Tai Chi for osteoarthritis: How exercise is "rebranded" as complementary and alternative medicine

"Complementary and alternative medicine" (CAM), now more frequently referred to as "integrative medicine" by its proponents, consists of a hodge-podge of largely unrelated treatments that range from seemingly reasonable (e.g., diet and exercise) to pure quackery (e.g., acupuncture, reiki and other "energy medicine") that CAM proponents are trying furiously to "integrate" as coequals into science-based medicine. They do this because they have fallen under the sway of an ideology that posits a false dichotomy: To practice true "holistic" and "preventative" medicine, physicians and other health care professionals must embrace the pre-scientific, pseudoscientific, or anti-scientific ideas about medicine that underlie much of the "alternative medicine" being "integrated."

Unfortunately, they've been largely successful over the last 25 years or so. From my perspective, the strategy that has been the most effective in mainstreaming quack practices as part of "integrative medicine" has been what I like to call the "rebranding" of practices that could and should be part of standard, science-based medicine. I'm referring, of course, to nutrition and dietary interventions, as well as lifestyle interventions, specifically exercise. To the extent that standard medicine might have undervalued such interventions over the past few decades, we practitioners of science-based medicine might be said, to some extent at least, to have brought this on ourselves. On the other hand, it is not as though doctors haven't been advising our patients to quit smoking and moderate their drinking and to lose weight through altering their diet and exercising more for many decades. We do this because we know it works. For instance, when some naturopathic quack touts "curing" type II diabetes with a vegan diet plus exercise, we know that can work because we know that losing weight can normalize blood sugar values in many cases of type II diabetes. Heck, the Endocrine Society itself even says so, declaring "lifestyle optimization" as "essential for all patients with diabetes" and recommending that all patients with type II diabetes "strive to attain and maintain an optimal weight through a primarily plant-based diet high in polyunsaturated and monounsaturated fatty acids, with limited intake of saturated fatty acids and avoidance of trans fats," that they lose weight through physical activity, and get enough rest. A vegan diet just takes that dietary advice to an unnecessary extreme, and any supplements recommended are almost always unnecessary.

Yet, through the wonders of "integrative medicine," these sorts of diet and lifestyle interventions are "rebranded" as somehow "alternative" or "integrative" and then wedded to all sorts of quackery, like acupuncture, reiki, and dubious supplements. This "rebranding" unfortunately allows the respectability of effective interventions to be commingled with treatments based on prescientific vitalism or pseudoscience, like acupuncture. Worse, these science-based interventions end up being blended with the same sort of nonsense. For instance, I've often said that yoga is simply a system of exercise if you strip it of its mystical ideas of kundalini, which are based in vitalism. Ditto Tai Chi. I've often noted that exercise, at least gentle exercise, is good for almost everything, most importantly, general health, and speculated that yoga or Tai Chi is unlikely to be any better than other forms of exercise that encourage and develop similar levels of cardiovascular fitness and musculoskeletal flexibility. But yoga and Tai Chi are "cool," "hip," and "alternative." So they're sexier, but probably no more effective than other similar interventions, as a paper in published in the Annals of Internal Medicine showed.

Tai chi versus osteoarthritis

Tai Chi, for those of you unfamiliar with it, is a martial art that combines slow, deliberate, graceful stretching with breathing exercises, relaxation, and visualization. I've also discussed a seemingly positive study published in the New England Journal of Medicine looking at Tai Chi as an intervention in fibromyalgia patients. At the time, I pointed out that fibromyalgia symptoms could potentially be helped by exercise, and that Tai Chi, therefore, would appear to be at least as good a candidate exercise regimen as any because of its gentleness, requirement for control, and relaxation. It is not at all unreasonable to hypothesize that Tai Chi might benefit patients with fibromyalgia, as it does appear to benefit some patients with other conditions, although not for any reasons of "energy flows" or alterations of the flow of qi. I was actually underwhelmed, asking "What is 'alternative' or 'complementary' about any of these findings?"

