The results suggest that tai chi improves flexibility and positively influences levels of disease activity in AS patients. Tai chi, which is easily accessible to patients, may also be an effective intervention for further randomized studies.
Eun-Nam Lee,1 Young-Hee Kim,1 Won Tae Chung,2 and Myeong Soo Lee3
Abstract
Introduction
Ankylosing spondylitis (AS) is a chronic inflammatory
rheumatic disease that primarily affects the sacroiliac joint and spine, which
causes physical outcomes such as reduced physical activity, fatigue, sleep
disturbances and psychologic consequences such as depression, anxiety and
stress (1–5).
Because of its insidious nature, this condition's diagnosis may be delayed
until the final stage of the disease (6). AS
treatment aims to prevent the stiffness and flexion deformity that accompany
the disease and to maintain a healthy physical and psychologic state for the
patient (7).
First-line treatments for AS include physical exercise and the
administration of non-steroidal anti-inflammatory drugs (NSAIDs) or anti-tumor
necrosis factor (TNF) (6,8–10). Of many
available treatments, physical exercise appears to benefit patients coping with
the disease because activity provides opportunities to enhance their sense of
control over its symptoms, especially pain and immobility (9,10).
Tai chi is a combination
of physical exercise and relaxation techniques rooted in ancient Chinese
philosophy and is used to enhance its practitioners’ mental and physical health
(11). Several
previous studies have determined that tai chi is beneficial for
balance control, flexibility, aerobic capacity, headache (12),
improving immunity (13) and
psychologic variables such as depressive symptoms (14), mood
and anxiety (15). It
also improves muscular strength and reduces the risk of falls in the elderly (16–18). Tai chi also has been
determined to improve symptoms related to rheumatoid arthritis (RA) and
osteoarthritis (19,20).
Based on these findings, it is reasonable to assume that tai chi can help patients
with AS. However, no studies have been conducted on the effect of tai chi exercise in AS
patients. The present study clinically assesses tai chi'seffects
on disease activity, flexibility and depression in patients with AS.
Methods
Patients
Patients with AS were recruited through bulletin board
advertising to participate in an 8-week tai chi program at the
University Medical Center's Rheumatism Center. Patients were eligible to
participate in the program if they (i) were out-patients with no complications,
(ii) could understand the content of questionnaires and experimental schedules,
(iii) had no changes in their current prescription medication in the past 4
weeks, (iv) were classified as functional class II for AS according to the
Modified NY, USA Criteria for AS and (v) had not experienced tai chi, qigong or other related
relaxation training.
Sixty-one patients were eligible per our study's criteria. We randomly
selected 40 subjects from among the volunteers and allocated them to either the tai chi group (n = 20) or the
control group (n = 20).
The study's dropout rates were 35 and 15% for the tai chi and control
groups, respectively, so that both pre- and post-test data for 8 weeks of tai chi were available
from 13 subjects in the tai chi group and 17 controls. The primary reasons for
dropout in the tai chi group were that
participants moved to another city (three subjects), had no time available to
participate (two subjects) or were readmitted to the hospital (two subjects).
The primary reason for dropout in the control group was failure to complete due
to having no time available to participate (three subjects) (Fig. 1). We
conducted additional analysis to compare the demographic and pre-test data for
the dropouts to those of the remaining members of the tai chi and control
groups, which revealed no significant differences.
Diagram
of study design showing the flow of participants.
Subjects were informed about the nature of AS and the
study procedures. We received approval for the study from the University
Hospital's Institutional Review Board before we approached the subjects; all
subjects provided written informed consent.
Outcome Measures
This study's outcome measures included the
following: (i) disease activity (as the primary outcome measure) and (ii)
finger to floor distance (FFD) and depression (as secondary outcome measures).
Outcome measures were assessed by a nurse, who did not know the experimental
protocol or the subjects’ allocation, before and 8 weeks after the experiment.
Disease Activity
Disease activity the week prior to study
admission was measured as a baseline reading using the Bath Ankylosing
Spondylitis Disease Activity Index (BASDAI) (21),
which includes six questions related to five symptoms during the past week:
fatigue, spinal pain, joint pain, tenderness and morning stiffness. All items
are scored on a 10 cm visual analogue scale (VAS), on which higher scores
reflect greater disease activity. Analysis of this experiment indicated a high
level of internal consistency (Cronbach's α = 0.94).
Finger to Floor Distance (FFD)
FFD was measured with the patient bending
forward maximally with knees straight. We used a ruler to assess flexibility by
measuring the FFD. Two measurements were made and averaged.
Depression
The Center for Epidemiologic Studies
Depression Scale (CES-D) was used to measure the subjects’ depression level.
The CES-D is a 20-item self-report questionnaire that has been used extensively
for research purposes (22). It assesses the
current level of depressive symptomatology over the past week and has been
shown to possess good internal consistency (α = 0.85
as reported by Radloff (22); α = 0.96 in the
present study). Participants indicate their level of endorsement of each item
on a four-point scale ranging from ‘rarely or none of the time (less than one day)’
to ‘all of the time (5–7 days)’.
Intervention
The intervention program used 21 movements
based on tai chi for (RA) developed
by Dr Paul Lam et al.(23). The tai chi for RA consisted
of a warm-up exercise (10 min), 21 main movements (30 min) and a cool-down
exercise (5 min). This study's warm-up and cool-down exercises involved
stretching and relaxing the head, neck, upper and lower body and whole body.
The exercises were not modified from original tai chi for the arthritis
program.
The 21 basic tai chi movements involved
commencement form, opening and closing hands, single whip, waving hands in the
cloud, brush knee and twist step, playing the lute, stepping forward to deflect
downward, parrying and punching, pushing the mountain, closing form and
alternating sides for all previous motions (20).
