Respectful Insolence

I tell ya, I go away for a few days and something always seems to happen that I’d be all over if I were at home and blogging normally. Either something major happens in the anti-vaccine movement or there’s a new study being touted by woos or womthing else big happens. In the old days, I’d try to cover it anyway, but lately I’ve learned just to let it go until I get back home. If I’m still interested in it, the end result will usually be better, and if I’m not still interested in it then it’s probably better that I never bothered writing about it anyway. This particular bit of blog material happened to appear in, of all places, in the New England Journal of Medicine, which a mere three and a half weeks ago published a credulous and one-sided article about acupuncture for low back pain.

Last week, as I was on my way to Chicago, it was tai chi.

Last Thursday, the NEJM published an article reporting a study of the use of tai chi in treating fibromyalgia. Entitled A Randomized Trial of Tai Chi for Fibromyalgia, the study comes out of the Tufts University School of Medicine and the Newton-Wellesley Hospital in Boston and was carried out by a team led by Chenchen Wang, MD, MPH. Not surprisingly, the study has gotten a lot of play in the media, for example, in this story in the L.A. Times, which is at least reasonably restrained, probably because it an AP wire story by Marilynn Marchione, who has written some excellent articles about “alternative” medicine before. Even the normally reliable GoozNews seems smitten with this study beyond what it rates, characterizing it as “rare victory for the National Institute of Health’s National Center for Complementary and Alternative Medicine and Sen. Tom Harkin (D-IA), who routinely comes under fire for pushing funding for these types of studies.” I’m less impressed. You’ll see what I mean in a few minutes, I hope.

First, however, let’s look at the study itself.

Fibromyalgia sucks. If there’s one condition or disease (or whatever you want to call it) that is pretty poorly understood by science thus far, it’s fibromyalgia. Indeed, like some diseases that are also not well understood, there has even been some debate whether or not fibromyalgia exists as a distinct disease, although that debate appears to have been largely settled in favor of fibromyalgia as a clinical entity. Unfortunately, the pathogenesis and pathobiology of fibromyalgia are not well understood, and there is little agreement on precise diagnostic criteria. The authors of this study describe it thusly:

Fibromyalgia is a common and complex clinical syndrome characterized by chronic and widespread musculoskeletal pain, fatigue, sleep disturbance, and physical and psychological impairment.

And an accompanying editorial by Gloria Y. Yeh, M.D., M.P.H., Ted J. Kaptchuk, and Robert H. Shmerling, M.D. describes fibromyalgia thusly:

Fibromyalgia is a common and poorly understood pain disorder that afflicts an estimated 200 million or more people worldwide.1 The lack of objective abnormalities detected on physical examination and standard blood and imaging tests has led many physicians to question the existence of this disorder.2 However, for those experiencing the pain and other associated symptoms (including fatigue, stiffness, and nonrestorative sleep), there is little doubt that the condition is real — and so is the need for relief. Studies over the past decade suggest that fibromyalgia may be due, at least in part, to an alteration in pain sensitivity in the central nervous system.3 Other potential mechanistic contributors include a genetic predisposition, emotional or physical stress, disordered sleep, and neurohormonal dysfunction.

These sorts of conditions are often the most frustrating of conditions to deal with, particularly for patients but also for doctors. After all, no one goes into medicine to tell patients that there’s not much we can do for them; yet that’s what doctors all too often end up having no choice but to tell fibromyalgia patients. Not surprisingly, patients are not satisfied with this. They’re suffering, and they want relief. Also not surprisingly they’re willing to try almost anything, including the rankest forms of quackery peddled by unscrupulous quacks.

Of course, tai chi is not a rank form of quackery pedaled by unscrupulous quacks. It’s a martial art that combines slow, deliberate, graceful exercises with deep breathing and relaxation. I was merely using the reference to quacks to explain why it’s not surprising that physicians might consider tai chi as an intervention in patients with fibromyalgia, given that the standard interventions recommended consist of exercise, sleep hygiene, and medications. All of these interventions have problems, particularly the pharmacological interventions, which in general aren’t all that effective. One might even say that demonstrating their efficacy to be greater than that of placebo interventions has been difficult. Although exercise is helpful in fibromyalgia, it is not known what kind, intensity, or combination of exercise modalities works, and, of the ones that may work, which one works the best. Tai chi, therefore, would appear to be an excellent candidate exercise regimen because of its gentleness, requirement for control, and relaxation. So testing tai chi in fibromyalgia is not an unreasonable hypothesis.

In this particular study, the design was fairly straightforward and is summarized below (click for a larger image):

i-a3f425af18b81f85cab3050f16e56de3-Randomization-thumb-480x621-54964.jpg

Basically, the study examined 66 patients diagnosed with fibromyalgia by the time randomization was complete, of which 33 were assigned to the tai chi group and 33 to a sham group that underwent stretching exercises. This design had 78% power to detect a difference between means at a significance level of 5% with the use of a two-sided t-test.

The tai chi intervention was described thusly:

The tai chi intervention took place twice a week for 12 weeks, and each session lasted for 60 minutes. Classes were taught by a tai chi master with more than 20 years of teaching experience. In the first session, he explained the theory behind tai chi and its procedures and provided participants with printed materials on its principles and techniques. In subsequent sessions, participants practiced 10 forms from the classic Yang style of tai chi18 under his instruction. Each session included a warm-up and self-massage, followed by a review of principles, movements, breathing techniques, and relaxation in tai chi. Throughout the intervention period, participants were instructed to practice tai chi at home for at least 20 minutes each day. At the end of the 12-week intervention, participants were encouraged to maintain their tai chi practice, using an instructional DVD, up until the follow-up visit at 24 weeks.

The control intervention consisted of this:

Our wellness education and stretching program similarly included 60-minute sessions held twice a week for 12 weeks.19 At each session, a variety of health professionals provided a 40-minute didactic lesson on a topic relating to fibromyalgia, including the diagnostic criteria; coping strategies and problem-solving techniques; diet and nutrition; sleep disorders and fibromyalgia; pain management, therapies, and medications; physical and mental health; exercise; and wellness and lifestyle management.20 For the final 20 minutes of each class, participants practiced stretching exercises supervised by the research staff. Stretches involved the upper body, trunk, and lower body and were held for 15 to 20 seconds. Participants were instructed to practice stretching at home for 20 minutes a day.

One can certainly argue whether the sham control intervention was an appropriate sham control or not. It would depend to some extent what sort of stretching exercises were included, as well as other factors, such as the quality of the instructional material and the attention paid to the patients by the wellness education instructor. Also, one might imagine that the self-massage part of the tai chi intervention might have some benefit. It’s hard to say.

Patients were evaluated before starting the trial and then periodically for the severity of their fibromyalgia symptoms. The primary outcome measure was the change in the score on the Fibromyalgia Impact Questionnaire, a 100-point scale that estimates intensity of pain, physical functioning, fatigue, morning tiredness, stiffness, depression, anxiety, job difficulty, and overall well-being at 12 weeks. Secondary outcomes included the FIQ score at each week, as well as a number of other measures of fibromyalgia severity, chronic pain, and quality of life. Participants continued their regular medications and treatments, making note of any changes that occurred during the study period.

The results demonstrated improvement in FIQ scores in the tai chi group from 62.9±15.5 to 35.1±18.8, with an improvement in the control group from 68.0±11 to 58.6±17.6, with a highly statistically significant p-value. Investigators also noted improvements in other measures of pain and quality of life, all in favor of the tai chi group. More patients in the tai chi group had discontinued their medications to treat fibromyalgia by the end of the study period, but the difference was not statistically significant.

As you might expect, this study had a number of limitations. First, it isn’t very large. Another problem is that it looked at fairly short term outcomes. Fibromyalgia is a chronic condition for which 12 to 24 weeks do not represent a sufficiently long period of time to judge whether any potential responses will be durable. Previous studies have found that exercise can help fibromyalgia but that the effects are not always durable. This is particularly true given that fibromyalgia, like many chronic pain syndromes, is prone to placebo effects due to interventions, regardless of whether they’re effective or not. That’s one aspect of the condition that makes fibromyalgia so difficult to study.

More importantly, one has to remember that this study was not double-blind. The authors justify this lack of blinding by arguing that there is no accepted and validated sham tai chi intervention. Fair enough. It took many years before scientists studying acupuncture managed to develop and validate various forms of sham needles that successfully blinded both patient and practitioner as to whether they were undergoing “true” or sham acupuncture. The authors also point out that investigators told study subjects that tai chi was being tested. Rather, they told subjects that they were testing the effects of two different exercise training programs, one of which was combined with education. Fair enough as well, but whether this “deemphasis” of tai chi worked or not to minimize expectations and placebo effects is highly arguable. Do the investigators really think that most of the tai chi group didn’t realize they were doing some form of “Eastern” martial art? Yeh et al sum up the difficulty in coming up with an adequate sham intervention for tai chi very well:

The authors state that they tried to minimize any a priori differences between expectations for tai chi and the control intervention, which consisted of stretching and health education, and they report that expectations in the two groups were similar at baseline. However, it seems likely that when a persuasive and enthusiastic teacher of tai chi first explained its potential benefits to the class, expectations in this group were heightened. The authors dutifully suggest that a sham tai chi intervention would have been desirable as a control. Ideally, a placebo control matches all aspects of the therapeutic intervention except for the “active” element of that intervention. But what is the active element of a complex, multicomponent therapy such as tai chi?11 Is it rhythmic exercise, deliberate and deep breathing, contemplative concentration, group support, relaxing imagery, a charismatic teacher, or some synergistic combination of these elements? If so, would the matched control include awkward movements, halted breathing, participant isolation, unpleasant imagery, or a tepid teacher? Would the resulting sham intervention be credible, valid, or even genuinely inactive?

These are all excellent questions. Unfortunately, Yeh et al then conclude that a “quixotic” search for the “ideal sham” is a waste of time, which is rather annoying because such a search doesn’t have to be quixotic. All you have to do is to break down tai chi into its key elements: the slow, graceful stretching exercises, the breathing exercises, the relaxation exercises. On the other hand, maybe Yeh et al have a point–except that they didn’t go far enough. I’ll show you what I mean.

Let’s for the moment and for the sake of argument accept the findings of Wang et al. Let’s say that tai chi is the greatest thing since sliced bread and that it slaps down fibromyalgia symptoms better than anything we’ve yet come up with. Let’s assume all of those things, just for the moment and then think about it. What thought comes to mind to you? I know what thought comes to mind to me:

Why on earth is this result “provocative” (as Yeh et al describe it) or even the least bit surprising? Why on earth is it in the least bit “alternative”? Stripped to its essence and particularly stripped of its woo elements about qi, all tai chi is is exercise and relaxation, and we already know that exercise is useful for fibromyalgia! The only question is what kind, intensity, and regimen does the most good, and this study answers that question to the extent that it tells us that an exercise regimen resembling tai chi is pretty good. Excellent! We can build on that! But why is this finding “alternative”? It shouldn’t be. Why was this study funded by the National Center for Complementary and Alternative Medicine (NCCAM) and why is it being touted by NCCAM (and GoozNews) as a “success”? It’s not “alternative.”

As I’ve said time and time again, exercise and relaxation interventions have been completely co-opted by the CAM movement as “alternative” when there is no a priori reason that they should be considered anything other than science-based interventions. Just because they are difficult to study doesn’t make them any less science-based. However, CAM supporters know that co-opting less controversial modalities with some degree of prior plausibility that have no real reason not to fall under the mantle of science-based medicine allows them to slip the woo in alongside it. The Trojan horse is diet, exercise, and natural products derived from plants (i.e., herbal medicine). The Greeks jumping out of the belly of the horse is the woo, including acupuncture, “energy medicine” (including the “qi” aspect of tai chi), and even homeopathy.

Can anyone tell me again why this study is in any way “alternative”?

Why are we seeing videos like this one, for example, from the Mayo Clinic?

Comments

  1. #1 Akheloios
    August 24, 2010

    I did Tai Chi for several years, and it’s not just stretching, breathing and relaxation. Depending on how much you bend your knees in each position and how long you hold each position, it can be quite a demanding isometrics workout and you can build quite a bit of muscle. Holding your entire body weight on one bent leg for a few minutes at a time is quite difficult, especially as you bend your knee further as you get better at each stance, and the arm positions act the same way. That may well have helped with the illness symptoms as well, but you’re right, even considering the isometric elements, there’s nothing that couldn’t be replicated through standard exercise/breathing/relaxation techniques, it’s just packaged nicely together.

  2. #2 disgruntledphd
    August 24, 2010

    Dunno about Tai Chi, but Chi Kung (which is a similiar kind of practice) could quite reasonably be controlled.

