chi was also recommended. The main conclusion was ‘silver evidence’ that Tai Chi led to improvement in motion in joints of the lower extremities, while grip strength or joint tenderness was not improved.

A systematic review by Lee et al. extended the findings of the Cochrane review by Han et al. , including three more studies. In two additionally included Korean studies referenced in the systematic review , Tai Chi was applied over 6 and 12 weeks. Compared to the control groups, positive effects were seen with respect to affectionate and sleep variables. On the other hand, studies with mixed interventions were not considered . Only two of five studies were randomised trials, and, in general, there was low methodological quality. In summary, the review concluded that evidence is not convincing enough to suggest Tai Chi as an effective treatment for RA.

Since the publication of the reviews on Tai Chi, more studies on health effects of Tai Chi in RA have been performed. In a pilot randomised controlled trial, Wang et al. included 10 patients with established RA and 10 controls in a Tai Chi study where Yang style was taught twice weekly in sessions for 12 weeks. No changes were made for medication and patients maintained ordinary visits to rheumatology care. At 12 weeks, some improvement was seen in the active group with respect to disease activity (American College of Rheumatology (ACR20) response), and physical function improved more than in the control group .

In an uncontrolled pilot study from Norway, Tai Chi was taught twice weekly over an 8-week period to patients with RA who had been recruited from the Oslo Rheumatoid Arthritis Register . No clear effects of Tai Chi could be observed on disease activity, muscle strength, flexibility, balance and health status, whereas there were no concerns for possible injuries or difficult movements when an adapted exercise form for Tai Chi was used. Considering lack of observed health benefits in this pilot study, the authors hypothesised they had probably been too careful and slow in increasing the pace of instruction for this non-Western form of exercise, an exercise which may initially have been considered as unfamiliar to a patient with RA. Further, there was a clear floor effect for scoring instruments selected to detect health-care effects, thus making it difficult to detect improvement. Measuring outcomes already after 8 weeks may in retrospect also be seen as ambitious and impatient, not giving the patient time to fully practice the full form of six movements. However, patients became enthusiastic about Tai Chi during the supervised session and rated it more joyful and useful than the previously practised exercise form .

To improve methodology applied in the first study , we then studied the patient perspective in a qualitative study. We further increased the intervention to 12 weeks duration to give more time for the manifestation of an exercise effect. Another change was to include measures which we thought would be especially sensitive for change when individuals exercise with Tai Chi. After 12 weeks, the group improved statistically significantly in the timed-stands test, and this improvement was sustained at 3 months follow-up . The timed-stands test measures in seconds the time used to rise up and sit down and could be sensitive to change when patients during Tai Chi exercise strengthen their quadriceps muscles. Muscle strength and endurance are important to patients and the observed improvement in muscle function of the lower limbs was also supported by patient experience of improved walking ability and increased confidence while moving . Even if this was no randomised controlled trial, this study gives clues on what to expect and measure in future Tai Chi trial in patients with RA.

Although existing evidence regarding Tai Chi on RA remains limited and inconclusive , these promising results suggest that Tai Chi may be a safe adjunctive therapy for RA and warrants further investigation.

Tai Chi in OA

OA is the most frequent joint disease and is considered a growing problem not only in the United States , but also in Europe with a large impact on the individual and on society . There is a clear increase in the incidence with age, and among females. With an ageing population and increasing obesity, a search for suitable exercise methods is important. A large proportion of individuals will during their lifetime be affected by OA in the hip, knee or hands. Among general strategies for the prevention of OA, modifiable risk factors are obesity and the lack of exercise.

No disease-modifying drug therapies exist as of today, and symptom relief by non-steroidal anti-inflammatory drugs and analgesic are widely applied. However, anti-inflammatory drugs have limitations when treating the elderly . As a consequence, exercise remains a core recommendation in patients with hip, knee and possibly also for hand OA , and Tai Chi with its gentle movements may thus constitute a potential treatment modality.

There are a little more than a handful of randomised controlled studies in the English literature which have examined the effect of Tai Chi in OA. Most studies have been performed in knee OA and most with a limited number of individuals as well as short follow-up time. The first randomised controlled study was published by Hartmann et al. with patients affected by OA with a wide array of localisations; they could be included with radiographic or symptomatic OA in the lumbar spine, hips, knee, ankle and foot joints. Patients randomised to Tai Chi trained 9-form Yang style for 12 weeks while the control group was instructed to continue with usual physical activities. Tai Chi sessions lasted about 60 min twice weekly. After the intervention, Tai Chi compared to the control group led to greater improvement in self-efficacy for arthritis symptoms, tension and satisfaction with health according to the arthritis impact measurement scales (AIMS), but not lower extremity function.

In a Korean study by Song et al. , 43 patients with knee OA completed an intervention and evaluation after randomisation to Tai Chi. There was considerable drop-out among patients included. Patients in the Tai Chi group performing Sun style over 12 weeks experienced, after the intervention, less pain and stiffness than patients receiving routine treatment. In addition, physical functioning as measured by the Korean version of the Western Ontario and McMaster Universities (WOMAC) questionnaire, balance and abdominal muscle strength were significantly improved compared to the control group where participants were expected not to take part in other exercise modalities .

