Tai Chi is an ancient Chinese martial art with a growing interest. It is an aerobic exercise of mild to moderate intensity. The practice of Tai Chi involves an interaction of physical movement, meditation, and deep breathing. A review of the literature suggests a beneficial role of Tai Chi for improving physical and psychological health, and as an alternative treatment option for specific chronic pain condition such as osteoarthritis, fibromyalgia, and chronic low back pain. Future high-quality trials are required to assess for its role in other chronic pain conditions.
Keywordscomplementary and alternative medicine, mind-body control, physical health benefits, psychological health benefits, Tai Chi
Tai Chi is an ancient Chinese martial art and exercise that combines deep breathing and relaxation with slow and gentle movements. It has been reported that Tai Chi has beneficial effects in a variety of physical and psychological health conditions, including specific chronic pain disorders. The National Centre for Health Statistics in the United States estimates that up to 57% of Americans with chronic pain report significant ongoing limitation of their daily activities. In addition to conventional medical therapies, complementary and alternative treatment options have become increasingly common. Complementary and alternative medicine (CAM) practices are often grouped into two broad categories that include natural products and mind-body medicine (which is the category associated with Tai Chi). A number of investigators have examined the role of Tai Chi in various chronic pain conditions. This chapter will examine existing and recent literature on Tai Chi as it relates to chronic pain management.
Philosophy, History, and Development of Tai Chi
The practice of Tai Chi is also referred to as Tai Chi Chuan, Taiji, or Taiji Quan. The terms Chuan and Quan both translate to “fist,” and the resulting term Tai Chi translates to “supreme ultimate fist.” The practice of Tai Chi is rooted in both Confucianism and Taoism. Tai Chi is believed to be the driving force of the universe, and is composed of the two opposing forces—Yin and Yang—which form the symbol of the practice ( Fig. 61.1 ). Ill health is viewed as an imbalance between Yin and Yang, and Tai Chi is believed to help rebalance such energy disturbances. The practice of Tai Chi involves the constant, slow transfer of body weight that reflects the simultaneous separation and merging of Yin and Yang energies. In Chinese culture, this internal energy of the body is referred to as qi, and Tai Chi aims to achieve a balance of qi in an effort to maintain balance and harmony.
It is believed that Tai Chi was developed in the 12th century by Master Zhang San Feng, a Taoist priest. However, more recent historical sources assign the origin to Master Chen Wang Ting in the 17th century. As it evolved, Tai Chi differentiated into five main styles: Chen, Yang, Wu (Hao), Wu, and Sun. These styles share similarities in foundation, but vary regarding the approach to posture, pace, and order of movements. The traditional art form is complex, and many simplified forms have been developed. In 1956 the Chinese government developed an abbreviated version of Tai Chi as an exercise that could be taught to the masses, which included 24 postures that could be performed in 4–5 minutes.
Tai Chi has become a popular exercise worldwide. It is low cost, with no specific equipment or facilities needed. Requirements include a flat area of 4 m 2 , loose clothing, and flat-heeled shoes. It can be practiced alone or in a group, and in an indoor or outdoor setting.
Tai Chi Health Benefits
Physical Health Benefits
Physical Fitness, Musculoskeletal Strength, Balance
Tai Chi is considered an aerobic exercise of mild to moderate intensity, with considerable variations depending on training approaches, style, posture, speed, and experience of the practitioner.
The peak oxygen uptake is believed to be the best indicator for aerobic capacity and is one of the strongest predictors of the risk of death among normal subjects and patients with cardiovascular disease. A study by Lan et al. found that elderly Tai Chi practitioners had 18%–19% higher VO 2peak when compared with sedentary controls. Furthermore, a recent meta-analysis in 2008 found that Tai Chi may significantly improve aerobic capacity, with the greatest gains among middle-aged and older women.