Similarly, it's not unreasonable to hypothesize that gentle isometric exercise might benefit patients with osteoarthritis of the knee, and physical therapy is already known to be an effective intervention. That's why I was interested to note on the National Center for Complementary and Integrative Health (NCCIH) blog a reference to a study that was described thusly: "Study Shows Tai Chi and Physical Therapy Were Equally Helpful for Knee Osteoarthritis." Of course, NCCIH sells this study as Tai Chi being "as helpful as physical therapy in reducing pain and improving physical functioning." After what I've heard from a lot of integrative medicine advocates touting Tai Chi for all manner of ills, I can't help but refer to the study as having found that Tai Chi is no better than physical therapy. The actual study was published in the Annals of Internal Medicine by a research group mainly based at Tufts University, along with recommendations for patients, both as Online First prepublications.

One thing I can't help but point out here is that one of the key prerequisites for doing a comparative effectiveness study for two interventions is that both interventions need to have been validated in randomized clinical trials as being safe and effective. So it's only natural to ask whether Tai Chi reaches that bar. The authors state in their introduction:

Tai Chi is a multicomponent traditional Chinese mind–body practice that combines meditation with slow, gentle, graceful movements; deep diaphragmatic breathing; and relaxation (6). Previous studies have indicated that Tai Chi can reduce pain and improve physical and psychological health among patients with chronic rheumatic disorders, such as rheumatoid arthritis and fibromyalgia (7–13). In our previous randomized trial, participants with knee osteoarthritis who completed 12 weeks of Tai Chi showed greater improvements in pain, physical function, depression, and health status compared with an attention control group (12). A 2013 updated meta-analysis of 7 studies that included 348 participants with osteoarthritis showed significant reductions in pain and improvements in physical function after 8 to 24 weeks of Tai Chi training compared with a waiting list, attention control, or usual physical activity (14).

Those prior trials suggested that Tai Chi could provide a practical exercise regimen with an integrative mind–body approach to manage knee osteoarthritis. The physical component provides exercise benefits that are consistent with recommendations for knee osteoarthritis (physical function, balance, and muscle strength) (15), and the mind component promotes psychological well-being, life satisfaction, and improved perceptions of health (9, 16). To date, however, no randomized trials have directly compared Tai Chi and standard care treatments. The primary goal of this study was to compare the effectiveness of Tai Chi versus a physical therapy regimen among a large sample of patients with symptomatic and radiographic knee osteoarthritis who were seen in the clinical setting and followed for 12 months.

The one thing that stands out here is that none of the Tai Chi studies listed had anything resembling a proper control group. They all compared Tai Chi with wait list, usual activity, or attention groups, which means, in essence, that Tai Chi was compared to no specific treatments with physical activity above and beyond what patients normally did. The NCCIH itself is less sanguine about the benefits of Tai Chi for osteoarthritis, summarizing the science, citing a single small 2009 randomized study funded by the NCCIH that found that Tai Chi was associated with "improvement in pain and physical function as well as in depression and health-related quality of life when compared to participants enrolled in an education and stretching program."

Personally, although I'm not entirely convinced that Tai Chi is all it's cracked up to be for osteoarthritis, it does appear to be a modality worth testing in comparative effectiveness research.

Tai chi versus physical therapy for knee osteoarthritis: The cage match

So let's look at the study itself. Its design is pretty straightforward as these things go: A randomized, single-blind comparative effectiveness trial comparing standard physical therapy with Tai Chi for 52 weeks. Patients were randomly assigned to either Tai Chi (2 times per week for 12 weeks) or physical therapy in a clinical setting (2 times per week for 6 weeks, followed by 6 weeks of rigorously monitored home exercise). If you want the gory details of the design of the clinical trial, they were published in 2014 at BMC Complementary and Alternative Medicine. The primary outcome measured is pain as estimated by the Western Ontario and McMaster University (WOMAC) Index pain subscale. Secondary outcomes measured include WOMAC stiffness and function domain scores, lower extremity strength and power, physical performance tests, psychosocial functioning (mental health, self-efficacy, stress, depression, mindfulness, and social support), durability of effect after treatment ends, healthcare utilization, outcome expectation, adherence, and occurrence of adverse events.

