Resources

  1. Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial BMJ 2018;360:k851  PMC5861462 

Transcript

Dr. Frank Domino:
Amy is a 38-year-old woman who has suffered significant trauma in the past and has developed fibromyalgia. She reports experiencing chronic intermittent pain, fatigue, and wakes from sleep feeling very tired. She often states she feels like she was run over by a truck. She has tried medication with limited benefit, and when you suggest exercise as a treatment for her fibromyalgia she's worried that it'd be far too painful. She said she's heard that some people do Tai Chi to treat their fibromyalgia, and she asks you what you think of that option. Hi, this is Frank Domino, Professor of Family Medicine and Community Health at the University of Massachusetts Medical School. Joining me today on today's episode is Dr. Alan Ehrlich, Associate Professor of Family Medicine and Community Health at the University of Massachusetts Medical School, and Executive Editor for DynaMed. Welcome to this episode, Alan.

Dr. Alan Ehrlich:
Thanks Frank.

Dr. Domino:
So fibromyalgia and Tai Chi, what's our standard approach to treating fibromyalgia in 2018?

Dr. Ehrlich:
Well, fibromyalgia can be somewhat difficult to treat in the first place. There are a number of things that are tried, some of them work temporarily. There's no cure for it. So the general approach is some analgesics such as NSAIDs, certainly aerobic exercise has been advocated and it's important when you think about aerobic exercise that it be a graded experience where you start slow, and gradually increase as tolerated. Some patients with fibromyalgia will report increased pain following exercise, and so that has to be weighed into it. The exercise often helps with better sleep, and sleep disorder is part of what many patients with fibromyalgia will report, and so you get a beneficial effect making the sleep more restorative, but you have to be able to tolerate it. Also, there are issues with pain perception, and cognitive behavioral therapy can be helpful, and health education and support groups also are an important component.

Dr. Domino:
Yup. I've seen that data, and I endorse trying to work on some form of exercise and intervention and good sleep effort. What about Tai Chi? Why did Amy think Tai Chi might be a good option?

Dr. Ehrlich:
So there have been some studies, small studies, looking at Tai Chi for many different conditions, but also for fibromyalgia. And there was recently actually a good-sized randomized trial that was looking at some different Tai Chi regimens versus aerobic exercise to see which would be more effective for treatment of fibromyalgia.

Dr. Domino:

Well, what did they find?

Dr. Ehrlich:
Well, first of all, the Tai Chi group, they did four different arms, one of which was twice a week for 24 weeks, one was twice a week for 12 weeks. Then they had one arm that was once a week for 12 weeks, and once a week for 24 weeks. And the aerobic exercise was twice a week for 24 weeks.

Dr. Domino:
How did these researchers evaluate whether the Tai Chi intervention was superior to the aerobic exercise?

Dr. Ehrlich:
Well, they compared on a number of different measures, one of which was the fibromyalgia impact questionnaire, and that one clearly showed a benefit, particularly with the twice a week for 24 weeks. They looked at things like patient's global assessment and things like that, and overall it was better with the Tai Chi compared to aerobic exercise. There are a couple of caveats to keep in mind, and some of that may help explain why. First of all, more patients who were in the Tai Chi group were able to follow through with the treatment program. They attended more sessions, and fewer of them dropped out of the study altogether. That may be because the programs were set up as an hour of Tai Chi for each session or an hour of aerobic exercise, and when you have someone who has fibromyalgia they're often deconditioned, and starting off with an hour of aerobic exercise, even if it's a graded activity, can be too much for many patients. So that's something to keep in mind. If someone has said they've tried aerobic exercise, it's important to understand how was that done, did they just start trying to jog three miles three times a week, or was it more gradual?

Dr. Domino:
So it sounds like the Tai Chi seemed at least as good if not better than the aerobic exercise with fewer dropouts. Which of the Tai Chi arms seemed to have the best outcomes?

Dr. Ehrlich: 
So the best outcomes seemed to be with the twice a week for 24 weeks, so the same intensity as the aerobic exercise. In both the Tai Chi groups and the aerobic exercise groups, the study participants were encouraged to do at least another hour on their own in between. But again, I think the Tai Chi by its nature, it's this slow moving activity, it's something that is easier for patients with fibromyalgia to get into without doing too much and feeling like they're hurting themselves.