The largest trial on Tai Chi in OA was performed in a three-armed design among individuals with hip or knee OA. In this study by Fransen et al. , an exercise group with modified Sun style Tai Chi practised 1 h twice weekly for 12 weeks as well as a group receiving hydrotherapy were compared with a waiting list control group. The magnitude of the treatment effect for physical function (WOMAC) was moderate for both hydrotherapy and Tai Chi classes with standardised response means (SRM) of 0.62 and 0.63, respectively, when comparing with the control group, and low for physical function measured by SF-12, up-and-go test as well as stair climb test, and moderate for physical function (measured by WOMAC). These improvements were sustained also at 24 weeks.

A more intensive but shorter Tai Chi intervention was reported by Brismée and colleagues where Tai Chi was taught three times a week but only over a 6-week period and then maintained by home video instruction. The 41 patients with knee OA were randomised and in a control group lectures were given with health education also on other medical conditions not related to rheumatologic diseases. While some benefits for knee pain and physical function (visual analogue scale) and WOMAC were observed at weeks 6 and 9 compared to the control group, these differences in improvements were no longer present after follow-up through week 18.

The best evidence for Tai Chi in OA has been researched by Wang et al. in a large and well-performed Tai Chi study on patients with knee OA. Tai Chi with Yang style was performed after randomisation of 40 symptomatic OA patients. Patients also satisfied the American College of Rheumatology (ACR) criteria for knee OA with radiographic changes according to the Kellgren and Lawrence classification. The study was a single-blind randomised controlled trial and tested the effectiveness of Tai Chi modified Yang style with two weekly sessions over 12 weeks against an attention control. Outcomes were assessed at baseline, 12, 24 and long-term follow-up at 48 weeks. Measures were WOMAC pain, WOMAC function, patient and physician global assessments, timed chair stand, depression index, self-efficacy scale and health-related quality of life. The results showed that participants in the Tai Chi arm had greater improvements in pain, physical function, depression and self-efficacy than controls and effects were sustained with statistically significant differences present until 48 weeks.

A randomised study in women with OA examined the effects of Tai Chi on muscle strength, bone mineral density (BMD) and fear of falling . The intervention with Tai Chi lasted for 6 months and 65 patients were randomised to Tai Chi or to a control group receiving self-help education and completing a 24-week follow-up. The Tai Chi group hat at week 24 significantly greater knee extensor strength within the Tai Chi group, but knee extensor and flexor strength did not differ significantly between the groups.

In a study by Lee et al. , 44 elderly knee OA patients were randomised (2:1) to an 8-week Tai Chi Qigong training programme given 1 h twice weekly, or to a waiting list. Quality of life as measured by SF-36 was the primary outcome and improved more than in the control group, while WOMAC scores were non-significantly improved.

The above-reviewed evidence suggests that Tai Chi training may provide a useful form of exercise for older individuals with OA, improving muscle strength, coordination and balance, and thus enhancing the physical capacity and activities of daily life.

Tai Chi in other conditions

As Tai Chi could be beneficial against poor balance, falls and non-vertebral fractures, a systematic review evaluated the effectiveness of Tai Chi in osteoporosis and included five randomised controlled trials, and two controlled clinical trials. The systematic review found a wide range of Tai Chi sessions applied, ranging from 32 to almost 300, with exercise from twice to daily sessions of up to 1 h. In postmenopausal women, one trial found Tai Chi to be superior for loss of BMD compared with sedentary lifestyle. The meta-analysis showed no significant effect of Tai Chi on BMD change at the spine compared with no treatment in postmenopausal women. One randomised controlled trial did not show superiority of Tai Chi on BMD as compared to resistance training. Another randomised controlled trial demonstrated a higher increase in markers of bone formation in the Tai Chi than in the resistance training group. The review did not impose any language restriction for published studies, but found considerable limitations in the quality of reviewed studies. On the whole, there was no impressive or convincing evidence for usefulness of Tai Chi in the prevention or treatment of osteoporosis.

A Korean study examined whether Tai Chi had effect on disease activity, flexibility and depression in patients with ankylosing spondylitis. In this chronic, inflammatory rheumatologic disease primarily the sacroiliac joint and the spine are affected, leading to reduced physical activity and flexibility, pain, sleep disturbance and fatigue. In this study, 40 patients were randomised to either Tai Chi exercise twice weekly for 8 weeks or to a control group. Disease activity was measured by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), flexibility as finger-to-floor distance and depression using the Center for Epidemiologic Studies Depression Scale (CES-D). At the end of the 8-week intervention, disease activity and flexibility improved with statistically significant improvements as compared to the control group, while only numerical improvement was seen for depression.

Recently, a randomised study found an effect of Tai Chi in fibromyalgia . The treatment response was exceptional and much higher than in other therapeutical trials in fibromyalgia. The study has however been criticised for methodological issues , and the implications of the study results are unclear.

Further, a specific systematic search was performed for the effect of Tai Chi in chronic musculoskeletal pain conditions . Of seven randomised controlled trials, six studies were performed in patients with chronic arthritis. The quality of the studies was generally rated as low. This review also took the approach of a meta-analysis and estimated pooled effect sizes of about 10 for pain reduction and improvement in disability on a 0–100 scale. Thus, small though positive effects were found with respect to two dimensions important to health-related quality of life. It needs to be kept in mind that due to the low methodological quality of trials, also results with effect sizes need to be interpreted with caution.