You may want to read my article Tai Chi: Where We Are and a Hope for the Future where I discussed this study's misguided reference to not having a "sham Tai chi" control group.
In the same NEJM edition that had the "Tai chi for Fibromyalgia" study, there was also an editorial titled Prescribing Tai Chi for Fibromyalgia — Are We There Yet? (N Engl J Med 2010; 363:783-784 August 19, 2010).
Unfortunately, it seems that the same sort of mindset that promotes Tai chi as an alternative health exercise is using this study to promote Tai chi as a prescription for fibromyalgia while wholly ignoring an accompanying editorial.
As I read the editorial, I found the last two paragraphs to be the most pertinent and copied them here. I split these paragraphs into sections to accommodate
my comments which appear in italics.
The authors state that they tried to minimize any a priori differences between expectations for tai chi and the control intervention, which consisted of stretching and health education, and they report that expectations in the two groups were similar at baseline. However, it seems likely that when a persuasive and enthusiastic teacher of tai chi first explained its potential benefits to the class, expectations in this group were heightened.
Maybe a future study needs to add a control for selling snake oil. Real Taiji instruction can be conveyed without the verbal hype.
The authors dutifully suggest that a sham tai chi intervention would have been desirable as a control. Ideally, a placebo control matches all aspects of the therapeutic intervention except for the “active” element of that intervention.
As I said in my article Tai Chi: Where We Are and a Hope for the Future, this study in fact used sham tai chi. For a future study, the placebo control could be any slow motion sequence of movements. You could re-choreograph Swan Lake, a karate kata or a Michael Jackson routine. No tai chi form in and of itself contains any active therapeutic intervention! That said, real Taiji does contain an "active" element however, this active element: can be developed outside of any Taiji form, can exist a-priori to any sequence of movements, can appear in any movement, not just in Taiji.
But what is the active element of a complex, multicomponent therapy such as tai chi?11
Good question! First, real Taiji is neither complex nor is it multicomponent. Second, the "active element" in real Taiji is a particular kinesthetic phenomena for which our American English language lacks words to articulate. Some people use the Chinese "Qi" paradigm, but this does not contribute to clarifying the kinesthetic experience in plain English. The best we can do for now is offer analogies; it feels like...
Is it rhythmic exercise, deliberate and deep breathing, contemplative concentration, group support, relaxing imagery, a charismatic teacher, or some synergistic combination of these elements?
Unequivocally and absolutely NO! It is none of the above for the real Taiji.
It's basically like this. The old "New Age" folks co-opted the shell of something they couldn't understand and repackaged that shell with a lot of other unrelated material like breath work, contemplation, imagery, a compelling backstory bound to legend, antiquity and nature, etc., and Voila! Tai chi was born and foisted on the masses.
Established medicine is right to be skeptical of popular Tai chi. That said, nearly everyone is ignorant of the real Taiji skill set and the training involved to develop that skill set.
Learning real Taiji is so much simpler, yet in the simplicity is hidden its depth and difficulty. (Not complexity! Difficulty!) The simplicity is consciously relaxing musculature with a particular intention. The difficulty is training the depth.
If so, would the matched control include awkward movements, halted breathing, participant isolation, unpleasant imagery, or a tepid teacher? Would the resulting sham intervention be credible, valid, or even genuinely inactive?
No. This line of thought is an example of the result of the mistake of inches; assuming the correct practice is a complex, multicomponent practice, and assuming the matched control must be the opposite. This is the wrong road!
Actually, the opposite of real Taiji is pretty much the way most people walk around in their usual day-to-day business which is pretty much how sham Tai chi is performed. People walk into a rec-sports or adult-ed or dojo class or seminar and learn a series of movements and stay pretty much stuck at this level for however many years they continue practicing. Some go on to be teachers and the cycle repeats itself.
Instead of embarking on a quixotic search for the ideal sham, what else needs to be done and what is a reasonable course of action for the physician who must counsel the patient with fibromyalgia?
Again, the popularized form of Tai chi is the sham version of real Taiji. So you've already found the ideal sham in Tai chi. No "quixotic search" needed. Regarding counseling patients with fibromyalgia, I cannot comment.
For next steps, we need replications of this study on a larger scale over longer periods of time, with different practitioners and different styles at multiple sites; determination of the optimal “dose”; comparisons with similar therapies such as yoga; and an assessment of cost-effectiveness.
Hooray! And before you set up your study, please do your homework!
Seek first to learn and understand the distinction between real Taiji and sham Tai chi!!!
The real Taiji people are in the minority. And in a field where anyone can claim to be a master, well, it becomes difficult to discern who's the real deal and who's using lineage as a front for selling snake oil.
Beware of seeking out different styles for the sake of diversity! Sham Tai chi can be found in all styles!
From my experience, yoga and real Taiji are not similar.
In the end, however, it may be that further evidence in support of tai chi for fibromyalgia, even if consistently positive, will never be as fully convincing as the results of double-blind pharmaceutical trials.
I don't know. I think this is a valid concern.
It is also possible that future studies will not replicate the dramatic findings of this small trial12 and that not all patients with fibromyalgia will find tai chi acceptable or available.
The training involved to achieve even a beginners level of real Taiji is probably way beyond what the ordinary person who signs up for a clinical trial would be willing to engage in and follow-through on. While sham Tai chi has become somewhat available, accessing training in real Taiji is like finding a needle in a haystack.
Even so, the potential efficacy and lack of adverse effects now make it reasonable for physicians to support patients' interest in exploring these types of exercises, even if it is too early to take out a prescription pad and write “tai chi.”
Agreed. If people are getting some health benefit from sham Tai chi, well, good for them! It's also good to go for a walk...