    The books I’ve read on it (not that many admittedly) suggest that it consists of three main components
    Body movements
    Breathing in synchrony with this
    Mental imagery
    I imagine that Tai Chi is somewhat similiar.
    So, the control:
    Real Tai Chi (breath, body, imagery)
    Visual Tai Chi (breath and imagery no movement)
    Body Tai Chi (body, breath, no imagery)
    Image and Body Tai Chi (body, imagery no breath)
    And so on.

    While the trial would need to be large, you could probably estimate interaction effects from all of this.

    Follow ups would involve testing practitioner effects in conjunction with the above variables.

    So it is possible, but its not easy.

  3. #3 Charles
    August 24, 2010

    Good exercise, breathing. Probably a big bonus is that tai chi, among other martial arts, teach good posture and efficient mechanics. Perhaps a sham should include posture coaching as well as toning and breathing exercises.

  4. #4 GreenAndCrunchy
    August 24, 2010

    I have done martial Tai Chi for several years now, and know several fibromialga sufferers who practice (they generally stick with the less martial applications). I also have a background in Yoga and Kung Fu.

    I think that anything that represented a reasonable sham placebo would be likely to confer some of the same benefits. The breathing exercises, strength and balance improvements and focus training all seem to be helpful in reducing pain. Properly done, tai chi training is also a low-level aerobic exercise.

    Another thing to keep in mind is that the training intensity increases as you get better at it. This is a martial art, and as a student’s physical ablilities improve, the exercises become more complex and strenuous. I suspect that that would have some effect on the durability of the effects.

    Basically, for the purposes of fibromialga relief, Tai Chi is a very good exercise regime which has been studied and improved for a very long time. All those monks over all those centuries added things that worked and removed those that didn’t. It would be fairly difficult to come up with a convincing sham for something so well-engineered.

    As a completely personal note, the practice is also very effective for relief of hangovers.

  5. #5 bwv1051
    August 24, 2010

    The summary of power you provide is incomplete:

    “This design had 78% power to detect a difference between means [of size delta=?] at a significance level of 5% with the use of a two-sided t-test.”

    Most studies have “78% power to detect [an unfixed effect size] at a significance level of 5% with the use of [some fixed test].”

    The delta is probably in terms of FIQ.

    Stats ftw.
    Thanks for your service, Orac.

  6. #6 Denice Walter
    August 24, 2010

    ( I’m in agreement with Akheloios : my friend, a PT, taught a class I attended for a few years. BTW, there’s a *wu* style ) About the study itself: is it possible that the E group had more actual exercise than did the controls ( E = most of class time ? vs. C = 20 minutes set amount )?. Generally, the activity has to be interesting enough for the person to “keep at “, practice at home, while simultaneously being “do-able” enough so that it isn’t impossible to achieve a measure of expertise. In addition, there’s the social interaction engendered by taking a class, the sense of accomplishment,seeing improvements in form,perhaps a sense of mystique, etc. You might be surprized as how many cancer survivors take up (or return as adults to )tennis for recreation, exercise, cameraderie, distraction, a sense of bodily control, opportunities for agrumentation, etc.

  7. #7 qetzal
    August 24, 2010

    Why did the control sessions consist of 40 minutes of lecture and only 20 minutes of stretching? Did the tai chi sessions consist of 40 minutes of talking about tai chi and only 20 minutes of doing tai chi? I’d bet not. Dollars to donuts the tai chi group was active almost the entire 60 minutes.

    If so, this was a comparison between ~ 60 minutes of isometric exercise vs. 20 minutes of stretching.
    Of course, participants were also told to practice tai chi or stretching for 20 min. a day at home. But even if they actually did it, it’s still a comparison between ~ 260 min/week for tai chi vs. 180 min/week for stretching. That’s still 44% more in the tai chi group.

    So the bottom line is what – more exercise is better than less exercise? Holy forgone conclusions, Batman!

    Seriously, I don’t get this design at all. Why compare 60 min of tai chi to 20 min of stretching plus 40 min of instruction on coping skills & problem solving? They might as well have compared tai chi vs. drinking orange juice.

  8. #8 Peter Deadman
    August 24, 2010

    Why is it alternative? Given that this is such a vague term, there are some reasons it could fall into the alternative bag. First, as a healing modality (as opposed to its martial application), tai chi is about as far as you can get from popping a pill. Secondly, integrating mindful attention with regulated breathing and non-aerobic and slow movement, is a long way from conventional ideas of exercise. Practised for health, there is an overlap between tai chi and qigong, and the latter can clearly be understood as a healing system that is alternative to both biomedicine and even to traditional Chinese medicine.

  9. #9 anthro
    August 24, 2010

    And all this time I just thought these symptoms were part of getting old! Now, it seems, I have a condition!

    So if I sign up for Tai Chi (no matter how silly I find it), the study says that I will get better? I don’t think so. I think the Tai Chi group got better because they think Tai Chi is way cool and the “master” make them feel a lot more important that the “instructor” at the stretching class.

    If Tai Chi works better than stretching, the only thing in this study that “proves” it is that the way the Tai Chi was presented was way more attractive and personal than the “sham” intervention. Hey, I can paint my own toenails or I can go get a pedicure at a nice salon–which is going to relieve my stress and aching feet better?

  10. #10 Ian
    August 24, 2010

    @qetzal

    The instruction component was 60 minutes, the participants were asked to do 20 minutes a day at home in both arms of the study. It wasn’t simply a matter of one group getting more intervention than the other.

    @anthro

    I think the Tai Chi group got better because they think Tai Chi is way cool and the “master” make them feel a lot more important that the “instructor” at the stretching class.

    Thanks for sharing your opinion. Since it’s based on nothing more than your bias against woo-woo (one which I share), it’s really not much of a substantive contribution.

    At no point do the authors claim this is the be-all-end-all of the research, or that the study “proves” anything. It was a small pilot study with promising results. The authors propose a psychophysiological mechanism by which it could work, and call for more research. The need for better controls is discussed, and no wooish claims about the alignment of meridians or chakras makes its way into the paper (except in the description of the theory behind Tai Chi in the intro).

    I thought this was an okay paper, and while my eyebrows are still raised, there really wasn’t anything obvious in either the methodology or the results to suggest that it was flawed or biased.

    The criticism of the term “alternative” is fair, considering that exercise is already part of the management of the disease. However, it’s doubtful that when doctors prescribe exercise, they have tai chi in mind. Insofar as it’s a deviation from (or if you prefer, refinement of) normal practice, it is not unreasonable to call it “alternative.”

  11. #11 Rogue Medic
    August 24, 2010

    @ 8 Peter Deadman.

    Why is it alternative? Given that this is such a vague term, there are some reasons it could fall into the alternative bag. First, as a healing modality (as opposed to its martial application), tai chi is about as far as you can get from popping a pill.

    Alternative medicine does not involve popping pills?

    What is homeopathy, but taking a drug?

    Herbal medicine is also taking a drug.

    The sales pitch is that you are not popping a pill, but the sales pitch has nothing to do with reality.

    If you are going to focus on the packaging, rather than the active ingredient, maybe it is because you understand that the active ingredient is not anything more than the packaging.

    Alternative medicine is about popping placebos.

    Secondly, integrating mindful attention with regulated breathing and non-aerobic and slow movement, is a long way from conventional ideas of exercise.

    Meditation and breathing are not used by conventional medicine because of what?

    There is evidence that these work, therefore they are not alternative medicine.
    .

  12. #12 Ian
    August 24, 2010

    @Ian

    Read for comprehension, dummy. There was more to qetzal’s comment than that…

    Yeah, it’s not clear from the description how much time in the class was broken down wrt instruction vs. actual exercise. Looking at Table 3, there doesn’t seem to be much improvement from Week 12 to week 24, which leads me to suspect that the in-class component is really what makes the difference, not the part done at home. However, it’s reassuring to see that people didn’t get worse once the in-class bit stopped.

    I’m now curious why Figure 3 stops reporting findings at 12 weeks rather than the full 24. It says on p. 751 that:

    …clinically meaningful change in the FIQ score… more patients in the tai chi group than in the control group had improvement: 79% vs. 39% at 12 weeks, and 82% vs. 53% at 24 weeks.

    A 3% change in the 2nd half of the study? Pretty dismal compared to a 20% change in the 1st half. Something stinks here…

  13. #13 Antares
    August 24, 2010

    @Peter Deadman: “Practised for health, there is an overlap between tai chi and qigong, and the latter can clearly be understood as a healing system that is alternative to both biomedicine and even to traditional Chinese medicine.”

    Why are we even talking about “healing systems” – this is a point I don’t understand. Healing is not “a school of thought” like what the old philosophers did. Nor is it a programming language or style, where different styles suit different people for a common result.

    Shouldn’t we divide healing modalities into “stuff that makes sense and works (SBM)”, “stuff that seems to work (EBM)” and “the rest (wooful BS quackery)” instead of different “systems”?

  14. #14 bluedevilRA
    August 24, 2010

    A follow-up study could examine yoga vs. tai chi vs. sham tai chi/yoga vs. generic stretching.

    A possible sham would be to use the same stretching techniques as the generic stretching but use made up Eastern names.

    I agree with other commenters that the Tai Chi group was likely moving/stretching for the entire 60 minutes, which is an unfair comparison to the 20 minutes of stretching in the control, particularly if they are arguing that the mechanism of action is exercise. The exercise time periods are not even equivalent! If you’re a fibromyalgia patient, its not surprising that you wouldn’t want to listen to someone drone on about fibromyalgia education for 40 min while you’re in pain.

  15. #15 Todd W.
    August 24, 2010

    Another thing that jumped out at me regarding the two groups. In the tai chi arm:

    Classes were taught by a tai chi master with more than 20 years of teaching experience.

    In the exercise arm:

    a variety of health professionals

    I may be reading this wrong, but it seems like the tai chi group is getting just one person who is there consistently for every guided session, while the exercise arm does not have the same stability in personnel. This may affect the outcomes, as well.

  16. #16 Rogue Medic
    August 24, 2010

    @ 15 Todd W.,

    Good point about the instructors.

    The text does specify that the stretching group had 20 minutes of stretching/exercise, but I did not see anything that specified the amount of time for the tai chi group.

    In the first session, he explained the theory behind tai chi and its procedures and provided participants with printed materials on its principles and techniques.

    Nothing about any further lecture time.

    Each session included a warm-up and self-massage, followed by a review of principles, movements, breathing techniques, and relaxation in tai chi.

    Does this match what was done by those in the stretching group with their 40 minutes of lecture?

    We don’t know. The authors do not specify. It does read as if the tai chi group went straight from warm-up and self-massage to tai chi, while the stretching group was sitting there listening to the lecture of the day.

    Was the review of principles, movements, breathing techniques, and relaxation in tai chi presented in a way similar to the material being presented to the stretching group?

    It would be nice if the authors had spent a bit more time clarifying this.
    .

  17. #17 viggen
    August 24, 2010

    My feelings about this study are tepid at best. I explored Tai Chi and various related martial arts for a very long time. The problem I see with these arts is that they are settled very closely with a lot of magical thinking and are taught by people who are completely inundated with woo and mythology –the teaching of “high level” skill is itself strongly selective toward blind, faithful belief by practitioners. After all, there is no sham for students that isn’t deliberately set up to authenticate the validity of the art. The art would not continue if the students weren’t sold on believing it. There is a level of “doing it exactly so” that is complete faith: if you don’t have the outcome the instructor told you about, it is stacked up to “doing the art poorly” rather than “the art isn’t necessarily itself correct.”

    While the practice of Tai Chi may have health benefits, I think they are probably inflated in students by indoctrination from the believer who is instructing them. In addition, while Tai Chi may have health benefits in and of itself, I think the indoctrination involved in its teaching can make people less credulous about Chi-woo (your acupuncture and Reiki and such) that could be detrimental to accepting solid, science-based medicine for other serious health problems later.

    I would be more interested in this study if there were a way to get strong Tai Chi instruction that is indoctrination free, which I doubt based upon who teaches it and what is needed in order to qualify as a “capable instructor”.

  18. #18 Karl Withakay
    August 24, 2010

    So the investigators think it’s a waste of time searching for a proper sham. How about leveling the playing field a little by demystifying the tai chi instead?

    “In the first session, he explained the theory behind tai chi and its procedures and provided participants with printed materials on its principles and techniques.”

    Try stripping out the mysticism and presenting technique instruction only, and don’t mention the word “tai chi”.

    Alternatively, invent a mythology and “eastern” name for the sham process.

    Normalize the oral and written presentations to the two groups so that the only difference is the type of exercise they are performing.

