Can Tai Chi Truly Help Those With Knee Arthritis?
Tai Chi – an ancient Chinese therapy used to reduce stress and fight anxiety – is as effective as standard physical therapy in patients suffering with osteoarthritis of the knee, according to results of a new study.
The research was published online in Annals of Internal Medicine.
But in this study, Tai Chi went one step further than traditional physical therapy : Tai Chi not only produced greater improvements in depression, but also physical aspects of quality of life.
Knee osteoarthritis is a major cause of chronic pain and disability in the U.S., as well as globally. In simple terms, arthritis develops from wear and tear to joints over the years, or due to injury, as cartilage that helps cushion joints is eroded, leaving bones to rub together, ultimately producing bony growths known as osteophytes. Osteophytes, which are the end result of progressive arthritis, lead to restricted motion, pain and swelling of joints, resulting in deficits in mobility and balance, placing sufferers at a higher risk for falls.
Obesity is also a well known risk factor that may help fuel the progression of arthritis , making weight loss an important part of a comprehensive plan to reduce its disabling consequences.
Over-the-counter pain medications such as ibuprofen and acetaminophen often fail to relieve symptoms and in some cases may be associated with serious adverse effects including liver damage, gastrointestinal bleeding and kidney damage.
Physical therapy is typically prescribed by healthcare providers, but the benefits are not considered to make a major impact in the degree of pain and general quality of life. As a result, it would be highly useful to identify innovative and beneficial approaches for those who suffer with debilitating knee arthritis.
Tai Chi is a multifaceted yet traditional Chinese mind-body practice that combines meditation with slow, gentle, graceful movements, deep breathing and relaxation. While it has been demonstrated to reduce pain in patients with knee osteoarthritis, no trials have directly compared Tai Chi with standard physical therapy.
In this study, investigators compared Tai Chi with standard physical therapy to assess its ability to reduce pain, improve physical function, fight depression, reduce medication use and improve quality of life in patients with knee osteoarthritis.
In the study, 204 participants, (age 40 and over) were randomly assigned to one of two treatment groups: Tai Chi or standard physical therapy. Patients in the Tai Chi group performed Tai Chi with a trained instructor two times per week for 12 weeks. Patients in the physical therapy group had standard physical therapy two times per week for six weeks, followed by six weeks of monitored home exercise.
After 12 weeks, patients in both groups showed significant improvements in pain. Pain was assessed and measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The improvement in pain in both groups lasted up to 52 weeks. But compared to those in the physical therapy group, patients in the Tai Chi group had significantly greater improvements in the physical aspects of well-being, along with reduced levels of depression.
“Tai Chi produced effects similar to those of a standard course of physical therapy in the treatment of knee osteoarthritis,” said Chenchen Wang, MD, MSc, lead author and director of the Center for Complementary and Integrative Medicine in the Division of Rheumatology at Tufts Medical Center, professor of medicine at Tufts University School of Medicine. “Standardized Tai Chi should be considered as an effective therapeutic option for knee osteoarthritis.”
Wang explains that “Tai Chi may systematically promote health by its effect on both the body and the mind by integrating physical, psychosocial, emotional, spiritual and behavioral elements.”
Research indicates that Tai Chi has the ability to modify and supercharge the mind-body connection . “It may elicit behavioral responses by activating neuroendocrine and autonomic functioning and navigating neurochemical and analgesic pathways, which in turn may modulate the inflammatory response of the immune system and modify susceptibility to chronic pain,” said Wang.
“By improving self-efficacy, social function and depression,” explains Wang, “Tai Chi may help patients bolster their self-confidence and overcome their fear of pain–the latter of which often leads to physical malfunction and debility.”
Amy McGorry, who holds a doctorate in physical therapy, and practices at Thrive Integrated Physical Therapy in Soho, believes that there is value in Tai Chi, by virtue of the fact that “it is conducted in a group setting involving the focus of breathing and movements with people not discussing their ailments,” she explained. “Breathing is shown to help decrease the fight or flight response, thus alleviating stress.” But on the flip side, she explains that people run the risk of focusing excessively on their particular ailment or injury, with the risk of this becoming a temporary identity for them while they are under treatment.
But seeing a physical therapist, she explains, also has the potential to lead to an excessive focus on the chronic ailment or injury in some patients–particularly regarding the way it distracts them from their normal routines and activities. The goal, McGorry believes, is to get them mobilized again, and this may include integrating Tai Chi as a compliment to their individualized physical therapy regimen.
“Tai Chi can take the focus off the injury with attention spent on breathing and form,” explained McGorry. But, as the reality of insurance sets in as payment for such services, she explains that “while it is important that physical therapy clinics promote health and well being, insurance companies have visits monitored based on pain and dysfunction, so that can weigh heavily on the emotional component of healing.”
Yet one of the most critical aspects of healing while undergoing physical therapy is also rooted in a human connection, described Patricia Ladis, co-founder and physical therapist at KIMA center for Physiotherapy and Wellness in the Chelsea section of Manhattan.
