Transcript Simplified Tai chi for Reducing Fibromyalgia Pain

Scott D. Mist PhD, LAc
K Jones, C Sherman, F Li, R Bennett, J Fisher
OHSU/ORI
R21 AR5335061-2 (NIAMS)
•Fibromyalgia (FM) is diagnosed in 6 to 12
million Americans, primarily women; annual
costs exceeding $20 billion
•Multisymptomatic chronic pain illness with
significant physical fitness limitations
•Average 40 year old FM patient
demonstrates physical fitness scores found
in a healthy person in their 8th decade
Wolfe, 1995, Arth Rheum; Wolfe, 1997, Arth Rheum
Jones 2010 J MS Pain; Jones 2009 NA Dis Clin
Carson, 2010, Pain
>90 exercise studies in FM have been
published to date.
•Most indicate that higher intensity
programs, regardless of mode, result in
improved physical fitness, but often worsen
pain.
•Recently, exercise that employs a
mind/body component has been found to be
effective in FM.
Previous research has suggested that Tai chi offers
a therapeutic benefit in patients with FM
How
much are physical fitness variables improved
(balance, strength, aerobic conditioning, flexibility)?
What
is the mechanism(s) of action of pain
reduction?
What
is the optimum frequency, intensity, timing
and type/mode?
Taggart, 2003, Orthop Nurs
Wang, 2010, NE J of Med
Single-blind
Randomized
12
week trial of 8-form Yang style, group Tai chi
Compared
to group wellness education
Non-academic,
community setting
Supervised group 8 form Yang style
◦simplified from 24 form
◦both static and dynamic
Dose: 90 minutes, twice weekly x 12 weeks
15 min warm up
45 min Tai chi training
15 min break
15 min cool-down
Progressive based on mastery and Borg PE scale.
1 Interventionist
Supervised group education
Including diagnostic criteria, pacing, problem
solving, diet, sleep, pain management,
medications, mental health, wellness and
lifestyle management.
3 Interventionist: MD, RD/LD, MSW. Same
interventionists and curriculum for all 5 waves.
Dose: 90 minutes, twice weekly x 12 weeks.
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Examiners blinded
Medications monitored/not washed out
Adherence defined as number of classes
attended
Enrollment occurred in 5 waves with
randomization by computer generated
numbers blocking on age
Tai chi DVD given to all participants after final
data collection
Treatment expectations
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40 years of age or older with FM per 1990 ACR
Independent ambulators without assistive devices
MD clearance for exercise within past 3 months
Willingness for random assignment
Willing to keep all treatments/meds steady
Absence of dyscognition (>3 Pfeiffer Mental Status)
Excluded: Tai chi training within the past 6 months,
or exercising > 30 mins/3x weekly for past 3 months
Serious medical conditions that might limit their
participation
Planned elective surgery during study period
The primary end point was between group
differences in change scores on FM symptom
severity and physical function (Fibromyalgia
Impact Questionnaire [FIQ] total) at the end of
12 weeks.
The end point was between group differences in
change scores on pain at the end of 12 weeks.
Pain was measured with Brief Pain Inventory (BPI
severity & interference) and VAS FIQ #15.
Pittsburg Sleep Quality Index - Global
FIQ symptoms
FIQ physical function
Static balance (stork)
Dynamic balance (forward reach)
Timed- get up and go
Upper body flexibility
FIQ total and pain outcomes will be
mediated by change in ASES (selfefficacy for pain control and
symptom control)
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Powered off 4 FM exercise studies and 1 Tai
Chi study in older adults without FM
Assumption: 80%power to detect 15%
between group differences in FIQ
Allow for 20% drop out, final n=96
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Intent to treat analyses
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Conditional change score analysis adjusting
for centered baseline1
Similar to two group mean comparison t-test
Advantages of method
◦ Less artifact of regression to the mean
◦ Lessen baseline differences if present
◦ Lower Standard Error (More accurate estimate of
treatment effect)
1
Aickin M, The Permanente Journal, Spring 2009
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Age: 54 years (range 40.7 – 74.1)
93% female
96% Caucasian
Body mass index: 30.5
2+ Rx for FM (non-narcotic analgesics and antidepressants)
Symptomatic 18.4 years
Approximately half did not work outside the
home despite that fact that 85% had attended or
graduated from college
FIQ total of 63.9
pain VAS of 7
Control
10
5
0
Frequency
15
20
Tai Chi
7.5
36 7.5
Hours of Intervention
36
70
65
60
55
50
45
40
Tai Chi
Education
p=0.0002
2.5
2
1.5
1
0.5
0
-0.5
Tai Chi
Education
p<0.001
8
1.5
6
Seconds
Inches
2
1
0.5
4
2
0
0
One Leg Stand
p<0.0001
Back Scratch p=0.41
1
2
Inches
Seconds
1.5
0.5
1
0.5
0
-0.5
8 Foot Get Up & Go
p<0.0001
0
Maximum Reach
p<0.0001
10
8
6
4
Tai Chi
2
Education
0
p<0.001
-2
-4
-6
Pain
Function
Other
10
8
6
4
Tai Chi
2
Education
0
p<0.001
-2
-4
-6
Pain
Function
Other
12 weeks of supervised group Tai chi improves
FM symptoms including pain and fitness
Findings were both clinically and statistically
significant FIQ, pain and sleep on PSQI
Replicated Wang’s Tai Chi study and
reproduced improvement in FM symptoms
Extending Wang’s work by examining more
fitness variables
Single blind vs. double blind
Optimum length of intervention unknown as
improvements were seen at endpoints in both
Wang’s and our study
Findings may not generalize to men, children or
minorities
Tai Chi master-intervention or interventionist?
Longer
study to quantify most efficacious dose
Multi-sited
trial or multiple interventionists
Laboratory
based fitness testing for 1RM,
postural stability, V02 max
Laboratory
based pain testing such as QST,
NFR and neuroimaging