The study population consists of 204 people ≥ age 40 who meet the American College of Rheumatology criteria for symptomatic knee osteoarthritis confirmed by the study rheumatologist and who have radiographic evidence of knee osteoarthritis confirmed by a radiologist. Exclusion criteria include prior experience with Tai Chi or other similar types of complementary and alternative medicine such as Qi Gong or yoga, or prior experience with physical therapy programs for knee OA in the past year; serious medical conditions that limit their ability to safely participate in either the Tai Chi or physical therapy programs; any intra-articular steroid injections or reconstructive surgery in the three months prior to baseline screening on the most severely affected knee (study knee); any intra-articular hyaluronic acid injections in the six months prior to baseline screening; inability to pass the Mini-Mental Status examination; or inability to walk without a cane or other assistive device for the entire duration of the baseline assessments. Pregnancy and inability to speak English were also exclusion criteria.

The interventions to which subjects were randomized included either Tai Chi or physical therapy. The Tai Chi instructors taught Yang-style Tai Chi, which is apparently the most popular of the five main styles of Tai Chi and looks like this:

The Tai Chi taught to the subjects was standardized, and the investigators condensed the 108 postures of classical Yang style Tai Chi to 10 forms that could be learned by older subjects with knee osteoarthritis within 12 weeks, selecting these forms because they are easily learned, represent progressive degrees of stress to postural stability, and are likely to improve physical function without unduly stressing the knee joints. In contrast, the physical therapy sessions consisted of a personalized program developed by one of the physical therapists after assessment of the diagnostic and physical findings to address specific treatment goals developed collaboratively and consistent with current evidence-based recommendations. After six weeks, the participants transitioned to an at home exercise program. For both groups, along with primary and secondary outcomes, changes in medication use were tracked.

Overall, 1,195 patients were prescreened for participation, leading to 282 being assessed, of which 204 met the eligibility criteria and were randomized. The mean age was 60 years. Of these, 70% were women, and the racial/ethnic composition was diverse (53% white). Participants were pretty well-balanced.

Overall, the results are summarized in the graphs below (click to embiggen):

Tai Chi and osteoarthritis

As you can see, most of the differences between Tai Chi and physical therapy are not statistically significant, and those that are turn out to be small in magnitude, as you can see. Given that, it's important to keep in mind that this study is only single-blinded. Only the research study nurses, physical function assessors, and sponsor personnel were blinded to the treatment assignments, while the participants, obviously, knew what group they were in, as did the Tai Chi instructors and the physical therapists. This led the investigators to concede:

Limitations of this research include patients' awareness of their treatment group assignment and preconceived notions of treatment benefit potentially influencing their health and functional outcomes. For a study involving complex, multicomponent mind–body therapy, searching for and finding a feasible, useful, and valid sham comparison group remains challenging, with no well-accepted solution (40). Our study was necessarily single-blinded, a design with well-known limitations. To try to mitigate the influence of preexisting beliefs and expectations about the relative benefits of the interventions, we explicitly informed potential participants that the study was designed to test the effects of 2 different types of exercise programs. By emphasizing equipoise, we hoped to decrease expectations and minimize bias by not mentioning Tai Chi specifically. Using the Outcome Expectations for Exercise Scale to assess the possibility of bias, we found that participants' expectations of benefit from their randomly assigned treatment regimen were similar (Tai Chi, 3.9 [SD, 0.5]; physical therapy, 3.9 [SD, 0.6]). Furthermore, total session attendance rates were similar between groups (74% for Tai Chi and 81% for physical therapy).