“If a patient connects with their physical therapist, trusts them, and feels like he/she is being treated with dignity & respect AND the therapist is well focused on an individualized approach to getting them better, they will have huge benefits with standard physical therapy,” said Ladis.
“Top factors that determine physical therapy success have been getting 7-9 hours of sleep while in treatment, and connecting with their physical therapist. This is in contrast to “Tai Chi, where you are in an introspective space,” she emphasized. “You can be quiet in your mind as you explore and focus on the movements of your body.”
Ladies offered “that is a hugely beneficial thing for healing from pain. A quiet mind leads to a quiet body. Similar to the beneficial effects of meditation, someone in a daily introspective practice like Tai Chi or Yoga can have great health benefits.”
But pain and stiffness can still derail a plan for Tai Chi, which can also be compounded by obesity.
“Sometimes people can not even endure Tai Chi because any global movement hurts, and in those cases physical therapy is crucial,” said Ladis. “Tai Chi is a great movement practice and has been very efficient at restoring proprioception and balance that physical therapy aims to accomplish. But it is also balancing to the mind and mobilizes the chi (energy) of the body which is crucial when we have degenerative changes and as we age. This is why this ancient practice is adopted by many and has helped so many. I believe for prevention or post physical therapy, Tai Chi can be very beneficial,” she added.
“Tai Chi has its merits and is a more holistic than traditional physical therapy offered in North America,” said Anthony Romeo, M.D., FAAOS, Professor of Orthopedic Surgery at Rush University in Chicago, and team physician for the Chicago Bulls and Chicago Whitesox. “One of the big differences [between the two groups in the study] is that Tai Chi was instructed two times a week for 12 weeks by a Tai Chi “master”, but PT was only instructed for 6 weeks and the level of the physiotherapist was not described (are they equivalent to a Tai Chi master?). The second six weeks were a home exercise program that was monitored but it’s not the same as having someone directly instructing you.”
Romeo further explained that “Tai Chi as taught by Tai Chi masters includes a very holistic approach to the person, including not only the physical requirements, but also the balance in mental health, whole body stability, meditation, breathing, and mind-body focus or connection. This helps people develop more positive mental attitudes and well-being, which is likely to also play a role in overall recovery from the stress musculoskeletal impairment.”
And, he continued, “since a significant part of the patient’s concern is pain from osteoarthritis, and the mental perception and coping with pain is based on our mental status, Tai Chi is approaching this problem from many angles not typically addressed with traditional physiotherapy.”
“The explanation for the benefits of Tai Chi is rooted in the fact that it provides patients a ‘way of life ‘beyond just their knee arthritis,” which Romeo believes, “provides them an alternative, and something they can do independent of a therapist, but also establishes a feeling of ‘community ‘if practiced in groups.”
Romeo concludes that “maybe the very best approach is 6 weeks of physiotherapy followed by Tai Chi. Further studies should be done to investigate it’s positive effects as an adjunct to treating osteoarthritis of the knee and other joints.”
The Real World Benefits of Tai Chi
Putting a real-world spin on the ultimate benefits of Tai Chi, another expert advocated for the benefits of staying active as we age.
“It makes perfect sense that Tai Chi should be offered as an effective modality in the promotion of joint health,” said Jeff Schildhorn, M.D., orthopedic surgeon at Lenox Hill Hospital, Northwell Health in New York City. “The two debilitating features of osteoarthritis are pain and decreased range of motion. Some common pieces of practical wisdom in osteoarthritis are ‘keep moving,’ or even ‘use it or lose it.’ While pain often inhibits the activities of those with osteoarthritis, I encourage my patients to remain very active within their own levels of tolerance.”
“Tai chi embodies fundamental elements that promote joint health,” added Schildhorn, because it leads to “controlled and fluid movement, which allows for better neurological control, otherwise known as joint position sensitivity.”
“Gentle strengthening and improved flexibility remain other essential benefits,” he offered.
Value of Meditation for Pain Relief
But it’s ultimately the embodiment of meditation that can lead to relief of pain, according to Schildhorn.
“The meditative aspects of Tai Chi also help patients to transcend the pain associated with osteoarthritis. People become more mindful and understand that pain is a sensation, but they are able to attach less negative emotion to their pain,” he explained.
But the true value of Tai Chi may ultimately be in its ability to empower patients to help themselves, connecting movement with pain relief and ultimately some degree of easing of depressive symptoms.
“Mostly, Tai Chi, among other movement arts, allows patients to actively participate in the treatment of their osteoarthritis–they are empowered to make a difference in their own conditions, not simply relying on the treatments of others,” emphasized Schildhorn.
“Osteoarthritis is a disease that exists on a continuum. For the worst cases, joint replacement surgery is an extraordinarily successful option. But, for the millions of patients suffering with the pain and stiffness of osteoarthritis in its early and moderate stages, Tai Chi is an ideal treatment option,” concluded Schildhorn.