  19. #19 Jim Laidler
    August 24, 2010

    An interesting study, but their control arm isn’t comparable to their treatment arm. What I see is data supporting the hypothesis that an organized exercise class of 60 minutes twice a week is more effective than a class that only does 20 minutes of exercise twice a week.

    Despite the recommendation that the study participants do the exercises at home 20 minutes a day, we have no way of knowing how many actually did that. Even if we assume that they followed the recommendations faithfully, the Tai chi group got 220 minutes of exercise a week, compared to the control group’s 140 minutes a week (assuming they counted their class as the 20 minutes of exercise for that day).

    It’s an intriguing result, but it in no way validates Tai chi as any better than simple stretching. I’m amazed that the authors (or the editors) didn’t see that.

    Jim Laidler
    Portland, Oregon

  20. #20 wfjag
    August 24, 2010

    Obviously, you need some fresh Hitler Zombie material for inspiration. http://www.youtube.com/watch?v=z-Ln_rqPpPk&feature=player_embedded

  21. #21 trrll
    August 24, 2010

    It seems like a reasonable study. About the only thing I thought slightly objectionable was the bit in the intro about “moving qi around the body,” with no mention that there is no measurable physical or physiological correlate to “qi.” It seems to me that sentence could have been left out, since the study does not attempt to investigate the value of the “qi” aspects of Tai Chi.

    Of course, it doesn’t answer every question one might be interested in, such as whether another exercise regimen might be equally beneficial. It seems likely that that would be the case. On the other hand, it is hard to think of any common exercise regimen that has the characteristics of Tai Chi that have made it such a popular exercise regimen: It is adjustable to the condition of the patient by altering the depth and width of the stance, it does not require rapid movement, it is non-impact, and it is widely available. To construct something “like” Tai Chi that was not Tai Chi, one would probably have to incorporate the same characteristics that are likely to be beneficial in Tai Chi, so such a comparison would not be particularly useful or informative. There is nothing comparable to the piercing the skin at highly specific points in acupuncture that could be changed or deleted without altering the overall characteristics of the treatment.

    Nevertheless, it would be nice to see follow-up comparisons to other forms of exercise, as well as other stretching regimens such as Yoga, which also would likely have a similar (slightly exotic, Eastern) placebo value.

  22. #22 trrll
    August 24, 2010

    Despite the recommendation that the study participants do the exercises at home 20 minutes a day, we have no way of knowing how many actually did that. Even if we assume that they followed the recommendations faithfully, the Tai chi group got 220 minutes of exercise a week, compared to the control group’s 140 minutes a week (assuming they counted their class as the 20 minutes of exercise for that day).

    They do state that the participants maintained daily logs of the time spent doing the assigned exercises, although they don’t provide any statistics or other analysis of the logs.

  23. #23 cervantes
    August 24, 2010

    Well, the basic view of “medicine” in the culture is that it’s about pharmaceuticals, surgery and elaborate machines. Most people if you prompt them will recognize that physicians often prescribe physical therapy, and that medical science recognizes the benefits of appropriate diet and physical activity, but they don’t really classify these as part of medicine or health care.

    So, having people do an activity that comes out of a different tradition seems “alternative,” seems to be adding something that scientific medicine (or whatever you want to call it) has underappreciated up until now. How true that is would be a subjective judgment, I think — I’m not sure how you would quantify it.

    But doctors do tend to give up pretty quickly on convincing people to undertake lifestyle changes and head straight for the pills. Most don’t really have skills or tools to successfully get their patients to change their habits. Hiring a charismatic guy with an aesthetically appealing and exotically interesting program of collective activity is something specific and concrete, which might just work pretty well. And it doesn’t have that “mediciny” smell.

  24. #24 Terrie
    August 24, 2010

    Tai Chi is excellent, low impact exercise, that improves overall health, reduces stress and can be done by people of a variety of physical capabilities. That alone should be enough to be considered impressive.

  25. #25 LovleAnjel
    August 24, 2010

    @ 15

    Spot on about the instructors. The Tai Chi class offered a more consistent experience. I would also bet that hearing soothing words about moving energy and healing is better than going through dry lectures about a disease you suffer from. The two groups should have received the same lectures.

  26. #26 jane
    August 24, 2010

    The thing about standard American stretching exercises is that they are, which you here no doubt like, highly reductionist. You are instructed to assume a particular position that “isolates” one particular muscle and hold it for thirty seconds or so. A few notable limitations of this method are:

    1. It focuses stretching activity only on the selected large muscles. Exercises like yoga and tai chi, whose methods have been selected over time to work the whole body, guide you through movements (including potentially useful martial arts moves in tai chi) in which smaller muscles not determined by the Experts to merit their very own stretches also get worked naturally. In the absence of proof to the contrary, I would presume that this was the superior method (just as if your goal is genuine physical fitness rather than big lats, you will do better by doing real-world work or free weight exercises, rather than using gym machines that similarly seek to work only single major muscle groups).

    2. Since standard stretching programs target a limited number of muscles, and the Experts tell us that holding a stretch for more than a minute or so is more likely to overstrain the muscle than to give extra benefits, a stretching routine suitable for unfit lay people simply does not take an hour. Even if we accepted the false claim that the full 60-minute tai chi session represented active exercise, it would be ridiculous to demand that the comparator arm must therefore involve 60 minutes of active stretching. Participants could suffer harm.

    3. “Static stretching” itself is relatively new. The American Experts a few decades ago told us to bounce on the muscle we were trying to stretch. Then it turned out that oops, that causes tearing that can actually make you less flexible. Apparently, since they have learned enough to have corrected that mistake, we are supposed to presume that the reductionist exercise routines they now prescribe, though still having little resemblance to any natural use of the human body, must surely be better than any icky, obsolete, ASIAN stuff.

    And then there is the bizarre suggestion that patients should prefer the LESS effective method just because they don’t know how the more effective method works. Who cares? Start enjoying the benefits now, I would say, and if in thirty years the Experts actually manage to characterize the full biological effects of exercise, you will be interested to learn something new. (Yes, I said exercise, not tai chi. I do not think that the Mechanism[s] of the meager improvements associated with standard stretching have been fully elucidated either. Feel free to direct me to literature that will explain precisely how stretching reduces fibromyalgia pain.)

  27. #27 viggen
    August 24, 2010

    with no mention that there is no measurable physical or physiological correlate to “qi.”

    I beg to differ with this particular point. Qi is a name for a feeling. Because of when and where the name was invented, it’s tied to spiritual connotations. That’s kinda what you’re bound to get from a bunch of monks. In the modern world, we have much better names for the sources of these feelings: Lactic acid build-up, cramps, hunger, sugar high, endorphin high, etc. Qi is a catch-all name for things you feel in your body on an everyday basis that a bunch of exercise-happy monks needed a name for that fit within their religion-saturated context. The problem is that people in the modern world don’t want to hear that Qi is just a name for something that they already know backward and inside out: people want The Force (thank you George effin’ Lucas).

  28. #28 viggen
    August 24, 2010

    Qi is a name for a feeling.

    To be completely clear, I’m not suggesting that there’s anything to Qi woo. Acupuncture (and -by extension- acupressure and dim mak and the rest) is based entirely on the mythology that sprung up after the name “Qi” was coined. It’s religion, nothing more.

  29. #29 BKsea
    August 24, 2010

    The following extract from the article tells us why it is “alternative:”

    “Tai chi is a mind–body practice that originated in China as a martial art. It combines meditation with slow, gentle, graceful movements, as well as deep breathing and relaxation, to move vital energy (or qi) throughout the body. It is considered a complex, multicomponent intervention that integrates physical, psychosocial, emotional, spiritual, and behavioral elements.10 Because of its mind–body attributes, tai chi could be especially well suited to the treatment of fibromyalgia”

    Any credulous statement about moving “vital energy” does not belong in a scientific publication. Fortunately, in the discussion, the authors stick to scientifically supportable mechanisms for an effect.

  30. #30 trrll
    August 24, 2010

    I beg to differ with this particular point. Qi is a name for a feeling.

    I said that there was no measurable physical or physiological correlate with “qi.” If you disagree, tell me what physical or physiological measurement you can take to reliably tell whether I am experiencing “qi.”

    This is certainly the way in which some modern people try to rationalize the use of the term, but the fact is that it is a relic of an obsolete pneumatic theory of physiology–the same one that is the basis of the theory of acupuncture. I don’t disagree that some people label certain subjective experiences with the term, but I’ve heard “qi” applied to a wide of experiences and martial arts techniques that are almost certainly very different from a physiological or physical point of view. I do think that the term can be useful, at least in a martial arts training context, but that doesn’t mean that it is appropriate for a scientific publication without significant clarification about what is and is not meant.

  31. #31 Vicki, pouring my tea from Russell's teapot
    August 24, 2010

    viggen–

    What feeling is it a name for, though? The experiences of cramps, low blood sugar, and endorphin high are very different. I don’t think the Chinese language is so limited that its speakers would have settled on one word for all the things you list, with no distinctions even given centuries of use and thought.

  32. #32 stripey_cat
    August 24, 2010

    Jane @26
    I didn’t read the comments as anyone saying that patients should prefer the less effective stretching regimen, but that we ought to be trying to work out what it is that makes Tai Chi effective so we can use it in other contexts, customise it to suit patients (perhaps develop non-weight-bearing forms, or forms for wheelchair users) and so on. My money is on the actual forms of the exercises used being the important bit, not on qi. In fact, it would be very interesting to present tai chi shorn of its accumulated mysticism. (I suspect that, because of our interesting perceptions, it would be less effective in credulous populations, but more effective in the sort of sceptics who are likely to want to hit an instructor who mentions qi.)

  33. #33 jane
    August 24, 2010

    stripey-cat – Some people (not you!) do seem to try pretty hard to reject evidence showing a benefit for tai chi or perhaps any Asian exercise style. I certainly agree that tai chi’s superiority is not due to influence on qi, but there’s no evidence that in this study either the researchers, tai chi instructor, or patients thought it was. I have taken a tai chi class in which the instructor told us to visualize, e.g., gathering a ball of energy between our hands. She did not tell us that this “energy” was physically real or would be responsible for any benefits we gained, and there’s no evidence that Wang et al’s tai chi instructor did so.

    I believe that visualizations of “qi” are useful because they help us to feel how we use our bodies and how we should use them to improve performance. Elsewhere in martial arts, people are taught to envision a strike going through a target, rather than stopping at its surface, to maximize striking power. There’s an exercise whereby when you climb stairs, you imagine a balloon tied by a string to the top of your head. It really does encourage you to keep correct posture, instead of pointing your face at the stairs, and thereby makes climbing less effortful. Someone who bellowed that it was impossible to punch through a human being, or that invisible balloons are irrational woo, would be seriously missing the point.

  34. #34 trrll
    August 24, 2010

    In fact, it would be very interesting to present tai chi shorn of its accumulated mysticism.

    In fact, Tai Chi is not uncommonly taught without any reference to “qi”
    Even some traditional Chinese masters are of the opinion that the form itself teaches everything you need to know about the use of qi (whatever it may be) and that explicit instruction in qi is not required.

    I suspect that, because of our interesting perceptions, it would be less effective in credulous populations, but more effective in the sort of sceptics who are likely to want to hit an instructor who mentions qi.

    I’d be very cautious about actually trying to hit a Tai Chi instructor, although it could be a learning experience. Tai Chi is, after all, a martial art ;-)

  35. #35 Calli Arcale
    August 24, 2010

    jane:

    I believe that visualizations of “qi” are useful because they help us to feel how we use our bodies and how we should use them to improve performance. Elsewhere in martial arts, people are taught to envision a strike going through a target, rather than stopping at its surface, to maximize striking power.

    Very true. And these visualizations can, with practice, feel very real indeed. I’ve wondered lately whether or not qi is a manifestation of proprioception. Neurological studies have shown that athletes really do “become the ball”, at least in the sense that their brains develop a proprioceptive map for the ball and its behavior. Some call it “muscle memory”. It’s also like how, when I go skiing, before long I perceive the tip of the skis and the tips of my poles as parts of my body — and it feels strange to take them off at the end.

    I have a hunch that the balls of energy that they often teach one to visualize are a means of developing your body’s proprioception in order to meet certain goals. After all, although the ball of energy is not real, your kinetic energy most certainly is, and if you’ve got a good proprioceptive model for how to put that energy into a block of wood, your brain will be able to plan the correct trajectory for your hands without much conscious thought. Instead of thinking “start here, push hand here, remember to keep fingers straight like a knife, push *through*” you will think simply “direct the energy through here”, just as a professional basketball player thinks “put the ball through the net” rather than how to move his hands to achieve that.