Tai Chi practice involves continuous weight shifting and body rotation, which increases the load on the lower limbs. As a result, Tai Chi has been shown to improve overall muscle strength and balance. Jacobson et al. found that subjects between ages 20 and 45 who practiced 3 times per week for 12 weeks had significantly increased strength of the knee extensors. Long-term Tai Chi has also shown to significantly decrease the latency of semitendinosis muscle. The prevention of falls in the elderly depends on the timely initiation of a postural response, and it is believed that the improved muscle strength and response can contribute to improved overall balance. This is an important health issue, as approximately 30% of community-living people aged 65 years and older experience a fall at some point in their lives, with approximately 20% of those requiring medical attention. A recent systematic review and meta-analysis by Leung et al. found that Tai Chi was effective in improving balance of older individuals, but its superiority to other interventions remains equivocal. Future research in this area is required.
It is well known that higher cognitive centers play an important role in nociception and pain perception. Attention is a mechanism by which nociceptive information is processed and enters our awareness. Neurocognitive models postulate two distinct modes of attention (“top-down selection” and “bottom-up selection”), both of which are discussed in further detail outside of this chapter. It is believed that the practice of Tai Chi may help an individual exert executive control over this nociceptive input, thus enhancing one’s ability to cope, by improving either the top-down or bottom-up selection processes. Similarly, this concept may help an individual exert executive control over anticipated (or expected) nociceptive input that may arise. The use of imagery techniques and meditation strategies are some of the methods employed by Tai Chi for this purpose.
Tai Chi is an excellent exercise for training the mind-body interaction. The fundamental teachings of Tai Chi emphasize the interrelationship of the mind and body: consciousness (yi) leads to the movement of energy (qi), which in turn leads to the movement of the body. Tai Chi demands synchronized and harmonious movements of the body. This requires concentration, focus, and awareness of both self and environment. When practiced correctly, the practitioner aims to feel the internal movement of energy (qi) like water flowing across the body. The use of visual imagery (“grasp the bird’s tail” or “white crane spreads its wing”) can help the user achieve this goal.
Epidemiologic and clinical studies have demonstrated a high prevalence of psychological comorbidities in patients with chronic pain. A World Health Organization (WHO) survey of nearly 26,000 patients found that chronic pain sufferers exhibit a fourfold increase in the odds of having an anxiety or depressive disorder compared to those without chronic pain. Tai Chi is a useful practice because it is safe to perform, with low physical and emotional risk, and allows patients to take a more active role in their care.
A systematic review and meta-analysis by Wang et al. evaluated the role of Tai Chi and psychological well-being. This review included 17 randomized controlled trials (RCTs) and approximately 3800 subjects. Tai Chi was found to be associated with reduced stress, anxiety, depression, and mood disturbance, and increased self-esteem. These improvements are thought to be related to both the mind-body interaction and the physical therapy components, which help amplify the psychological benefits.
Tai Chi Benefits in Chronic Pain Conditions
Osteoarthritis (OA) is one of the most common causes of pain and disability in older adults in Western countries. OA causes pain and stiffness in the affected joint, and often results in significant limitation of daily activities and loss of independent function with progression over time. Treatment modalities include pharmacologic, nonpharmacologic, and surgical options. Nonpharmacologic strategies focus on the importance of weight loss, exercise routines, and self-management programs that aim to improve pain, function, and psychological well-being. Various exercise modalities have been investigated as potential treatment options, including walking, resistance training, and hydrotherapy. Tai Chi has gained increasing popularity for patients with OA. A growing number of randomized controlled trials have evaluated its role in the OA population, and more recently, the American College of Rheumatology (ACR) guidelines have listed Tai Chi as a conditional recommendation for managing knee OA.
