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. 2019 Sep 25;9(9):CD004849.
doi: 10.1002/14651858.CD004849.pub2.

Tai Chi for rheumatoid arthritis

Amy S Mudano  1 , Peter Tugwell, George A Wells, Jasvinder A Singh
Affiliations

Tai Chi for rheumatoid arthritis

Amy S Mudano et al. Cochrane Database Syst Rev. .

Abstract

Background: Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory, autoimmune disease that results in joint deformity and immobility of the musculoskeletal system. The major goals of treatment are to relieve pain, reduce inflammation, slow down or stop joint damage, prevent disability, and preserve or improve the person's sense of well-being and ability to function. Tai Chi, interchangeably known as Tai Chi Chuan, is an ancient Chinese health-promoting martial art form that has been recognized in China as an effective arthritis therapy for centuries. This is an update of a review published in 2004.

Objectives: To assess the benefits and harms of Tai Chi as a treatment for people with rheumatoid arthritis (RA).

Search methods: We updated the search of CENTRAL, MEDLINE, Embase, and clinical trial registries from 2002 to September 2018.

Selection criteria: We selected randomized controlled trials and controlled clinical trials examining the benefits (ACR improvement criteria or pain, disease progression, function, and radiographic progression), and harms (adverse events and withdrawals) of exercise programs with Tai Chi instruction or incorporating principles of Tai Chi philosophy. We included studies of any duration that included control groups who received either no therapy or alternate therapy.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: Adding three studies (156 additional participants) to the original review, this update contains a total of seven trials with 345 participants. Participants were mostly women with RA, ranging in age from 16 to 80 years, who were treated in outpatient settings in China, South Korea, and the USA. The majority of the trials were at high risk of bias for performance and detection bias, due to the lack of blinding of participants or assessors. Almost 75% of the studies did not report random sequence generation, and we judged the risk of bias as unclear for allocation concealment in the majority of studies. The duration of the Tai Chi programs ranged from 8 to 12 weeks.It is uncertain whether Tai Chi-based exercise programs provide a clinically important improvement in pain among Tai Chi participants compared to no therapy or alternate therapy. The change in mean pain in control groups, measured on visual analog scale (VAS 0 to 10 score, reduced score means less pain) ranged from a decrease of 0.51 to an increase of 1.6 at 12 weeks; in the Tai Chi groups, pain was reduced by a mean difference (MD) of -2.15 (95% confidence interval (CI) -3.19 to -1.11); 22% absolute improvement (95% CI, 11% to 32% improvement); 2 studies, 81 participants; very low-quality evidence, downgraded for imprecision, blinding and attrition bias.There was very low-quality evidence, downgraded for, blinding, and attrition, that was inconclusive for an important difference in disease activity, measured using Disease Activity Scale (DAS-28-ESR) scores (0 to 10 scale, lower score means less disease activity), with no change in the control group and 0.40 reduction (95% CI -1.10 to 0.30) with Tai Chi; 4% absolute improvement (95% CI 11% improvement to 3% worsening); 1 study, 43 participants.For the assessment of function, the change in mean Health Assessment Questionnaire (HAQ; 0 to 3 scale, lower score means better function) ranged from 0 to 0.1 in the control group, and reduced by MD 0.33 in the Tai Chi group (95% CI -0.79 to 0.12); 11% absolute improvement (95% CI 26% improvement to 4% worsening); 2 studies, 63 participants; very low-quality evidence, downgraded for imprecision, blinding, and attrition. We are unsure of an important improvement, as the results were inconclusive.Participants in Tai Chi programs were less likely than those in a control group to withdraw from studies at 8 to 12 weeks (19/180 in intervention groups versus 49/165 in control groups; risk ratio (RR) 0.40 (95% CI 0.19 to 0.86); absolute difference 17% fewer (95% CI 30% fewer to 3% fewer); 7 studies, 289 participants; low-quality evidence, downgraded for imprecision and blinding.There were no data available for radiographic progression. Short-term adverse events were not reported by group, but in two studies there was some narrative description of joint and muscle soreness and cramps; long-term adverse events were not reported.

Authors' conclusions: It is uncertain whether Tai Chi has any effect on clinical outcomes (joint pain, activity limitation, function) in RA, and important effects cannot be confirmed or excluded, since all outcomes had very low-quality evidence. Withdrawals from study were greater in the control groups than the Tai Chi groups, based on low-quality evidence. Although the incidence of adverse events is likely to be low with Tai Chi, we are uncertain, as studies failed to explicitly report such events. Few minor adverse events (joint and muscle soreness and cramps) were described qualitatively in the narrative of two of the studies. This updated review provides minimal change in the conclusions from the previous review, i.e. a pain outcome.