    But I don’t know whether or not that’s actually true. It would be interesting to figure out a way of studying whether or not the proprioceptive map changes as you get more experienced with Tai Chi or any martial art, and whether it changes in a manner consistent with the brain mapping how your kinetic energy has to move. I’m sure the same thing happens with all athletes (and also musicians and artists), though in various highly specialized ways.

  36. #36 qetzal
    August 24, 2010

    jane,

    In case you think I am one of those ‘trying to reject a possible benefit’ for tai chi, let me assure you otherwise. I’m happy to entertain the possibility that tai chi is better than many other exercise styles. Even if the benefit is entirely due to patients thinking it’s better because of the associated mysticism, that’s still worth knowing.

    The problem I have with this study is that we can’t reach any useful conclusion at all. There are too many variables between the groups to judge which one(s) mattered (if any). Those variables include (at least): type of exercise (stretching vs. tai chi), duration of in-class exercise (20 min vs. ~ 60 min?), duration of straight didactic instruction (40 min vs. ~ 0 min?), instructional content (coping strategies, problem solving, diet, etc. vs. principles of tai chi), and leadership (various health professionals vs. a single tai chi master). There may also have been differences between the amount of at-home exercise; apparently the authors don’t say.

    There is no possible way to conclude whether any single one of these variables played a role in the outcome. All we can say is that 60 min devoted exclusively to tai chi & led by a single instructor appears to be better than 20 min of stretching plus 40 min of lecture on a variety of topics, led by a variety of people.

    I don’t understand why the groups weren’t better matched. Keep the tai chi group as is, just compare it to a 60 min stretching class, led by a single, enthusiastic physical therapist. No didactic instruction beyond what’s directly relevant to the tai chi or stretching. That would at least allow a tentative conclusion whether tai chi was better than stretching. If it was, then other studies could be designed to see if it’s better because of the exercise itself or because of the associated mysticism, how it compares to yoga or other types of exercise, & so on.

  37. #37 Peter Deadman
    August 24, 2010

    Actually there’s a growing body of tai research out there now. It started with the benefits of tai chi on preventing falls and has moved on to include benefits in type 2 diabetes, enhancing the immune system etc.

  38. #38 jane
    August 24, 2010

    qetzal – Your comment was not as extreme as some, but you did suggest that because the weekly session with a trainer involved somewhat (not 40 full minutes) more exercise, they “might as well have been comparing tai chi to orange juice.” I noted that there is no evidence that a full 60-minute period of standard Western static stretches would be superior to a 20-minute period; it might be inferior. This trial appropriately compared the two interventions according to a usual standard of practice for each, such as people would experience in typical use.

    As for the other possible factors you mention (time and content of “didactic instruction), this instruction was provided ONLY to the static-stretching group, I presume either to give that group a combination of all standard doctor-recommended lifestyle interventions or just to fill out a 60-minute period so nobody could claim that the extra 40 contact minutes made all the difference. If it was getting didactic instruction on lifestyle changes that prevented static stretching from looking as good as tai chi, that would indicate that standard advice on diet, pain management, and problem-solving was actively harmful. I doubt this, but will warrant that it is a possibility.

  39. #39 DrWonderful
    August 24, 2010

    @Peter Deadman- As a chiropractic physician I am not surprised to hear that Tai Chi may have demonstrable benefit with regard to preventing falls, managing fibromyalgia, and possibly type 2 diabetes. On this site the focus is on the “woo” (whatever that is) but in the evidenced based physical medicine world this falls right in line with a growing body of evidence that shows movement essentially means health (dare I say wellness).

    If we take the Tai Chi label off of it, despite what the author inserts into the study, the benefits may be distilled down to well understood and established mechanical and neurological principles. Increased movement stimulates joint mechanoreceptors. When mechanoreceptors are stimulated corresponding nociceptors (pain) are inhibited…sort of like a see-saw. When repeated over time the mechanoreceptors tend to stay more easily excited and the nociceptors tend to stay more easily inhibited. Add in the balance and coordination that Tai Chi promotes and the “righting reflex” proprioceptors are now stimulated. Any time these neuro paths are influenced simultaneously on a consistent basis they are literally being “trained” (ie rehab) to revert back to a state of near optimal performance. That means less pain, better movement, better balance, better function.

    It makes a difference to practice this type of thing in a reptitive and structured way and that is what Tai Chi offers. Many of our rehab protocols incorporate the exact same types of principles of balance and movement but unless you are a rehab oriented Chiro, PT, up-to-date neuro, or super modern ortho this type of mechanical/neuro interplay tends to be ignored, under appreciated or poorly understood. Usually out of sheer arrogance and ignorance because the basic science is actually there (re Janda, Lewitt, Liebenson, McGill, etc.

    There really is no woo here, just an author that did not fully understand and appreciate the modern, but basic, mechanical and neuro principles at work in the study. Take the name Tai Chi name away and you have movement, balance, exercise, breathing and relaxation. You have modern Chiropractic and PT really.

  40. #40 Johnny
    August 24, 2010

    Actually there’s a growing body of tai research out there now. It started with the benefits of tai chi on preventing falls and has moved on to include benefits in type 2 diabetes, enhancing the immune system etc.

    Cite? In particular the enhancing the immune system evidence. Preventing falls makes sense, and exercising and reducing weight will help diabetes, I believe, but I’m wondering how enhancements to the immune system were measured.

  41. #41 gaiainc
    August 24, 2010

    jane, in case you missed it, your comment at #38 is a very good reason why this study was not useful in determining the efficacy of tai chi in fibromyalagia. There were too many variables and thus alternative explanations as to why the difference was seen. High quality trials works to minimize those variables and make the best case possible as to why one particular mechanism is the most reasonable explanation for the differences between the group. This trial was not one of them.

  42. #42 Jack
    August 24, 2010

    Bizarre claims of a “win” for CAM aside, this is actually quite a good study. I don’t think the purpose was to change clinical practice (especially not with such a small sample size) but rather to provide some evidence that supports the benefit of doing further research. Absolutely the control group has to be better designed and we definitely need a larger sample size if we’re going to make clinical decisions about tai chi in fibromyalgia. However, this study does show us that future research is worthwhile.

    Many therapies go through the same process: a small trial with good (but not great) methodology paves the way for a more definitive study.

  43. #43 Todd W.
    August 24, 2010

    @jane

    If it was getting didactic instruction on lifestyle changes that prevented static stretching from looking as good as tai chi, that would indicate that standard advice on diet, pain management, and problem-solving was actively harmful.

    Minor quibble, but if something prevents treatment A from looking as good as treatment B, that does not mean that treatment A is harmful. It just means that it might not be as effective.

    You need to be careful with terminology when discussing medical issues. “Harm” generally means that the individual’s condition worsens as a direct result of the intervention. If their condition stays the same or only nominally improves, then we would say that the intervention is not effective or that there is no benefit.

    Back to the point of qetzal’s comment, it seems like you are missing his point a little. Yes, we can say that the tai chi group appears to have had better outcomes than the non-tai chi group (which also had some improvement). However, we cannot say what was the reason for this.

    * Was it the difference in instructors (single, consistent one vs. multiple, changing ones)?
    * Was it the difference in instruction (enthusiastic vs. didactic, brief vs. lengthy, hints of mysticism vs. fact-based)?
    * Was it the difference in the exercises themselves (tai chi movements vs. stretches)?
    * Was it the difference in adjunct techniques (focused breathing and visualization vs. no equivalent)?
    * Was there a difference in the atmosphere (e.g., relaxed seating/mats/environment vs. classroom-like desks, perhaps) that may have had an effect on symptoms?
    * Was it the difference in duration of exercise (unknown amount for tai chi vs. 20 minutes for non-tai chi)?

    Because of these questions, we cannot make any meaningful conclusions based on this study. The best we can say is, “Needs more research.” We cannot conclude that tai chi is better than stretching.

  44. #44 jane
    August 24, 2010

    For measures of immune enhancement, the most relevant PubMed abstract numbers seem to be:
    16505081 (CD4:CD8 ratio and quantity of CD4CD25 regulatory T cells)
    17397428 (varicella zoster virus cell-mediated immunity)
    18487887 and 17708626 (double publication of the same study, response to influenza vaccine)
    18385192 (T-cell helper function, T-bet transcription factor and IL-12 production in diabetics, also HbA1c reduction)
    18540736 (each of 3 stress management treatments in people with HIV augmented lymphocyte proliferative function)
    20718659 (increased circulating myeloid dendritic cells).

    And reviews imply that a number of other publications exist that are not listed on PubMed. Interesting. I am no expert on this stuff, but it doesn’t seem like a big surprise that either moderate exercise or relaxing activities should improve immune function, based on what is generally thought to be known. The most interesting study to me was Irwin et al. (2007), which randomized older adults to tai chi or health education and after 16 weeks gave them a varicella vaccine, then measured increase in CMI. Tai chi and the vaccine gave about the same level of increase, and the effects were additive (so that vaccinated people got more benefit from the vaccine if they had done tai chi). Tai chi also improved general measures of physical health, comfort, and function.

  45. #45 trrll
    August 24, 2010

    It seems to me that the result provides an adequate basis for suggesting Tai Chi to a fibromyalgia patient. I suppose that one could imagine that stretching is harmful, and that Tai Chi is superior because it is not stretching, but that seems (excuse me) a stretch.

    It is certainly possible that some other exercise might prove to provide equivalent or greater benefit, so further study is warranted, but it still appears that this study is clinically useful, as it stands. If there were significant risks associated with Tai Chi, one might demand a higher standard of evidence, but based upon what we know about moderate exercise (our prior probabilities, if you will) one would expect it to be at least mildly beneficial and without major adverse effects, and the evidence supports that.

    It would also be useful to investigate other parameters related to therapeutic Tai Chi. Is this the optimum exercise regimen, or would more be better? Do you actually need a Tai Chi master, or just a therapist who knows the basic movements and has a general understanding of how they should be performed? Is this the best form of Tai Chi for this purpose? (there are actually quite a few variants: Yang long and short forms, Wu, Chen etc.) How is long term compliance and benefit? If patients find Tai Chi enjoyable enough that they continue to do it, it might have an advantage over other exercise regimens that are less appealing to perform.

  46. #46 Andrew M
    August 24, 2010

    I’m not sure why it matters whether or not the study is “alternative” or not. All that matters is whether or not people can expect to benefit from the treatment or activity.

  47. #47 jane
    August 24, 2010

    gaiainnc – “jane, in case you missed it, your comment at #38 is a very good reason why this study was not useful in determining the efficacy of tai chi in fibromyalagia. There were too many variables…”

    There always will be multiple variables in studies of cultural practices done by free-living human beings. Had they cut out the forty minutes of education, “skeptics” would have suggested that the extra contact time created major lasting health benefits. Had they used the same instructor for both treatment arms, skeptics would have yelled that the tai chi instructor was not competent to teach reductionist stretching, or that his bias in favor of the other treatment would have been communicated to the students. And so forth.

    You, and Todd W, and many others here over time, have essentially suggested that no study that asks the questions patients want answered about lifestyle interventions can be “high quality” or “meaningful” – in which case, if the best available science will inevitably be “low quality,” I will happily accept “low quality” data as the best we can get. You cannot double-blind placebo-control exercise or diet. If what you want to know is whether basketball or jogging will do more for your cardiovascular fitness, the best kind of study possible in real life, far more expensive than simply looking at current practitioners, is to take people who are not currently doing either, divide them into two groups, and have each group do one or the other. You’re not going to have another arm for “placebo basketball.”

    Todd W – “if something prevents treatment A from looking as good as treatment B, that does not mean that treatment A is harmful. It just means that it might not be as effective.”

    If we were to suppose that tai chi is really no better than static stretching, yet tai chi was almost three times better than static stretching plus didactic instruction, I have to conclude that something about the didactic instruction either independently reduced function and increased pain, or prevented the static stretching from reducing pain and increasing function as it normally would have. I think this is, not to be punny, a stretch – but it is what you have to argue to blame the didactic instruction for the failure of the reductionist exercise to look good.

  48. #48 Kermit
    August 24, 2010

    Mark Chen, author of “Old Frame Chen Family Taijiquan”, says that qi (chi) is simply good body mechanics.

    As a long time martial artist I’d like to add that one of the health benefits of a martial art is that it’s *interesting*, and is so complex that it cannot be mastered in a lifetime. This means that anybody who enjoys it can continue to improve (at least in knowledge) no matter how old. Similar benefits might come from gardening; or hiking in the wilderness if accompanied by learning about terrain, history, and local biology; for similar reasons. Stretches the brain as well as the muscles…

    And nothing like a stick flying at your ear to distract one from daily woes (or woo) – it demands attention. Who wants to do jumping jacks for 50 years? Meh.