Subjects in the tai chi group attended two
group tai chi classes per week
for 8 weeks, led by two instructors (the first two authors, ENL and YHK, who
are certified as tai chi instructors and
have 4 years of instruction experience). The instructors explained and
demonstrated how the exercises should be performed and the subjects followed. A
videotape was shown during the group session. We also individually instructed
subjects in the appropriate movements. Six weeks were devoted to learning the tai chi routine, so the
subjects were actually performing the routine competently for the last 2 weeks.
A special guide book for home practice was produced, which contains pictures
and written descriptions of the same exercise as the tai chi program. Subjects
were asked to practice their exercises at home for repetition with the guide
book (once daily for first 6 weeks and twice daily for last 2 weeks) and were
telephoned by the researchers twice each week. Participants recorded the
frequency and duration of their tai chi performance at
home in their exercise log, which the instructors assessed during every weekly
session (final compliance with home-based tai chi was 93.3%
according to the exercise logs).
Subjects in both groups received standard
drug treatments provided by the outpatient clinic. Control subjects received no
other treatment and did not participate in any structured exercise programs
during the study period. They were contacted by researchers twice weekly by
telephone to confirm that they were not taking part in any other exercise
activities and to provide impetus to keep them engaged in the study. Control
group subjects who were interested in tai chi were provided with
an exercise program after the study ended.
Results
No Differences in Baseline Homogeneity Between the Two
Groups
Adverse Events
No adverse effects associated with the
practice of tai chi were reported by
the participants.
Tai Chi Improves BASDAI, FFD and Depression
Fig. 2 shows the change
in outcome measures between the pre- and post-test scores (post-test –
pre-test) and an unpaired group test was conducted to assess tai chi's effects on AS
symptoms. By the 8-week study's endpoint, BASDAI had improved significantly
compared to the control group (intergroup difference, P < 0.05). FFD in
the tai chi group also
differed significantly from that of the control group (P < 0.05). No significant intergroup differences were
seen in depression scores.
The
changes (post-pre) of outcome measures including Bath Ankylosing Spondylitis
(AS) Disease Activity Index, flexibility and depression between the pre- and
post-tests. Values are expressed as mean (SD). FFD: finger to floor distance.
Compared to the change scores from the
pre-test data, the tai chi group exhibited
negative scores in their BASDAI, FFD and depression scores of −7.38 (SD 13.02),
−4.56 (SD 2.74) and −5.86 (SD 8.10), respectively; while the control group had
more BASDAI (0.35, SD 6.77) and FFD (1.84, SD 10.58) or reduced depression
(−2.12, SD 8.57).
Discussion
This preliminary controlled clinical trial
was conducted to investigate the efficacy of tai chi exercise in
patients with AS. Subjects in the active treatment group showed greater
improvement in disease activity and flexibility after 8 weeks than controls.
This result supports previous findings that tai chi benefits
flexibility and disease activity in different conditions (11,16,18,20). The
results of the current study also suggest that tai chi may be used to
treat symptoms of AS. This finding has not been previously reported.
The effect size (ES) in terms of disease activity
(BASDAI) improvement was significant for the tai chi group versus the
control group. Compared to previous studies, the ES of tai chi (0.60) was
greater than that of home exercise (0.09) (24),
conventional exercise (0.24) (25,26),
global posture re-education (0.15) (25,26) and
NSAIDs (0.55) (27).
FFD improvement was significant for the tai chi group versus the
control group. The ES of tai chi (0.30) was greater
than that of home exercise (0.1) (28), but
group exercise (0.38) (28) and
home-based exercise (0.39) (29)
resulted in a higher ES than tai chi.
One-third of AS patients experienced depression
related to pain (30). In
our study, the depression level decreased (i.e., improved) more in the tai chi group than in the
control group; however, the difference was not significant. These results are
consistent with previous results. For example, Taylor-Piliae (15)
reported no significant changes in depression level after six or 12 weeks of tai chi. Data
from other studies also failed to find an effect on depression level of two or
three times weekly tai chi for 12 weeks (31,32). However, an
average of four times weekly tai chi for 18 weeks reduced depression level in
osteoarthritic patients (33). We speculate
that training time and duration seemed to relate to reducing depression level,
but further studies are required to prove this.
Assuming that tai chi is a potentially
useful treatment option for patients with AS, its possible mechanism of action
may be of interest. When performed regularly, the physical exercise of tai chi (11) affects the
cardiovascular and muscular systems, resulting in muscular adaptation and,
ultimately, increased muscle strength. Physical activity can also improve joint
stability and aid in reducing excess weight, effectively decreasing joint pain,
increasing function and improving other symptoms related to AS (3,10,34–36).
This study has several limitations, including its
small sample, high dropout rate and lack of an equivalent exercise control
group to estimate the expectation effect. Moreover, we cannot completely
confirm the absence of performance bias, such as complete separation of contact
between the two groups, which may indicate a possible placebo effect in this
study.
In conclusion, our results suggest that tai chi improves flexibility and positively influences levels of disease activity in AS patients. Tai chi, which is easily accessible to patients, may also be an effective intervention for rther randomized studies, with more objective measures, larger samples,
measurements after multiple sessions and long-term follow-up, are needed to
verify tai
chi's effects
on patients' quality of life, pain, mobility, psychologic variables and
physical functional improvement.
Learn more about the predecessor of Tai Chi, Shaolin Rou Quan
Original source
Evid Based Complement Alternat Med. 2008 Dec; 5(4): 457–462
Learn more about the predecessor of Tai Chi, Shaolin Rou Quan
Original source
Evid Based Complement Alternat Med. 2008 Dec; 5(4): 457–462
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