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Conflict of interest statement

AM – none

JAS – JAS has received consultant fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Medscape, WebMD, Clinical Care options, Clearview healthcare partners, Putnam associates, Spherix, the National Institutes of Health and the American College of Rheumatology. JAS owns stock options in Amarin pharmaceuticals and Viking therapeutics. JAS is a member of the executive of OMERACT, an organization that develops outcome measures in rheumatology and receives arms‐length funding from 36 companies. JAS serves on the FDA Arthritis Advisory Committee. JAS is a member of the Veterans Affairs Rheumatology Field Advisory Committee. JAS is the editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta‐analysis. JAS previously served as a member of the following committees: member, the American College of Rheumatology's (ACR) Annual Meeting Planning Committee (AMPC) and Quality of Care Committees, the Chair of the ACR Meet‐the‐Professor, Workshop and Study Group Subcommittee and the co‐chair of the ACR Criteria and Response Criteria subcommittee.

GW – none

PT – travel and accommodation for OMERACT meetings – a registered non‐profit independent medical research organization, whose goal is to improve and advance the health outcomes for patients suffering from musculoskeletal conditions. OMERACT receives unrestricted educational grants from the American College of Rheumatology, European League of Rheumatology, and several pharmaceutical companies listed below, which is used to support fellows, international patient groups, and support a major international bi‐annual conference, which results in many peer‐reviewed publications; Amgen, Astra Zeneca, Bristol Myers Squibb, Celgene, EliLilly, Genentech/Roche, Genzyme/Sanofi, Horizon Pharma Inc, Merck, Novartis, Pfizer, PPD, Quintiles, Regeneron, Savient, Takeda Pharmaceutical, UCB Group, Vertex, Forest, Bioiberica. PT is an independent committee member for clinical trial Data Safety Monitoring Boards for FDA approved trials, being conducted by UCB Biopharma GmbH & SPRL, Parexel International, and Prahealth Sciences. He is an independent medical consultation professional services for CHEOR Solutions (Canada) Ltd., Innovative Science Solutions LLC; and an advisory committee member of the Canadian Reformulary Group Inc., a company that reviews the evidence for health insurance companies employer drug plans.

No authors have an interest in Tai Chi or any comparators considered for this review.

Figures

1
1
Study flow diagram – 2018 update
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1 Major efficacy: clinical and functional outcomes, Outcome 1 Change in pain, Visual Analog Scale (VAS) at 12 weeks.
1.2
1.2. Analysis
Comparison 1 Major efficacy: clinical and functional outcomes, Outcome 2 Change in disease activity (DAS‐28‐ESR) at 12 weeks.
1.3
1.3. Analysis
Comparison 1 Major efficacy: clinical and functional outcomes, Outcome 3 Change in function, Health Assessment Questionnaire (HAQ) at 12 weeks.
2.1
2.1. Analysis
Comparison 2 Major safety: withdrawals, Outcome 1 Withdrawals Overall.
3.1
3.1. Analysis
Comparison 3 Minor efficacy: clinical and functional outcomes, Outcome 1 ACR20 at 12 weeks.
3.2
3.2. Analysis
Comparison 3 Minor efficacy: clinical and functional outcomes, Outcome 2 Number of tender joints.
3.3
3.3. Analysis
Comparison 3 Minor efficacy: clinical and functional outcomes, Outcome 3 Number of swollen joints.
3.4
3.4. Analysis
Comparison 3 Minor efficacy: clinical and functional outcomes, Outcome 4 Grip strength.
3.5
3.5. Analysis
Comparison 3 Minor efficacy: clinical and functional outcomes, Outcome 5 50 foot walk (seconds).
4.1
4.1. Analysis
Comparison 4 Minor efficacy: range of motion, Outcome 1 Ankle plantar flexion (degrees).
4.2
4.2. Analysis
Comparison 4 Minor efficacy: range of motion, Outcome 2 Lower extremity flexion: hip, knee, ankle dorsal flexion (degrees).
4.3
4.3. Analysis
Comparison 4 Minor efficacy: range of motion, Outcome 3 Shoulder flexion (degrees).
4.4
4.4. Analysis
Comparison 4 Minor efficacy: range of motion, Outcome 4 Shoulder internal and external rotation (degrees).
See this image and copyright information in PMC

Update of

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