  49. #49 Todd W.
    August 24, 2010

    @jane

    Had they cut out the forty minutes of education, “skeptics” would have suggested that the extra contact time created major lasting health benefits.

    We’re not saying to cut out the 40 mins of education. We’re saying that the amount of talk time should be about the same in both groups, and the amount of exercise time should be about the same.

    Had they used the same instructor for both treatment arms, skeptics would have yelled that the tai chi instructor was not competent to teach reductionist stretching, or that his bias in favor of the other treatment would have been communicated to the students.

    Again, this is not what we are arguing (well, at least not me). Group A gets instructor W, and no one else at every session. Group B, as it currently stands, gets instructors L, M, N, O and P. What should happen is that Group B get instructor L, for example, and no one else at every session. We are not saying that Groups A and B both get instructor W. What matters is that the consistency of interaction is similar for both groups and that the overall presentation style should be similar.

    have essentially suggested that no study that asks the questions patients want answered about lifestyle interventions can be “high quality” or “meaningful”

    No, we are not suggesting that. This study is of, IMO, average quality. It has a number of limitations, but that is to be expected from a pilot study. A larger study, addressing some of the concerns that have been raised by various people in this thread, would be of higher quality.

    You cannot double-blind placebo-control exercise or diet.

    I’m not suggesting that this study should be double blind. However, putting in place as many controls as are feasible would improve its validity. Depending on what interventions are being compared, it may be possible to blind the subjects, if not the researchers (though the ones doing the analysis could be blinded to the groups), if subjects are naive to both interventions and the interventions are of similar nature. Your example of jogging vs. basketball doesn’t fit this scenario. However, tai chi and yoga have some similarities and a comparison of the two could potentially be blinded.

    I have to conclude that something about the didactic instruction either independently reduced function and increased pain, or prevented the static stretching from reducing pain and increasing function as it normally would have.

    It is interesting that when those of us critiquing the study focus on details, you interpret that as us basically saying that the study is total crap and there is no benefit to tai chi, yet here you are focusing on a specific detail to make your argument.

    We cannot conclude from what is reported which aspect(s) of the non-tai chi group was responsible for the difference, if any, in outcomes. We cannot say that some aspect was detrimental in the non-tai chi group. It is possible, but nothing in the study suggests that one way or another. Both groups showed improvement, so we know that the non-tai chi intervention is probably better than doing nothing. We know that the tai chi group showed greater improvement. The difference between the two may be due to some detrimental aspect of the education/stretching intervention, or it may just be that tai chi is, in fact, superior. Unfortunately, this study is not designed in such a way to determine the answer to that question.

    Just because we are critical of the study’s design does not mean that the study has no value. Although we cannot look to this study to support a solid recommendation of tai chi for fibromyalgia, it does suggest potential value and that more research is needed. What we want is to make the research more rigorous so that we can have more meaningful conclusions drawn from it. If it supports tai chi, great! If not, well, then we look at other candidates. Although it may seem harsh, this sort of close scrutiny is what makes future research of better quality.

  50. #50 Tacroy
    August 24, 2010

    Actually there’s a growing body of tai research out there now. It started with the benefits of tai chi on preventing falls and has moved on to include benefits in type 2 diabetes, enhancing the immune system etc.

    I’d just like to point out that this is exactly the lifecycle of woo studies that Orac and others have pointed out – several small studies show promising effects due to pure chance and the fact that negative results don’t get published as often, which creates the impression of a “growing body of evidence”. Then a larger study is commissioned, finds no result, and we’re back to step one.

    But back on topic: did anyone else find it funny that one person in the control group was “outside the U.S.”? I mean, how the heck did he get through the telephone prescreening, the area screening and the baseline evaluation without anyone realizing that he wasn’t in the United States?

  51. #51 The Blind Watchmaker
    August 24, 2010

    It seems to me that this would pass into the “alternative world” when an implausible claim about mysterious energy forces gets tagged onto it. This is the fundamental difference between practices like Tai chi and massage, and woo-laden practices like acupuncture and Reiki.

    There should be no extra, implausible beliefs required for reasonable treatments. I doubt that patients getting massage, Tai Chi, or other such things attribute their benefits to magic or forces beyond the understanding of science. Clearing the mind of stress and stretching the muscles feels good. It is not a mystery.

  52. #52 Heatherly
    August 24, 2010

    You have no idea how happy I was to see this post. My sister sent me the article yesterday, and after reading it I was really, really hoping you’d cover it. I’m a social worker and I freely admit my research methods classes were my lowest grades in grad school. I read through the article carefully, but reading your break-down made things a lot clearer.

    I’ve had fibro for 20 years this September. I’ve tried many, many, many things over the years–including acupuncture, during my younger and more credulous days. (Now at 32 I am much older, wiser, and completely non-gullible now. ;) It did nothing, shockingly. Actually the only non-pharmacological intervention that has helped is basic massage–decreases the pain and gives me a little more mobility.

    Fibromyalgia sucks.

    Hah. Yeah, no kidding. And yes, I am willing to try just about anything, at least anything that isn’t woo. But it isn’t always easy to sort through studies and try to figure out which ones to trust, so thank you for your careful analysis. I might consider trying Tai Chi to see if it helps, but I feel better knowing that while there may be a possible benefit, I shouldn’t put all my hopes in it as a miracle cure.

  53. #53 viggen
    August 24, 2010

    If you disagree, tell me what physical or physiological measurement you can take to reliably tell whether I am experiencing “qi.”

    What feeling is it a name for, though? The experiences of cramps, low blood sugar, and endorphin high are very different. I don’t think the Chinese language is so limited that its speakers would have settled on one word for all the things you list, with no distinctions even given centuries of use and thought.

    First off, Qi mythology is definitely not just one word or concept. It’s a whole array of different, related things. People boil it down to one simple thing in lack of understanding exactly how complicated the religious concept was that formed around it.

    As far as a set of Chinese monks a thousand years ago were concerned, you feel pain and that’s a form of Qi. You feel pleasure, that’s another form of Qi. You feel a cramp, that’s stagnant Qi. Blood, semen, both tangible manifestations of Qi. A bruise? Qi blockage! Your breath, a billows to stoke your Qi. Your bones, solidified Qi storage. There are about a thousand different gradations of Qi, but it boils down to a crappy, metaphysical model of something we know a lot better by other names now. This mythology is why acupuncture exists. The idea was that Qi was a sort of currency that got traded back and forth in the systems of the body to literally form your consciousness and enable your body to operate–everything you feel (your feelings are real!) was considered some manifestation of this engine, where warmth and pleasure and jarring electric fight-or-flight feelings are considered the most free-flowing Qi experiences. As such, regulating Qi became a way to control and manage one’s own being. You want an out of body experience? Stop having sex and start practicing X-brand of Taoist yoga in order to fuel the experience (yes, I’m being tongue and cheek now, but this is what they believed). I’ve been through the Taoist training manuals and that’s literally where it all comes from–I’ll dig out references if you want me to, but it will be in support of what I consider a non-cause.

    You want measurements, all the normal measurements you make in western medicine are better measurements of the very thing “Qi” was intended to describe. Take an alcohol thermometer and pop it in your mouth: your warmth is your Qi. Take a mirror and hold it in front of your mouth, the mist that forms there from your breath is some of the excess Qi you failed to hold in. This is why breathing was so important: the object was to slow your breathing down presumably so that you wouldn’t wastefully exhale all your Qi more quickly than you could collect it during your specialized, Qi gathering exercise (Qigong!)… someone who has achieved immortality by their martial practice presumably never exhaled mist on a cold winter day. In the west, we used to have “humors” and “homunculi”… in the east they had Qi. Everything we know now phenomenologically in medicine was once some form of Qi in absence of a better explanation.

    Problem is that people don’t want to recognize that this is all it is… in martial arts, people are set up by presumption to look for something that they don’t normally feel within themselves, so they’re willing to pursue the mysticism to the ends of the Earth. It’s deliberately nebulous! A part of the swindle of how many of these schools make money is to give the small believable parts first and gradually wean you deeper into the myth as you get more advanced–a school offering you Death Touch (dim mak or Dian Xue–pressure-point fighting, acupuncture’s dark twin) will eventually go that way. If you think acupuncture is borderline credible, learn a bit more about dim mak and prepare to get turned off. That’s how I got into it initially and a big part of why I’m not much of a believer now. Visualization may be a useful thing in and of itself, but that’s not how Qi started out; visualization is what culture has changed it into in the process of learning the reality of what the rest of Qi is. Visualization is the extent of Qi mythology which most modern people are willing to accept without question. Qi, as a religious construct used to explain physiology, is a lone passenger on a rapidly sinking boat: the more we learn about the reality, the more metaphysical and intangible Qi has to become in order to not disappear from culture altogether.

    Anyway, summing up my whole initial point, Qi is not immeasurable nothing per se (my physiology certainly isn’t nothing and I hope not to be dead and cold for a while yet)… it’s just a profoundly bad name for something we are much more capable of describing now. If I want 10th century medical care, I’ll go to an acupuncturist.

  54. #54 adelady
    August 24, 2010

    Heatherly, I’m amazed!

    I also have fibromyalgia and I can’t imagine anything worse than massage. The pain is just awful, I even have to be careful applying moisturisers and the like. I can’t even use a towel to dry off after a shower (you might think I’m self indulgent investing in thick, cuddly, cotton robes, no, it’s the way to get dry).

    As for acupuncture, I can’t stand needles but I found a lovely doctor – yes, a real doctor, who uses a dainty little laser, or occasionally a heat method, and that was excellent. The great advantage is speed. I’d previously gone for pressure point therapy from a physiotherapist but it took ages, an hour at a time, and was draining for both the therapist and me because of the pain involved.

    Far and away the best thing was – yes, drugs!! But then I got allergic to that. Hey ho. For the time being, I’m on the suffering must be character building regime.

  55. #55 qetzal
    August 24, 2010

    jane, you write:

    qetzal – Your comment was not as extreme as some, but you did suggest that because the weekly session with a trainer involved somewhat (not 40 full minutes) more exercise, they “might as well have been comparing tai chi to orange juice.” I noted that there is no evidence that a full 60-minute period of standard Western static stretches would be superior to a 20-minute period; it might be inferior.

    So, if there’s no evidence, then why not make the times comparable, and eliminate a variable?

    This trial appropriately compared the two interventions according to a usual standard of practice for each, such as people would experience in typical use.

    If 20 minute of stretching is really the accepted standard (despite not having evidence that it’s optimal!), and if the authors were really trying to compare two accepted programs, I’d accept that. However, I very strongly doubt that it’s standard practice to provide 40 minutes of didactic instruction on diagnosis, coping, diet, etc., before stretching. So no, I don’t believe that the authors were simply comparing two interventions according to the usual standard practice for each.

    Let me say again: I’ve got no bias against tai chi. It’s quite easy for me to accept that tai chi could be beneficial for fibromyalgia patients, either because it’s good exercise, or because patients like the mystic aspects, or both. Nor do I have a problem with doing more studies on tai chi.

    The only thing I’m objecting to is the design of this particular study. It could have been designed to address a useful and generalizable question, such as: “Is tai chi better than a comparable program of stretching?” Instead, it merely addressed whether tai chi is better than a particular and arbitrary combination of wellness coaching and stretching. That’s why I said it’s like comparing tai chi and orange juice. Even if you find that one is better, what does it mean? Are you in a better position to decide what to do next? In this case, not really.

  56. #56 Anthro
    August 24, 2010

    @Ian, #10

    You said: “Thanks for sharing your opinion. Since it’s based on nothing more than your bias against woo-woo (one which I share), it’s really not much of a substantive contribution.”

    I doubt you’re still around Ian, but what makes you think the above comment from you is a “substantive contribution”?

    This kind of thing is completely uncalled for. I have read many things on this blog that I don’t agree with, but I have yet to make such a pointless, subjective attack. People desperately want to verify their woo and all I’m saying is that if you take away all the “eastern” and “the master” and even the term “tai chi”, what you have left is stretching and that ain’t woo. If you like tai chi, Ian; be my guest and pose yourself all you want. I think it was clear that my comment was opinion-oriented and not directed directly at any particular part of the study–I still think it’s a pointless study other than showing that stretching helps fibro somewhat and that when you dress up stretching with eastern mysticism, which appeals to many people, it seems to work better–maybe. Big deal.

  57. #57 trrll
    August 25, 2010

    Is tai chi better than a comparable program of stretching?