Dr. Domino:
Well, and that... That sounds wonderful. I've done Tai Chi in the past and it really is remarkably effective at making you feel better. It's a great thing to do first thing in the morning. One of the challenges I have with my patients with fibromyalgia is their ability to practically get into some form of exercise routine. Any idea how you'd help patients with fibromyalgia, practically get involve with Tai Chi and make it part of their treatment regimen?

Dr. Ehrlich: 

So there are a number of different ways that someone could get involved. I would say that certainly contacting a local health facility like a hospital they often have Tai Chi programs for any number of conditions that they're offering them. And again, you can just reach out to community. There are Tai Chi instructors. One of the things that I think is interesting, this study was published in the British Medical Journal, and there was some accompanying opinion pieces, one was by a woman named Amy Price and she is an editor for patient-related materials at the BMJ and Amy, in fact, has fibromyalgia and she talked about her experience and the benefit she has had with fibromyalgia and people are interested, it's well worth reading. She made a number of points in her piece that I think are very practical for helping patients who might be interested in this. The first one that I would like to point out is that if things hurt, stop doing it, don't overdo things, talk to the instructor, let the instructor know they may be able to help you with your technique, show you what you could do differently, so that it wouldn't be as uncomfortable.

A lot of instructors have a free introductory class, so you can see, does this work? Is the instructor a good fit for me? That type of thing. Not every instructor is going to do things exactly the same. So if you're not having a good experience or it doesn't seem to be something that's a fit, then you could consider seeking out someone else. In addition, it takes time, you're talking about an hour at a time. When we talk about aerobic exercise, a lot of times, we're talking about just starting with a walk and it could be 10 or 15 minutes. But with a formal class, sometimes you're committing to an hour-long program. That's a significant investment of time. There's money involved. Not every Tai Chi class is gonna be covered by insurance. And so, you may have out-of-pocket expenses. Some may be bundled with a physical therapy program and if the doctor is sending you to physical therapy and that the physical therapy department has that as an option then it might be covered. So a lot of these types of things that are worth looking into, to see what can make the program most successful for the patient.

Dr. Domino:
I like the fact that we're recommending something that is effective as well as non-pharmacologic and ideally something that's going to improve patient outcomes. Alan, I think our listeners and I myself know that there's challenges in making the diagnosis of fibromyalgia. Any thoughts or bit of advice on how we should approach making that diagnosis when we suspect a patient might have fibromyalgia.

Dr. Ehrlich: 

I think there are certain key components of making the diagnosis, but I think that the idea of being very precise is probably not all that helpful. If you're identifying certain problems, there's a general approach that is going to be helpful to them, and should be tried along the lines of what we said. But in general, you're looking forward at someone who has widespread pain. It's not just localized to one limb, or one part of their body, it should be present for at least three months, and there should not be some inflammatory or other disease that explains it. It doesn't mean you can't have another disease that might cause pain also, but it shouldn't be something where this is what you believe is a manifestation of this other condition.

Now, people are probably familiar with these tender points that are supposed to be on both sides of the body and above and below the waist and so many of them have to be counted up. And that was originally a criteria developed by the American College of Rheumatology and the purpose of that criteria was to establish standards for people enrolling in clinical trials, it was never meant to be exclusively a diagnostic set of criteria. They have tried to simplify this, they have some severity scales that can be used and any type of resource who someone can look that up and utilize that, but the main points are what I had said at the beginning, the widespread pain present for three months, no other explanation to account for it. And if you have that, I think, where the person ultimately formerly gets diagnosed with fibromyalgia by a rheumatologist or someone, I think you can treat that person along the lines of, how someone with fibromyalgia is treated and you're gonna be right the vast majority of the time.

Dr. Domino: 
Alan, thank you so much. I really find the challenges with helping patients treat their own fibromyalgia. And this paper certainly opens up a new door and some new insights into helping patients help themselves.

Dr. Ehrlich:
Thanks, Frank.

Dr. Domino:

Practice pointer. When treating fibromyalgia, consider recommending Tai Chi twice a week to help control both their symptoms and possibly improve outcomes. Join us next time when we discuss the proper methods of obtaining accurate blood pressure readings in your office and helping the patients do so using a home blood pressure monitoring. And visit us at pri-med.com to stay current on many primary care topics.