Of course, the participants knew what they were getting after they were randomized and could easily have evolved as they continued in their assigned program over the course of 52 weeks. Personally, I consider the single-blind nature of the study to be likely enough to explain the two seemingly positive results found, which were basically the ones most susceptible to placebo effects. In addition, one glaring weakness in the study that I can't help but note is that the subjects using Tai Chi were instructed twice a week for 12 weeks before being on their own, while the physical therapy group only had therapy with a physical therapist for six weeks before being set loose on a "monitored" exercise program, whatever that meant. It almost seems as though clinical trial was set up in a way designed to minimize the effect of physical therapy relative to Tai Chi. I rather suspect that insurance considerations might have played a role, as insurance tends to be reluctant to pay for more than 4-6 weeks of physical therapy for anything, and insisting on more would have necessitated a funding source to pay for the additional sessions.

Tai chi versus physical therapy: A draw but a victory of rebranding

This study's results simply reinforce what I've been saying all along. For the most part, gentle exercise and joint mobilization are gentle exercise and joint mobilization and the specific form they take doesn't much matter, as long as care is taken to make sure they are not potentially injurious. It surprises me not at all that this study found a course of Tai Chi and physical therapy to be basically the same in effectiveness at relieving pain and stiffness due to osteoarthritis of the knee. Had I known about this trial when it was first announced, that's the result I would have predicted.

So what's the problem?

Here's the problem. The vitalistic component of Tai Chi is being touted as the reason why it's seemingly more effective at alleviating depression. For instance, see this quote by an "integrative physiotherapist" named Patricia Ladis in an article about the study:

"Top factors that determine physical therapy success have been getting 7-9 hours of sleep while in treatment, and connecting with their physical therapist. This is in contrast to "Tai Chi, where you are in an introspective space," she emphasized. "You can be quiet in your mind as you explore and focus on the movements of your body."

Ladies offered "that is a hugely beneficial thing for healing from pain. A quiet mind leads to a quiet body. Similar to the beneficial effects of meditation, someone in a daily introspective practice like Tai Chi or Yoga can have great health benefits."

And:

"Sometimes people can not even endure Tai Chi because any global movement hurts, and in those cases physical therapy is crucial," said Ladis. "Tai Chi is a great movement practice and has been very efficient at restoring proprioception and balance that physical therapy aims to accomplish. But it is also balancing to the mind and mobilizes the chi (energy) of the body which is crucial when we have degenerative changes and as we age. This is why this ancient practice is adopted by many and has helped so many. I believe for prevention or post physical therapy, Tai Chi can be very beneficial," she added.

No, no, no. If Tai Chi is as effective as physical therapy in relieving pain and stiffness due to osteoarthritis, it's because of the exercise, because it mobilizes the affected joints in a gentle manner. Chi has nothing to do with it, but, thanks to the rebranding of exercise as somehow "integrative" or "alternative" through Tai Chi, Qi Gong, or yoga, woo is legitimized, and you get even orthopedic surgeons characterizing Tai Chi as "more holistic than traditional physical therapy offered in North America" and going on to say:

Romeo further explained that "Tai Chi as taught by Tai Chi masters includes a very holistic approach to the person, including not only the physical requirements, but also the balance in mental health, whole body stability, meditation, breathing, and mind-body focus or connection. This helps people develop more positive mental attitudes and well-being, which is likely to also play a role in overall recovery from the stress musculoskeletal impairment."

No, exercise works, whether it's Tai Chi, yoga, Qi Gong, or the regimen developed by a physical therapist. No woo is needed, but that's not how studies like this are reported by CAM advocates.

Unfortunately, "rebranding" works.

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I've always thought as the 'flow of chi' as being a metaphor for fluidity and ease of movement as an ideal - my instructor thought that it was a metaphor for the circulation of blood.

(Disclosure: in the 1990s, I played tai chi for about 7 years- Yang and Chen, not Wu- including associated exercises, martial applications and choreographed fight sequences with a partner),

Some of its most important aspects involve weight bearing, weight shifting, general strengthening/ endurance and circular movements of joints ( e.g. Chan Ssu Chen- 'silk reeling - you can see videos') that might indeed provide appropriate physiotherapy. Not all of it is slow either ( animal exercises and Chen style) so it may be used in an aerobics fashion as well. There is a related method that employs standing for increasingly long periods of time which could help people with mobility issues.