    There is no comparable program of stretching, because tai chi isn’t stretching. Some people do a few minutes of stretching before doing tai chi, but probably not 20 minutes, and it isn’t really necessary. One could do a comparable duration of stretching and tai chi, but who knows if duration is the appropriate measure for comparison of two such different activities? Perhaps one should measure oxygen consumption and strive for the same number of calories expended. So the study is legitimate in terms of comparison of a standard session of tai chi to a standard therapeutic regimen, but stretching and counseling is not really the sort of control one would devise if the goal were to determine what aspect of a tai chi regimen is beneficial. For that, I’d suggest something like a comparable period of slow exercise, perhaps on something like an elliptical trainer, with monitoring of heart rate to verify similar exercise intensity.

  58. #58 Jimbo Jones
    August 25, 2010

    Anthro: the difference between you getting old and a fibromyalgia sufferer is thus: there are fibro sufferers who are in their early 20s, or even teens. I’m not sure if there are prepubescent sufferers, though.

    That said, It’s not as simple as the description implies, or else it would just be written off as old age.

    Moving on, there’s a very easy way of making sham tai chi. Most people here who have suggested how hard it is probably know at least the basics of tai chi. I don’t, and can’t tell tai chi from some loon dancing without music. If you want to control for the placebo effect, you just have to make the people think they’re doing tai chi, no? Then make sure that your experimental group knows about as much about tai chi as I do, get some of them to do some light dance lead by someone who looks like they could be a tai chi master, and the others can do real tai chi.

    From what I know of fibro, there’ll be a pretty massive difference between the two groups.

  59. #59 ZenMonkey
    August 25, 2010

    This reminds me of all the woo surrounding yoga or yoga-like exercise for chronic fatigue syndrome (possibly a related illness to fibro but that hasn’t been definitively proven). I’ve had people make the most ridiculous claims about yoga and spirituality and my health. But what are we really talking about? Focused deep breathing and gentle stretching and movement for people who are usually in pain, stressed out, and don’t get much exercise. When I do yoga I can feel my muscles relax, my mind clear, and so forth, but does it really have to be “spiritual” in order to see the benefits? No, and it does a disservice to the actual “power” of yoga or tai chi or whatever to wrap it all up in mysticism.

  60. #60 ZenMonkey
    August 25, 2010

    I missed Dr. Wonderful’s comment at #39, but yes. That.

  61. #61 Peter Deadman
    August 25, 2010

    A systematic review of 47 studies published in English and Chinese has shown that tai chi benefits balance, strength, cardiovascular and respiratory function, flexibility, the immune system, symptoms of arthritis, muscular strength and psychological well being. Its effect on improving balance is demonstrated in studies showing that it can reduce falls in the elderly – a common, distressing and expensive form of accident. (Arch Intern Med. 2004;164:493-501).
    I am definitely allergic to extremes of woo but the danger to a scientist is to dismiss ideas simply because they are strange and unfamiliar. Tai chi, and even more so qigong, embody more than two millennia of constant practice and development. Of course they may overlap with various more modern exercise, relaxation and psychoneuroimmunology systems, but they are unique in themselves. Their theoretical/philosophical basis is integrated and meaningful within the practice itself. Of course it’s fair to question this basis – to try to submit it to an objective reality test – but it’s not the only, or indeed the most important, question.

  62. #62 Willow
    August 25, 2010

    I’ve enjoyed reading this response to the study and articles. I have fibromyalgia and I fall into the category of ‘will try damn near anything if it might help’.

    I did want to comment on the control group though. In England, over the last decade, this exact sort of group is what is prescribed by doctors for fibromyalgia because ‘it will help’. You go, you sit on awful chairs for an hour or more listening to someone tell you about the condition and that not being overweight, exercise and relaxation are the answer to the condition. The last quarter of the time you’re there is spent with the speaker having slapped on a guided meditation CD so we can see how easy it is to relax or demonstrating how easy it is to exercise and what stretches we should do. Periodically over the years, I’ve been asked to attend classes just like this for ‘pain management’ and they’re bollocks. I’ve had to go to these ‘classes’ repeatedly – like I might have forgotten the symptoms FMS causes and might have forgotten that exercise and relaxation are ‘the answer’.

    So personally, I think the control group was a pretty accurate representation of what is currently offered as ‘treatment’ by many medical professionals.

    And I can see one big reason that Tai Chi would have have superior results. Movement. Going to a class and sitting in even decent seats for 20+ minutes can be absolutely excruciating for someone with FMS. Stretching during the course of the class or at the end is going to hurt – but it’s also an opportunity to get out of an uncomfortable position. Relaxation doesn’t hurt – but it’s pretty difficult to achieve when you’re in agony. Stretching is also difficult when you’re in agony – but sitting for any length of time often leaves me with a need to stretch as much as I can endure despite the pain. It IS useful to learn about the condition and learn how to pace yourself and even to hear that exercise is better than being sedentary – despite the pain. But many people are simply in too much pain to actually get started. In more than one of these classes I’ve been told to mimic the stretches being done and said, ‘You’re kidding, right?’ I have hypermobility syndrome as well as FMS – I’m definitely flexible enough to achieve the stretches. But I think it’s akin to performing surgery on yourself without anesthetic. You COULD attempt it if there was an absolute necessity for it – but there’s no guarantee that it’s not going to be so unbearable that you can’t complete it and by trying you could actually make the situation worse. Numerous times I’ve had health professionals say, ‘Come on – it can’t be that bad!’ and I’ve wanted to tell them to go slam an appendage in a car door 20 times and then let me ask them if they think doing the same exercise is going to bearable without drugs.

    I’d done Tai Chi as a child, so when I heard about the benefits for FMS, I got myself a Tai Chi DVD. And about 10 minutes into it, I realised something. Without having done Tai Chi in years, I have probably looked like I was doing Tai Chi while stood at the bus stop since getting FMS. I can’t stand still, but I have to be careful to not over exert myself or my energy will be gone or I’ll trigger a flare up. So I shift my weight from one foot to the other, bend one knee slowly, then the other, lean forward, lean back, step back and stretch my hamstrings… all slow, deliberate movements. Just like Tai Chi.

    So I Do think that Tai Chi is an ideal exercise for patients with FMS that are mobile. It already mimics some of the things we naturally do when our muscles feel tight and doesn’t require stopping between movements like some aerobic exercises do.

    But as always, this is a treatment that isn’t aimed at the FMS patients who are find the condition totally debilitating. Between the ages of 28-38 I have felt closer to 88-98 and it was not until I started receiving drug treatment for neuropathic pain that I was in a position where the pain was managed enough that I could actually attempt gentle exercise. I have absolutely seized the opportunity to regain some muscle tone and improve my fitness because I don’t know how long the drugs will work and for a decade I’ve been told that exercise is the answer.

    So I’ll carry on mixing it up with a bit of yoga, a bit of Tai Chi, a bit of interval training, a bit of cycling. But as far as studies regarding alternative treatments go – I have see far too many ‘miracle cures’ over the years to actually think that Tai Chi alone is the answer. But a lot of doctors need to actually start looking at treatment that includes decent pain management (even if there’s a risk of dependency) for those of us who have been in pain so long that we can’t focus on education, relaxation or exercise.

  63. #63 adelady
    August 25, 2010

    Willow, oh yes, the risk of dependency. What about the risk of years of immobility?

    I realise that I’m a lot older than you, but if I had the option of drugs on which I’d probably become dependent or continuing with both pain and limited mobility, I’d take the dependency every single time. Let’s face it, if I or whoever actually got fit and energetic on such a regime, we’d be in a better position to deal with a reduction / withdrawal process anyway.

  64. #64 qetzal
    August 25, 2010

    Willow writes:

    I did want to comment on the control group though. In England, over the last decade, this exact sort of group is what is prescribed by doctors for fibromyalgia because ‘it will help’. You go, you sit on awful chairs for an hour or more listening to someone tell you about the condition and that not being overweight, exercise and relaxation are the answer to the condition. The last quarter of the time you’re there is spent with the speaker having slapped on a guided meditation CD so we can see how easy it is to relax or demonstrating how easy it is to exercise and what stretches we should do.

    Really? Well, then, my objections may be out of line. If 40 min of lecture and 20 min of stretching really is something of a standard approach, then the authors’ design seems reasonable after all.

  65. #65 Heatherly
    August 25, 2010

    adelady:

    Oh, massage hurts like a son of a bitch. But it also helps with stiffness, which helps with mobility, which hopefully will help me move more and get closer to increasing activity levels, etc. For me, it’s worth it for that–particularly for my knees and hips, because they make it so hard to be adequately mobile. My current job is in an older building that has a really steep ramp and about three stairs to get in–I would love to get to a point where I don’t draw stares from everyone when tackling them.

    Jimbo Jones:

    I was diagnosed at 12, so early diagnosis is possible. I think it’s uncommon, but I’m not familiar with current research in that area.

  66. #66 adelady
    August 25, 2010

    Don’t worry about the stares, Heatherly. I’ve learned that coping and gritting my teeth only make me look like a bad-tempered harpie. Now I have no. shame. If it hurts I wince or groan or complain, regardless of who’s around.

    As for the massage, I find that therapists have a lot of trouble dealing with a client in tears, even when you tell them it’s OK. The problem for me is that, even if I cope for the half hour or so I’m there, it always takes 30 to 90 minutes to recover. So I’m better off with a quick doctor’s visit for 10-15 minutes acupuncture.

  67. #67 Davina - Aura & Chakras
    August 25, 2010

    I agree with you – exactly such common sense things as exercise and relaxation should be considered as alternative is not that clear.

    It’s almost as if they have to be titled under the alternative banner – until there is enough scientific proof,that leaves no question, no doubt – yet does that occur that much in ‘normal’ testing? We are all unique individuals and how you might react to a drug or a form of exercies will be slightly different to how I might.

    So many times intelligence can get in the way of common sense -so much so that it’s just not clever anymore!

  68. #68 Davina - Aura & Chakras
    August 25, 2010

    I agree with you – exactly such common sense things as exercise and relaxation should be considered as alternative is not that clear.

    It’s almost as if they have to be titled under the alternative banner – until there is enough scientific proof,that leaves no question, no doubt – yet does that occur that much in ‘normal’ testing? We are all unique individuals and how you might react to a drug or a form of exercies will be slightly different to how I might.

    So many times intelligence can get in the way of common sense -so much so that it’s just not clever anymore!

  69. #69 Davina - Aura & Chakras
    August 25, 2010

    I agree with you – exactly such common sense things as exercise and relaxation should be considered as alternative is not that clear.

    It’s almost as if they have to be titled under the alternative banner – until there is enough scientific proof,that leaves no question, no doubt – yet does that occur that much in ‘normal’ testing? We are all unique individuals and how you might react to a drug or a form of exercies will be slightly different to how I might.

    So many times intelligence can get in the way of common sense -so much so that it’s just not clever anymore!

  70. #70 Davina - Aura & Chakras
    August 25, 2010

    I agree with you – exactly such common sense things as exercise and relaxation should be considered as alternative is not that clear.

    It’s almost as if they have to be titled under the alternative banner – until there is enough scientific proof,that leaves no question, no doubt – yet does that occur that much in ‘normal’ testing? We are all unique individuals and how you might react to a drug or a form of exercies will be slightly different to how I might.

    So many times intelligence can get in the way of common sense -so much so that it’s just not clever anymore!

  71. #71 trrll
    August 25, 2010

    Moving on, there’s a very easy way of making sham tai chi. Most people here who have suggested how hard it is probably know at least the basics of tai chi. I don’t, and can’t tell tai chi from some loon dancing without music. If you want to control for the placebo effect, you just have to make the people think they’re doing tai chi, no? Then make sure that your experimental group knows about as much about tai chi as I do, get some of them to do some light dance lead by someone who looks like they could be a tai chi master, and the others can do real tai chi.

    This sounds like a study that would be pretty much useless for either clinical or scientific purposes. Tai Chi is not like acupuncture in that there is no claim that particular movements have a special “chi” significance. Indeed, I’ve seen variant forms of Tai Chi that share few movements with the most popular forms. And certainly there is no scientific reason to expect that the precise movements are critical–I doubt if you’d even find many Tai Chi masters who would claim that. So the reasonable hypothesis is that it is not the specific movements, but the way in which they are performed. And while most people couldn’t tell “real” Tai Chi from some forms of modern dance, they’ve probably seen enough Tai Chi here and there to have some idea of what it should look like.