Review of Evidence
The quality of studies reviewed in this chapter was evaluated using the Jadad score ( Table 61.1 ), a validated tool assessing the study design and quality of reporting. The level of evidence was assessed with evidence statements and grades of recommendations from the US Department of Health and Human Services Agency for Health Care Policy and Research ( Table 61.2 ). Seven RCTs ( Table 61.3 ) have evaluated the efficacy of Tai Chi on patients with OA. The duration of Tai Chi practice ranged from 6 to 20 weeks. As the practice of Tai Chi cannot be blinded, the maximum Jadad score achieved was 3. Out of the seven included RCTs, six reached a score of three, with the most recent RCT being of lower quality and achieving a score of 1. Five out of seven studies included patients with OA limited to the knee, and four of these five studies demonstrated a reduction in pain.
|Was the study described as randomized (this includes words such as randomly, random, and randomization)?||0/1|
|Was the method used to generate the sequence of randomization described and appropriate (table of random numbers, computer generated, etc)?||0/1|
|Was the study described as double-blind?||0/1|
|Was the method of double-blinding described and appropriate (identical placebo, active placebo, dummy, etc.)?||0/1|
|Was there a description of withdrawals and dropouts?||0/1|
|Deduct one point if the method used to generate the sequence of randomization was described and it was inappropriate (patients were allocated alternately, or according to date of birth, hospital number, etc.).||0/−1|
|Deduct one point if the study was described as double-blind but the method of blinding was inappropriate (e.g., comparison of tablet vs. injection with no double dummy).||0/−1|
|Statements of Evidence|
|Ia||Evidence obtained from meta-analysis of RCTs|
|Ib||Evidence obtained from at least one RCT|
|IIa||Evidence obtained from at least one well-designed controlled study without randomization|
|IIb||Evidence obtained from at least one other type of well-designed quasiexperimental study|
|III||Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case reports|
|IV||Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities|
|Grades of Recommendations|
|A||Requires at least one prospective, randomized controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels Ia and Ib)|
|B||Requires the availability of well-conducted clinical studies, but no prospective, randomized clinical trials on the topic of recommendation (evidence levels IIa, IIb, III)|
|C||Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities; indicates an absence of directly applicable clinical studies of good quality (evidence level IV)|
|First Author/Year||Osteoarthritis Regions; Total Number of Patients Randomized/Analyzed||Jadad Score/AC/Blind Assessor||Tai Chi Intervention||Control||Pain Outcome||Other Outcomes||Remarks|
|Hartman/2000||Multiple; 35/33||3/−/−||Yang; 2/week/12 weeks||Routine care and usual physical activity||NS—ASE||↑ Arthritis self-efficacy |
↑ Satisfaction general health (AIMS)
↓ Tension (AIMS)
|Baseline ↑ Arthritis pain in TC group|
|Song/2003||Knee: 72/43||3/+/−||Sun; 3/week; 12 weeks||Routine treatment||↓ Pain-K-WOMAC||↓ Stiffness, ↑ physical functioning K-WOMAC ↑ Balance|
|Brismee/2007||Knee; 41/39||3/−/+||Yang; 3/week for 6 weeks; home Tai Chi 6 weeks||Attention control program a||↓ Overall and maximum pain-↓ VAS||↑ Overall and physical function in WOMAC|
|Fransen b /2007||Hip/knee; 97/97 c||3/+/+||Sun; 2/week; 12 weeks||Wait list||NS-WOMAC||↑ Physical function in WOMAC; better timed stair climb||Three groups in comparison with hydrotherapy|
|Wang/2009||Knee; 40/40 c||3/+/+||Yang; 2/week; 12 weeks||Attention control program a||↓ Pain-WOMAC||↑ Physical function in WOMAC, patient, and physician global VAS; ↑ balance, SF-36 PCS; ↓ CES-D|
|Tsai/2012||Knee; 28/27 c||3/+/+||Sun; 3/week; 20 weeks||Attention control Program a||↓ Pain-WOMAC (From week 9)||↓ Stiffness-WOMAC (from week 17) |
NS-function-WOMAC and MMSE
|Wortley d /2013||Knee; 39/31||1/−/−||Yang; 2/week; 10 weeks||Usual physical activity||NS—WOMAC||↑ Mobility||Additional third group with resistance training|