I imagine though that one of the problems with tai chi as therapy is that most instructors haven't studied SB PT and anatomy/ physiology so I'm sure the surfeit of chi woo will flood into the gaps in their knowledge and classes may not be specific to students' particular challenges ( it's usually taught in groups). The guy I studied with was a physiotherapist who had a traditional Chinese master.

One positive aspect of tai chi- like yoga- might be that the coolness factor makes it more likely that people will continue for long enough to see results . I know from experience that I'm more likely to spend an hour in a dance class or playing tennis than running on a treadmill or riding an exercise bike ( while someone shouts orders at you , i.e. spinning)

By Denice Walter (not verified) on 30 May 2016 #permalink

Two points.

First of all, I don't see how anyone could possibly create an objective experiment that could accurately assess the potential of taijiquan to deal with arthritis or any other health complaint.

The problem is that only a very small percentage of the population have the right attitude to be able to really take advantage of what it has to offer. Taijiquan involves a great deal, but only if the person who practices is interested in doing regular personal practice and while doing so while consciously thinking about the subtle interplay between their musculature and posture. This also requires being aware of the way self-awareness constantly gets in the way of this awareness.

When I teach students I tell them that to do taijiquan properly they have to dissect their body with their minds. The vast majority of people simply are not motivated enough to perform such an intellectually demanding task. Most of them drop out. Of the small fraction who do stick with it, most of them do so because they have some sort of illness that they find is greatly relieved through the discipline. In my case, I suffered from migraine headaches that went away with regular practice. (And which came back when I tried to stop that regular practice.)

My second point is that yes there is a great deal of "woo" around taijiquan. But my belief is that there is a great deal of "woo" in the world in general. (If you doubt that, why are there so many climate change deniers? That's the most dangerous type of woo that I can think of.) It tends to fill the gaps in people's understanding.

I try to wean people off talking about "qi" by suggesting that what they really mean is self-consciousness or bodily awareness. Most people stumble through life without any idea of the subtle processes at work in their bodies (not metaphysical, but rather things like hormones, etc.) If they start something like taijiquan and do it seriously, they start to open up a whole new universe. Pre-modern people didn't have the theoretical education to talk about things like nerves, muscles, hormones, etc----so they talk about "qi" because that's the language they heard. Unfortunately, we live in complex societies with a lot of people who have never benefitted from the Western Enlightenment. :-(

I've practiced taijiquan and other Daoist things for something like 30 years and believe that it can be enormously helpful for a variety of health complaints. But it doesn't replace conventional medicine. It is only really of value for the vanishingly small percentage of the population who have the motivation and self-discipline to practice it at an elite level. Beyond that, for most people it is just another form of exercise.

This is a problem that underlies a lot of oriental disciplines such as Zen. That was what the koan about the thief, the master and the moon is all about:

&&&&

Ryokan, a Zen master, lived the simplest kind of life in a little hut at the foot of a mountain. One evening a thief visited the hut only to discover there was nothing to steal.

Ryokan returned and caught him. "You have come a long way to visit me," he told the prowler, "and you should not return empty-handed. Please take my clothes as a gift."

The thief was bewildered. He took the clothes and slunk away.

Ryoken sat naked, watching the moon. "Poor fellow," he mused, "I wish I could have given him this beautiful moon."

By Bill Hulet (not verified) on 30 May 2016 #permalink

One positive aspect of tai chi- like yoga- might be that the coolness factor makes it more likely that people will continue for long enough to see results . I know from experience that I’m more likely to spend an hour in a dance class or playing tennis than running on a treadmill or riding an exercise bike ( while someone shouts orders at you , i.e. spinning)

^^This^^.

People are much too sedentary these days, and finding some activity you actually like to do makes it far more likely that you'll actually do it long-term. For me, it's been bike riding.