    So a sufficiently convincing sham Tai Chi would probably be enough like real Tai Chi to have similar benefits. Let’s say this proves to be the case. Is there any clinical value to the discovery? Is anybody really going to train people in instructing sham Tai Chi for therapeutic purposes when there are many, many people already around capable of providing instruction in the real thing? So basically, such a study would, at considerable effort and expense, most probably confirm what most people already believe to be true, and the results would be of zero clinical value.

    It would be far more useful from a clinical perspective to compare other kinds of activities. Could one devise a set of movements that could be done from a seated position for people who are mobility impaired? From a scientific perspective, I’d like to know what aspects of Tai Chi are beneficial. Is it just the exercise? (compare it to a similarly energetic routine on an elliptical trainer) Is it the breathing? (have people stand still and do breathing exercises)? Is it the mediation? (compare other kinds of meditative training). Is it the placebo effect of training with a master? (train a physical therapist in Tai Chi, have them teach it purely as a set of exercises, and don’t even call it “Tai Chi”)

  72. #72 Clayton
    August 25, 2010

    BTW completely off topic

    @53 Viggen

    I think it depends on the martial art you practice. I practice Muay Thai and I get some Eskrima and Kali practice in when ever possible. The only death touch I know of is with an edged weapon…but then again people do die in Thailand during Muay Thai competitions, broken ribs from kicks and elbow strikes taking place in a country without first world medical care, not some mythological death touch. The more westernized the art the less you will hear of mystical things, but rather on form. The body can only move in so many directions, at the end of the day these arts are all the same, with peculiarities distinct to fighting each other. Silat looks kinda funny and has weird joint moves, until you put a small knife in your hand and you realize that those moves come from slicing tendons and veins. Karate makes the most sense when you put a knife in a practitioners hand. All very martial in nature.

    Slow is smooth, smooth is powerful. In the realm of any exercise program learning to do something smooth and slow sets of the pattern in the mind with the muscles ( I know there is a technical name for this nervous system). It is akin to forcibly learning good habits, this is where a master instructor comes in, practice makes perfect, in as much as how perfect was the practice, so a masterful instructor who has gone through training AND testing should be able to teach. Both arms of the study need that. Tai chi makes sense for fibro, but so would any movement that trains movement with out initiating painful stimuli. My PT says move the joint in as full a range of motion as you can without pain. As this teaches the body(well the nervous system really) to not tighten up, and you get less tension in the body as a result, but you have to practice perfectly for it to work.

  73. #73 Denise
    August 25, 2010

    @54 adelady;
    I have Dercum’s Disease, AKA adiposis Dolorosa, and one doctor at the pain clinic called it “Fibromyalgia with additude”. Almost everyone on the Yahoo support group had been initially diagnosed with fibro, but the big difference is that the pain isn’t mostly in the muscles, it is in the FAT and musculoskeletal system. The pain is definitely nociceptive, and responds to opioids, although a lot of people don’t take them “until I can’t take anymore” although regular doses that keep a relatively constant blood level work much better, preventing a lot of pain. They don’t know much about opioids and are afraid of addiction. Not frequent, and a good pain clinic (I go to the Wasser in Toronto, ON) can treat both pain and addiction at the same time.

    Inheritance pattern suggests dominant allele with variable effect. Your skin sensitivity sounds like mine. I don’t shower, and have found a bath deep enough to float relieves any pain except in the head, face, and neck. Nodules in the fat in places such as the inside of the upper arms, inside the upper thighs, the abdomen, etc. are common but hard to palpate if you don’t know how. You need to pinch a good piece of skin and fat (it will hurt like hell) and then ROLL that between your thumb and forefinger, from the tips to the balls of the fingers. They vary in size, inside of arm usually about like peas. They start singly, then grow into strings parallel to the limb, which then grow together into a mat or mass.

    Swelling that comes and goes is the other unusual feature of this disease. It isn’t normal edema, and can cover areas both small and large, for a day or months at a time. If you have it in your hands, at least some of your fingernails will start to arch, and at times even partially separate from the nail bed, when swelling recedes after it was too much to maintain integrity.

    Other symptoms are much like fibromyalgia, and there are a lot of other problems that it correlates or seems to correlate with.

    I hope you don’t have it, but if you do it is good to know. I’m sleep deprived, so I hope the above made sense.

    Of possible interest to ORAC, it appears to generate a lot of angiogenesis factors – hemangiomas, angiolopomas, and plain old cherry angiomas are common. Bleeding is frequent but clots normally. This has been attributed to delicate new blood vessels in the new fat. Spontaneous echymoses are sldo commmon.

  74. #74 GreenAndCrunchy
    August 25, 2010

    Um, about Qi being total mystical Woo?

    This could be filed under “crackpot hypothesis” as I am unaware of any good studies, but my Tai Chi master holds a doctorate in mechanical engineering, and believes that Qi is essentially electric impulses transmitted along the nerves. Relaxing reduces resistance, allowing a freer flow of energy. Read a description of “guardian chi” and you actually get a fairly good visualization of the human body’s electromagnetic field.

    I’m just sayin’.

    Naturally, the relaxation also affect the muscles and various circulatory systems…

    And as some of the previous posters have pointed out, something that the practice of Tai Chi is very effective at is teaching people how to relax. If the standard intervention is telling people that they should relax (easier said than done) then something that actually gets them to a relaxed state is going to have better results.

    Also, in such a short intervention, I seriously doubt that the teacher got heavily into the metaphysics. Teaching new students with chronic pain the proper stances would probably have taken up most of the class time. It’s fairly easy to do stances wrong (improper posture) and do things like overstrain your knees.

  75. #75 jane
    August 25, 2010

    Todd W – “It is interesting that when those of us critiquing the study focus on details, you interpret that as us basically saying that the study is total crap and there is no benefit to tai chi, yet here you are focusing on a specific detail to make your argument.”

    A double straw man. My own argument does not rest on the value or harm of didactic instruction, but on the fact that the best available clinical trial data show tai chi to be a high-quality form of exercise. I also did not say anything that could be construed to lump minor criticisms or speculations on mechanism together with an essentially religious unwillingness to accept scientific data. The “detail” we were discussing was among a list of unsupported alternative hypotheses offered as possible means of explaining away the superiority of tai chi. If I fail to argue against such “details,” I may be presumed to have conceded the point, yet if I take the time to point out why they’re implausible, I will be accused of nitpicking. Can’t win, can I? :)

    Anthro – “People desperately want to verify their woo and all I’m saying is that if you take away all the “eastern” and “the master” and even the term “tai chi”, what you have left is stretching and that ain’t woo. [Ad hominem attack on Ian deleted] … I still think it’s a pointless study other than showing that … when you dress up stretching with eastern mysticism … it seems to work better–maybe.”

    Wrongo. Tai chi is not only stretching, and it specifically isn’t only static stretching of single muscle groups. It involves stretches of the whole body in natural motion – plus a degree of strength training and aerobic exercise – plus balance training (not negligible as it may be the best “treatment” for most people with osteoporosis). Yes, this makes it more difficult to understand the mechanisms by which it works; that doesn’t entitle you to just write off the complexity, which is very likely related to benefits. Scientism has given us reductionist exercise whereby first you “do cardio” by grinding away at an exercycle or step class, and separately do static stretches of selected individual muscles, then separately do “strength training” of selected individual muscles. If the average Expert promoting this kind of drudgery could move as well as the average tai chi master, I would consider adopting it. Otherwise, not a chance.

    In general: as for the exercise-time shibboleth, let’s imagine what would follow if we accepted the speculation that stretching and tai chi are equal in terms of benefits per minute, and that stretching has no maximum desirable dose beyond which it becomes harmful, so that the differences between groups were due to training session length. The stretching group got 140 minutes per week of exercise. Let’s say that the tai chi group got 50 minutes – though it was probably less – one night and 120 minutes the rest of the week; that’s 170 minutes. The improvement in pain and function scores was close to three times better in the tai chi group, because they got 21% (30/140 minutes) more weekly exercise in one dose? I find this also very hard to believe. Anyone who has money to waste is free to do a clinical trial to try to prove it, but until and unless such is done, it should be clear to fibromyalgia sufferers which treatment is favored by the most real science. And certainly nobody should even by implication recommend that they pursue extremely long, clinically untested static stretching routines that might well worsen their condition.

  76. #76 Heatherly
    August 25, 2010

    adelady:

    I generally don’t (or try not to) care about stares, but I want my clients to focus on how I can help them–not how much it looks like I NEED help.

    I’m fortunate to have a very competent massage therapist who has extensive training in yoga, in addition to anatomy. She can frequently identify where I’m having the most trouble and do a little occupational therapy by helping me figure out positions and movements that go easier on those spots. Like anything else, it has its positives (more mobility) and its negatives (pain).

    As for acupuncture, that’s not something I would I consider a valid treatment. I’m glad it’s helpful for you.

  77. #77 T. Bruce McNeely
    August 25, 2010

    This could be filed under “crackpot hypothesis” as I am unaware of any good studies, but my Tai Chi master holds a doctorate in mechanical engineering, and believes that Qi is essentially electric impulses transmitted along the nerves.

    In other words, Qi is the same as nerve transmission of the usual type. Why is Qi undetectable by instruments that can detect electric impulses transmitted along nerves? How does it differ from ordinary nerve tranmission?
    A PhD in mechanical engineering wouldn’t necessarily know much about neurophysiology or electricity, but you’d think he would look it up.

  78. #78 Scott
    August 25, 2010

    This could be filed under “crackpot hypothesis” as I am unaware of any good studies, but my Tai Chi master holds a doctorate in mechanical engineering, and believes that Qi is essentially electric impulses transmitted along the nerves. Relaxing reduces resistance, allowing a freer flow of energy. Read a description of “guardian chi” and you actually get a fairly good visualization of the human body’s electromagnetic field.

    I’m just sayin’.

    That’s not even “hypothesis”, crackpot or otherwise. It’s pure rationalization – taking something he wants to believe in (qi) and trying to deny that it contradicts physical reality.

    Once he starts coming up with ways to measure said resistance, and test the claim, THEN it will become a hypothesis.

  79. #79 Composer99
    August 25, 2010

    jane @ 71:

    Wrongo. Tai chi is not only stretching, and it specifically isn’t only static stretching of single muscle groups. It involves stretches of the whole body in natural motion –

    jane, inasmuch as tai chi is a martial art (note the word art in there, consider the etymology), whatever its provenance and development, it is just as much a work of artifice as any contemporary set of exercises.

  80. #80 Peter Deadman
    August 25, 2010

    I think qi (chi) sensation in the practice of tai chi & even more so qigong, is a complex of sensations that feed back that the practice is correct. Some of what these sensations are is pretty simple, others harder to explain/understand. I mean if you close your eyes and focus your attention on one of your big toes, you’ll start to sense it in a different way … maybe heavier, maybe more alive, but something. It’s simple to do but probably hard to explain from a physiological point of view. Qi sensation comes when the fascia are engaged throughout the body, deep relaxation promotes vasodilation, so that blood flow is enhanced through the microcirculation, the mind calms and brain activity changes. There may be electrical changes and many other changes, but the key thing is developing and recognising the sensations – aliveness, warmth, peacefulness, a feeling of energy through the body or in particular parts etc. That’s what qi means. It’s not necessarily something separate and different from all these physiological changes, but it is the complex of many or all of them and I would suggest that the art of developing this ‘qi state’ is unique to the Chinese internal energy arts (it’s qualitatively different from yoga for example, however wonderful that might be). The post that started this debate off seems to me to be typical of a kind of hard-edged supposedly scientific knee jerk reaction that appears to be threatened by the growing popularity of the stronger forms of alternative health care (alternative to mainstream medicine that is). It’s usually profoundly ignorant of the traditions it’s so keen to dismiss and pretty arrogant too, because it’s disrespectful of the treasures to be found in other cultures simply because they are expressed in language that is unfamiliar (note to orthodox medics: pelvic inflammatory disease – a serious medical term if ever there was on – literally means ‘basin on fire’ disease.

  81. #81 jane
    August 25, 2010

    Composer99 – “jane, inasmuch as tai chi is a martial art (note the word art in there, consider the etymology), whatever its provenance and development, it is just as much a work of artifice as any contemporary set of exercises.”

    Gee, thanks for the etymology lesson. Not sure why I’m getting it, though, as I didn’t use the word artifice; perhaps you are displeased that I refer to tai chi as “natural motion”? We can agree that tai chi, like every other cultural practice, was invented and developed by humans and did not drop out of a tree. My point was that it uses the body in a way that more closely reflects what some people hope to get out of exercising, i.e., the ability to use one’s body, easily and gracefully, as it was evolved to be able to perform. If your goal were to speak German fluently, but your method of choice was to spend endless hours doing rote grammar drills, your eventual competence would be inferior to that of someone who spent the same length of time practicing conversing in German.

