Friday, October 15, 2010

Fibromyalgia: Is Tai Chi the Prescription?

As of this writing, a search on Tai chi and Fibromyalgia yielded a lot of sites referencing the August 2010 New England Journal of Medicine study, A Randomized Trial of Tai Chi for Fibromyalgia as if this study proved that Tai chi is a prescription for fibromyalgia! Wow!

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?

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...


  1. Mike! I've really enjoyed your last couple of articles about this research. One thing I'm concerned about is you've talked about "doing real tai chi" taking longer than a trial would last for. Remember, Even CXW doesn't do it right. Is tai chi an endpoint, or a journey? If CXW taught the beginners, would that be okay for a study? If Rick taught the beginners, would that be okay? People who would be doing tai chi as fibromyalgia sufferers would be beginners, so it makes sense to me to study if starting the journey that is Tai Chi is beneficial. You raise a lot of good points here, and I think your point of the special kinesthetic focus you have found is very important. Maybe you should contact the people who have conducted the study and act as a consultant. Think of the good you could do for the future of Tai Chi research if you raised these points to people who are interested in doing it!

    You are an expert, you've been doing Tai Chi for a long time, and I think you could contribute to its future here in the States.

    I believe in you, Mike. Just remember the story "Now I know what (Tai) Chi is, and keep exploring!

  2. Very nice work Mike!

    Yiquan's Wang Xiangzhai had a lot to say about Taiji where he lived (China.) Here is a link and a few bit from there:

    Bad for Health, Worthless in Combat
    As masters of the original Taijiquan, I should recommend the Yang brothers Shouhou and Chengfu. They are my friends, and I know that their Taiji has some knowledge of mechanics. But out of one hundred students, not even one gains its essence…and even then, it is still one-sided, because the skills of intuitive perception died out a long time ago. Originally, Taiji consisted of three fists, Wang Zongyue changed it into thirteen postures, and it was later embellished into as much as one hundred and fifty postures. This is the cause of the distortion.

    Sticking to mechanical movements, seeking beautiful postures and mistaking it for the glory of martial arts…that is terrible. Such a person cannot comprehend boxing for life. If a man of insight sees such a performance, he will feel sick for ten days.

    As a means of health preservation, Taijiquan restrains the spirit, and brings discomfort to its practitioner. For combat, it harms the practitioner’s limbs and trunk, and causes a useful body to become a mechanical and stiff thing…it’s nothing more than a waste of time.

    As for the training method—a punch with the fist here, a slap with the palm there, a kick to the left, and another one to the right—it is pitiful and laughable.

    As for dealing with an enemy in a fight: please do not even consider it. So ruined is this boxing that it has become useless. There are many more things, but I feel embarrassed to say them.

  3. R U all retarded?

    The great master was chinese. All translations to the english from the chinese are distorted one way or another.

    The great master said that tai chi had progressed into a complicated dance under which the basic principals are lost.

    He really did not care about the lineage or the history or who did what to whom. He was openly willing to show you what he could do to you.

    His concern was to embrace the basic principals as to how they related to fighting and in that process eliminate all the bs.

    My understanding is that if you can feel the "grand circulation" you can demonstrate "whole body connection" and therefore exibit "internal marshal arts"

    To the world "tai chi" is moving yoga, Kung fu is chinese karate and internal marshal arts are fake actors leaping onto two story roofs.

    I am so sorry that all of you are so frustrated on your personal journeys to enlightenment that you find it necessary to discuss how all the others have it wrong.

    There is no fake or real tai chi merely many peoples representation of their knowledge of various stuff.

    Where are all the fake golfers?

  4. Tai Chi research? Surely you jest? What is the point? Research on what? How to wave your arms? The relative benefits of waving your arms in different patterns? It is an obvious fact that everyone benefits from exercise and proper nutrition. Lets do karate reasearch and discover how hard you have to hit someone to kill them and use all of you as the control group!!!!!(Had alot of Cola with my garlic filled dinner) about the three loops of the tai chi set corresponding to our internal natural rythms as discoverd by Big Wang Inacave? What happens when chi starts flowing out of your butt?

    Get a grip people!

    1. Write in clear english
    2. Do all the sucking up in private
    3. Do not encourage others to write bullshit
    4. Write about stuff you really know or about stuff you have enough conviction for to lie or make stuff up about.
    5. Have enough gruff to not delete all the comments you dont like.

    I love all of you, peace be with you, may god have mercy on your souls.

  5. Here is a study about dance and movement being helpful. Tai Chi isn't any more or less special as far as I can tell. Just simply get up and shake your booty.

    Check this study out and learn more;
    Study on Dance/movement therapy in fybromyalgia