By palindrom (not verified) on 30 May 2016 #permalink

"The problem is that only a very small percentage of the population have the right attitude to be able to really take advantage of what (tai chi) has to offer."

Yes. How often have we seen legitimate and valuable alternative medicine practices dismissed as of limited or no value, when the real fault lies with the people who try them - not having the right attitude, spoiling their treatment by using mainstream medicine first, or just doing things wrong in some way.

I used to have severe migraines, but they went away many years ago, probably because I developed a Zen-like attitude without even realizing it.

By Dangerous Bacon (not verified) on 30 May 2016 #permalink

“… pure quackery (e.g., acupuncture, reiki and other “energy medicine”)…”

Has acupuncture been *definitively falsified* as the cause of beneficial bodily effects?

(I would assume acupuncture hasn’t been falsified, because it’s still legal.)

By See Noevo (not verified) on 30 May 2016 #permalink

I was diagnosed with bilateral osteoarthritis in both knees several years ago. Steroid shots and hyalauronic acid both failed to have any improvement. Not sure why I wasn't offered physical therapy. As a guess, it was probably an awareness of my fixed and low income, and the fact that, for as much as my knees hurt, I remained fairly active. We do have livestock, and I usually insist on walking to the barns and various chores required.

I have added a lot more exercise to my days in recent months since being diagnosed with diabetes. A twenty-five pound weight loss (so far) has done nothing to change my reaction to medication (which I considered suboptimal, which led to cycling and walking at least five days a week, plus strength training, in hopes of improving insulin response, etc.). Eating to my meter required complete elimination of grain products and potatoes, as well as some fruits, even with medication and exercise, at least for now. I had hoped that "doing everything right" would allow me to have a day here or there where I could hope to eat grapes or pineapple and similar fruits again safely even if baked goods were gone forever, but it seems I haven't found a way to make my body that efficient (a good workout spikes my blood sugar over 200 still).

I haven't noticed a major change in my knees even with all this regular low impact stuff, so I have decided to ignore the cautions about weight training focusing on my legs (squats/leg presses, extensions, curls) and just build up very carefully, and hope that increased muscle strength reduces things.

In another year I am at minimum recommended age for total knee replacement, but I keep hoping these major lifestyle revisions might give me the option to hold it off even longer.

For some reason. I don't expect tai chi to offer me anything additional, but wonder if I could find a class if Mr Woo might fare better there than tagging along with me. In two months he is up to walking almost ten minutes (otherwise he just sits and waits - I take just over an hour if left to my own devices and always end up cutting it short for him). He says he doesn't want to risk hurting himself.

Has acupuncture been *definitively falsified* as the cause of beneficial bodily effects?

Hi, I only read RI when I'm whoring for attention!

(I would assume acupuncture hasn’t been falsified, because it’s still legal.)

So is conjuring the dead. Go figure out something about the subjects being addressed, check the RCC at 2116–17, and fυck off.

DB @4, I don't think M. Hulet's comment was trying to push Tai Chi as a theraputic modality at all. He's clearly taken it very seriously and found it highly beneficial to his overall well being as a part of Zen practice, and finds that most folks aren't willing to give it the kind of attention he thinks it deserves. He basically seems to be against dilletantism.

This is very different from such folks as the cancer quacks blaming bad outcomes on people not believing enough, or not shooting exactly the right kind of vegetable juice up their butts, or whatever other weird excuses they offer.

By palindrom (not verified) on 30 May 2016 #permalink

I’ve always thought as the ‘flow of chi’ as being a metaphor for fluidity and ease of movement

I think we've been over the bit where the chi in "Tai Chi" isn't qi.

I should have said that when the flow of chi/ qi/ energy is unblocked/ unimpeded.
I know I know about the chi in tai chi.

By Denice Walter (not verified) on 30 May 2016 #permalink

Orac,

Sometimes your protestations strike me a bit like that of the cab companies angry at Uber.