  82. #82 trrll
    August 25, 2010

    One of the classic demonstrations of “chi” is the “unbendable arm.” A basic version is quite readily taught to almost anybody. First one does a “control,” which amounts to telling the subject to “be strong,” to hold his arm straight, and to resist while you forcibly attempt to bend the subject’s arm at the elbow. It is usually possible to overpower the subject (unless he is much stronger) by using both arms against the subject’s one, and in any case, the subject’s subjective impression is that he is working very hard to resist the force.

    Then (in the conventional version) the subject is instructed to relax their arm and to visualize the flow of chi through their arm and out their fingers, like water through a firehose. One then against to forcibly bend the subject’s arm, but now he seems much stronger; it is nearly impossible to overpower him, and he reports little sensation of effort.

    The magical power of chi, right?

    Except:
    The chi visualization is not actually necessary (although it is the easiest way to teach it). As an alternative, you can instruct the subject to relax his arm but to feel like he is trying to reach something just out of range, and to focus on the “reaching” feeling as you are trying to bend his arm. Or instead of telling him to focus on a feeling, you can get him to put his arm in the proper extended position, and then simply distract him. In one case, I saw it done by asking the subject to tell you about his girlfriend while force was applied.

    If you palpate the arm muscles during the exercise, the unbendable arm begins to look less magical. In the control case, both triceps and biceps are generally tight even before force is applied, and both muscles become even more so when force is applied to the arm. But the biceps is the muscle that bends the arm. So the subject is unwittingly assisting you to overpower him. And since both muscles are in full tetanus, it is very tiring.

    But with the “unbendable arm” setup, both muscles are flaccid before force is applied, and only the triceps tightens when force is applied, and the muscle tension increases proportionately to the force applied. No wonder that he seems much stronger, and he feels less effort.

    So in this case, the “power of chi” simply boils down to effective use of the muscles. When trying consciously to resist, the subject uses his muscles inefficiently, but if you can get it into his brain that the arm is supposed to be straight, and distract his conscious mind so that it doesn’t try to take over, then he uses his muscles far more efficiently.

    And once you learn how it “feels” to use your muscles this way, it is possible to learn to summon it up at will. It’s a bit like learning to wiggle your ears–it’s very hard to do it the first time, but once you know how it feels to twitch that muscle, you can do it whenever you want. It “feels” a particular way, and if you want, you can call that chi.

    So it has nothing to do with any mysterious power moving through the limbs, or with nerve conduction, for that matter–it is simply a matter of mindset.

    Pretty much all of the classic “chi” tricks are something of the sort. Ultimately, they boil down to physics or physiology, but not always in the same way. For example, if somebody is trying to push you backwards with both hands against your shoulders, and you place your palms under his elbows and press upward very gently (so gently that they don’t even feel you doing it), they are unable shove you backwards and you seem very powerful. This one is simple physics and skeletal geometry. So chi is not even a single thing, but rather a grab bag of useful physical and mental techniques.

  83. #83 jane
    August 25, 2010

    Very nice explanation, trrll.

  84. #84 Passerby
    August 25, 2010

    The might be a couple of important environmental and mechanics factor differences between the standard exercise and Tai Chi groups, that contributed to outcome. I think I can explain why most of the benefit in the Tai Chi group occurred in the first half of the study period.

    The Tai Chi group was led by an experienced practitioner. Master-led sessons were very likely practiced *outdoors*. That’s important, because it’s unlikely the standard exercise group sessions were held outdoors. They would be held indoors, because very few group exercises in the West are held outdoors.

    Fibromyalgia patients have been found to be deficient in vitamin D and magnesium, which effects pain sensing and sleep regulation. Some positive results have been reported for small groups of patients given supplements or exposed to UV-treatment. Vitamin D plays a molecular role in chronic musculoskeletal pain analgesia and bone pain sensing.

    Tai Chi movements are performed standing, and the movements are tightly proscribed, slow and flowing. The movement sequence taught to the patients in the Tai Chi groups would be repeated regularly; the study didn’t continue long enough for the beginner group to be instructed in nonrepetitive sequences.

    I think the combination of a break in sedentary behaviors, natural sunlight supplementation of vitamin D production, improved cognition of *breathing* and reduced hypoxia, and the meditative rhythm of Tai Chi did much to alleviate abnormal calcium activity (second messenger function in the CNS and primary player in muscle energetics), and normalize musculoskeletal/nerve tissue and matrix repairs. Muscle tear damage of formerly inactive large muscle groups, typical in standard physical exercise, is minimized in Tai Chi. You do not feel stiff nor do you experience substantial muscle pain early on in the training and practice of Tai Chi.

    The psychological bonus of Tai Chi, from sunlight exposure would extend to a reduction of muscle tenseness and would markedly improve sleep cycling, in individuals who were not only sedentary, but spent all of their time indoors.

    The majority of benefit would be experienced in the first period of activity, 6-8 weeks, because this is the known period of large muscle group acclimation to regular exercise with minimum pain from overnight repairs to microtears.

    It also corresponds to about the standard course of vitamin D supplementation needed to see plasma level improvements. And I suspect it is about the same duration needed to experience improvements in chronic hypoxia, with restorative balancing in calcium channel signaling in CNS and reduction in abnormal muscle/nerve pain signaling.

    Tertiary benefit would be realized in improved movement ‘memory’ in the brain, most of dedicated to balance and muscle coordination, with an improvement in peripheral circulation (the importance of standing, rather than sitting or lying for exercise movements). .

    The study mentioned in this thoughtful blog entry could have been improved, but it wasn’t improperly designed, conducted or evaluated.

  85. #85 Terrie
    August 25, 2010

    Trrll, my instructor once explained Qi as “a black box explanation of biomechanics.” He considered it an important concept to understand in the study of Tai Chi, because of it’s a historical role, but part of it was also about knowing the limitations of understanding that gave rise to it.

  86. #86 trrll
    August 25, 2010

    Martial arts woo can be an obstacle to teaching modern, scientifically literate students, because traditional explanations based upon prescientific ideas of physiology are passed down along with the techniques. A modern student is liable to conclude that if the explanation doesn’t make sense, then the whole thing is bullshit. I think there is a certain amount of that going on in this thread. Often, however, the “chi” term gets applied to real phenomena that seem “magical” because they exploit aspects of biomechanics that are not generally known (and in some cases, not well understood).

  87. #87 david
    August 25, 2010

    an interesting comparison group for the study would have been a treatment that is well-known (by medical professionals) to be ineffective except for the placebo effect, and with a placebo effect that is based on the same belief system as Tai Chi. Accupuncture would have been a good choice.

  88. #88 jane
    August 25, 2010

    david@84 – Your suggestion presupposes that “the placebo effect” is of the same magnitude no matter what type of treatment is used. This is simply not true, as the literature on the subject has demonstrated. Acupuncture may provide more pain relief than a pharma drug in head to head trials. Would you accept ibuprofen as a placebo? The study you propose just might show that both tai chi and acupuncture groups had dramatically decreased pain and increased walking ability; this would hardly entitle you to announce that you had proven tai chi worthless!

  89. #89 adelady
    August 25, 2010

    Heatherly.

    I’m pretty sure that using a laser would automatically shift my doctor’s procedures into Orac’s category of not-acupuncture. I also tend to think that the stimulation of damaged nerves in hands, legs and feet might be more beneficial to me than to others who don’t have my particular genetic neurological disorder (CMT).

  90. #90 DrWonderful
    August 25, 2010

    My God, I love this. I’m actually on the side of the skeptics here. You Chi masters seem nutty even to me, a chiropractor.

  91. #91 Clayton
    August 26, 2010

    Chi or any other mystical bs woo. Where and why did this concept arise?

    One must first look back at the history these arts and the manner in which they have been taught and developed (I am speaking entirely of the martial arts, not healing). Every country or region has developed something akin to this, in France you have Savat, in China Kung Fu in the philippines you have Kali and Eskrima etc. What most of these schools had in common was that students had to learn mastery and pay a fee for the right to learn them. Often times they really were used for martial combat. So certain things had to be kept secret or made out to be more magical than they were. Just look at the piece Ben Goldacre did on the Native American skeptic who became a shaman, and learned the sham part. In many, but not all oriental martial arts there is the same thing.
    Some of it couldn’t be described. Nerve bundle strikes can paralyze or deaden an arm temporarily if done right, but to get your students worked up, and your potential enemies scared you have damaged their chi. Modern British SAS troops have a system where they have utilized the endocrines system’s flight or flight system to disarm or slow a person. Either show extreme hostility and hope to engage the flight, or if out numbered turn it off by showing yourself to be week and docile, which stops the adrenaline pumping and causes your attackers to be over confident, but slower to respond. Go back to the 14th century and if this is learned, you call it mastering their chi.. which has been a catch all phrase for the many differing techniques that all have a basis in biochemical or physical processes.

    @jane
    What the hell are reductionist exercises? Are you referring to isolated muscle movements ala body building idea’s? So many things like step and cardio classes are developed and refined by individuals and then groups, only since the 60′s have scientists gotten in to the realm of sports and sports training. Prof. Bompa and other Soviet professors developed ideas like periodization, intervals recovery etc. Good bio mechanics work, and sometimes you need somebody outside of sport, outside of the physical fitness world to analyze the movements, and get rid of what doesn’t work.

  92. #92 David
    August 26, 2010

    jane (@85): “Your suggestion presupposes that “the placebo effect” is of the same magnitude no matter what type of treatment is used.”

    No, you’ve misread what I wrote. The degree of placebo effect associated with a treatment is largely determined by the patient’s expectation value. If they believe they’re getting the benefit of an ancient Chinese medical system, then they get a huge placebo response. If they’re given something dissappointing like a pamphlet, standard physical therapy, or ibuprofen, then the expectation is lower. That’s the major flaw in the NEJM Tai Chi study.

    By suggesting the use of accupuncture as a control group, I’m setting up a comparator with a similar expectation value as Tai Chi, which is also a comparator that is known to have no intrinsic activity.

  93. #93 Pined
    August 26, 2010

    I have been diagnosed with fibro by rheumatologists and neurologists and the usual assortment of meds provides the usual assortment of semi-relief.

    Have attended too many “helpful” lectures aimed at reducing pain and fatigue and they are all pretty much the same: a rehash of what fibro supposedly is and isn’t, and the startling information that exercise is good for me, ditto relaxation. Same for support groups.

    Started Tai Chi two plus years ago and it works. We practice indoors, so no vitamin D or magnesium aid. Even whern I’m in pain and stiff, after half an hour or so of Tai Chi I start feeling better and by the end pain is reduced, I’m relaxed and the typical anxiety (wouldn’t you be anxious if you hurt all the time?) is calmed.

    I’m my own control group. I tried it (I’m an active skpetic) and it helps. I tried acupuincture (with a licensed MD) and it didn’t, ditto for multiple other alleged beneficial activities, so I rule out placebo effect.

    Thanks for the tip that it helps with hangovers.

  94. #94 Pained
    August 26, 2010

    I have been diagnosed with fibro by rheumatologists and neurologists and the usual assortment of meds provides the usual assortment of semi-relief.

    Have attended too many “helpful” lectures aimed at reducing pain and fatigue and they are all pretty much the same: a rehash of what fibro supposedly is and isn’t, and the startling information that exercise is good for me, ditto relaxation. Same for support groups.

    Started Tai Chi two plus years ago and it works. We practice indoors, so no vitamin D or magnesium aid. Even whern I’m in pain and stiff, after half an hour or so of Tai Chi I start feeling better and by the end pain is reduced, I’m relaxed and the typical anxiety (wouldn’t you be anxious if you hurt all the time?) is calmed.

    I’m my own control group. I tried it (I’m an active skpetic) and it helps. I tried acupuncture (with a licensed MD) and it didn’t, ditto for multiple other alleged beneficial activities, so I rule out placebo effect.

    Thanks for the tip that it helps with hangovers.

  95. #95 Chai
    August 30, 2010

    The best practitioners advocate a strict regimen of chai tea with your tai chi.

  96. #96 hd cricket streaming
    December 13, 2011

    My God, I love this. I’m actually on the side of the skeptics here. You Chi masters seem nutty even to me, a chiropractor.

  97. #97 lilady
    December 13, 2011

    Spam alert above!

  98. #98 افلام
    April 23, 2012

    I’m pretty sure that using a laser would automatically shift my doctor’s procedures into Orac’s category of not-acupuncture. I also tend to think that the stimulation of damaged nerves in hands, legs and feet might be more beneficial to me than to others who don’t have my particular genetic neurological disorder (CMT).