Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k851 (Published 21 March 2018) Cite this as: BMJ 2018;360:k851
Opinion
Time to rethink exercise for fibromyalgia care
Opinion
The unintended consequences of tai chi for fibromyalgia
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It's not just an exercise, but moving 'chi' - the life force energy. It's comparatively more exhilarating and energizing. The movements have so much fluidity to them.
For any condition with pain, it's important that something improves circulation. It improves arterial circulation, increases venous return and hence removes tissue fluid: inflammatory mediators can be flushed out and pain is reduced.
Most important of all 'Tai Chi' is low impact and improves balance. On the other hand, any regular Aerobic exercise has the possibility of causing sore muscles or joints or even injury for beginners. We don't want to add more pain to their existing condition.
Plus it improves attention to the elements of exercise. Hence it is something to focus on other than the pain, which may be very helpful for people.
Competing interests: No competing interests
It is good to see such good research on the effectiveness of movement based therapies like Tai Chi for a chronic pain condition like fibromyalgia. Fibromyalgia can be quite devastating especially as it affects many youngsters. Yoga is another movement based therapy that has shown promise in fibromyalgia. We can clearly see that slow movement based techniques like Yoga and Tai Chi differ in many ways from fast movement based aerobic exercises in terms of practice, motivation and psychophysiological processes. But there may be a way of combining the two with good clinical outcomes. In my own clinical practice treating chronic pain that includes treating several young patients with fibromyalgia, I have experienced that a combination of simple Yoga and Tai Chi introduced in a graded form and later going on to simple aerobic exercise regimes appear to show benefits. Often I see that the motivation to take up movement based approaches in a condition such as chronic fibromyalgia is initially low perhaps due to the fear of the pain caused by movement, fatigability and also the psychological state of low mood, helplessness and low confidence. A very gentle introduction of simple Yoga routine of asana (gentle bends and stretches synchronized with deep breathing), pranayama (breathing techniques) and dhyana (mindfulness meditation) along with very basic and simple Tai Chi steps is commenced after initial counselling. In the follow-up sessions a gradual increase in the complexity and duration of sessions seems to show good results. Patients are allayed of their fears when they start gentle movements associated with relaxed feelings. As they progress there is a gradual increase in their levels of confidence and they grow bolder to push themselves a little more and they see that their stamina also improves gradually. Once they are able to see that in spite of what they went through and what they are going through, they are making steady progress they get motivated through modest success experiences and feel more in control and gain greater confidence in what they can achieve. Thus a virtuous cycle of positive conditioning of body and mind seems to get established gradually replacing the vicious cycle of pain, weakness and distress.
Competing interests: No competing interests
The finding that tai chi is superior to exercise is predicted by a network explanation of fibromyalgia [1,2] and tai chi is recommended as part of existing therapy based on that theory[3,4]. According to network theory, the unexplained pain of fibromyalgia is due to repeated association of voluntary movement with biological or psychological threat. Tai chi is helpful because mental relaxation and hence biomarkers associated with safety become associated with movement, and this association extinguishes the pathological threat-movement association. Exercise can be helpful for the same reason but the focus on mental relaxation may explain why tai chi was superior in this study. Additionally, exercise can produce a stress response, and if that occurred it would reinforce the threat-movement association. Some patients report a deterioration following exercise that is too strenuous for their level of illness – optimising exercise levels for patients is recommended in treatment guidelines.
Short periods of tai chi types of exercise are practiced during the body reprogramming courses for fibromyalgia patients (www.bodyreprogramming.org) provided by the Pain Management Service, Plymouth Hospitals NHS Trust [3,4]. Although we recommend tai chi classes to patients once they complete the course, patients report that many publically available tai chi classes last for too long for them to be able to manage. Optimising tai chi for patients may also be important as it is for exercise.
References
1. Hyland ME. A new paradigm to explain functional disorders and the adaptive network theory of chronic fatigue syndrome and fibromyalgia syndrome. In Sullivan GB, Cresswell J, Ellis B, Morgan M, Schraube E. Resistance and renewal in theoretical psychology. Concord, ON: Captus University Publications. (2017).
2. Melidis C, Denham SL, Hyland ME. A test of the adaptive network explanation of functional disorders using a machine learning analysis of symptoms. Biosystems 2018;165:22-30.
3. Hyland ME, Hinton C, Hill C, Whalley B, Jones RC, Davies AF. Explaining unexplained pain to fibromyalgia patients: finding a narrative that is acceptable to patients and provides a rationale for evidence based interventions. Brit J Pain 2016;10:156-161.
4. Davies T. I129 Body reprogramming for functional disorders: A new paradigm. Rheum 2016, 55(suppl 1), i25-i25.
Competing interests: No competing interests
When a simple management can be found for a disabling condition, it is clearly a good thing and evidence of effectiveness compared with alternatives is welcome.
It is interesting to speculate on why Tai Chi may be more effective than aerobic exercise. One explanation would be that increased use of bilateral cerebellar co-ordination assists by making muscular activity more efficient and therefore less painful.
Putative Cerebellar exercise (1) has been found to be effective in patients with PTSD, reducing scores on a validated scale by simply standing on one leg for 2 minutes twice daily. If cerebellar activity and bilateral co-ordination were found to be the basis of fybromyalgia or its treatment then it may be possible to deliver other targeted interventions.
1. Neil BA. Teaser Exercise to Prompt Neurogenenesis and restore the stressed mind. (2017), 3rd International Conference on Depression, Anxiety and Stress management.
Competing interests: No competing interests
Re: Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial
In the current study, and in every other study pertaining to tai chi as a therapeutic modality, there is a serious absence of objective comparison. Why didn't the researchers in the current study compare objective parameters of physical exertion and subjective measures of perceived exertion? Between groups? To say that tai chi is more or less effective, without a controll group of aerobic exercisers whose mental and physical efforts matched those of the tai chi group is an error. For example, is tai chi different from slow random movement of the same intensity?
Competing interests: No competing interests