By See Noevo (not verified) on 30 May 2016 #permalink

I'm fairly certain that Tai Chi beats PT hands down cost wise. I know several hospitals that offer free classes. For PT, even though I have great insurance it cost me $40 a session when I went.

The physical component provides exercise benefits that are consistent with recommendations for knee osteoarthritis (physical function, balance, and muscle strength) (15), and the mind component promotes psychological well-being, life satisfaction, and improved perceptions of health (9, 16).

There should be a study of "real" Tai Chi vs physical only Tai Chi. I feel like even this study points to the "mind-body" thing being BS.

By capnkrunch (not verified) on 30 May 2016 #permalink

OK. Let's try again.

The problem with taijiquan for health benefits is that any benefits that accrue beyond simple movement only begin when someone brings a level of personal commitment, intellectual rigour, and, self-awareness beyond the abilities of the vast majority of people. It is an elitist practice.

As a result, it cannot be studied using standard scientific protocols---which are difficult enough when all we are studying are the effects of taking a pill. As a result, even if it had totally miraculous results---something I am not trying promote---the only evidence for this would be anecdotal. Until we have some way of objectively identifying a large number of taiji "masters", it simply cannot be studied scientifically.

One last point. The issue of arthritis in knees was raised in this discussion. Poorly taught and badly practiced, taijiquan often causes problems for people's knees. I don't know if done properly it is very good for people with arthritic knees. But I do know that if you do it wrong, it can cause a lot of pain in the knees.

By Bill Hulet (not verified) on 30 May 2016 #permalink

We've had Tai Chi as the exercise component in our Aged Care Residential and Community falls prevention programs for several years now. Of course, it's part of an evidence based program developed by our Clinical Excellence Commision (with real doctors, nurses, and allied health professionals) and endorsed into policy directive by our ministry. And not a sCAM practitioner to be seen, the instructors are all qualified exercise trainers. Tai Chi was chosen and stripped of all the vitalistic crap, and it's a really good, gentle exercise for seniors for core strength and especially balance. The gentle, stylistic moves in a group setting gets them interested and then keeps them coming in to the sessions.
But yeah, gentle exercise that helps seniors with core strength and balance, and gets them active.
Nothing alternative about that at all.

My employer (a university) provides 'wellbeing' workshops throughout the year. One of these was a series of three tai chi sessions. I also have degenerative arthritis in both knees (as well as damaged cartilage in one knee), both hips and both feet due to sporting/dance injuries over 30 years ago. Signing up for these I thought "well, I'll at least get some exercise during my lunch break for a few weeks".

At the first session the elderly (70 years+) instructor sang the praises of tai chi. Apparently tai chi would fix my arthritis, repair the cartilage and also cure my short sightedness. All I had to do was 'believe' because that way I would feel the 'energy flow through me to the parts of my body that were broken'. After 10 minutes of berating me for my scepticism, he told me that even though I could stay for the class, I was not to speak to other participants because my 'energy' was wrong.

I only went once, and made sure the wellbeing department (who I am on good terms with as they provide me with support when my knees make it hard to do my job) were well informed about his lack of evidence. Poor form for a university I thought.

By RetroPastiche (not verified) on 30 May 2016 #permalink

I don't have arthritis, but I have Baker's cysts in one knee. Would taiqi be a bad choice for me?

I'm desperately looking for a gentle exercise that doesn't booooore me out of my mind.

By shay simmons (not verified) on 31 May 2016 #permalink

I think both Tai Chi and yoga are great for osteoarthritis. The huge advantage, imo, over simple stretching is that both provide a pattern that one can move through on a regular basis. I find that much easier than remembering which hamstring I need to stretch next. They also provide balance and some strengthening.

Otoh, it's very easy for the advocates of those two forms of exercise to get into the woo. For example, the author of a study on yoga for OA of the knee writes, in part, "Yoga . . . can theoretically reduce pain and stiffness associated with OA by realigning the skeletal structure, strengthening muscles around the joints, and stretching tight joint structures." That's great, but then she adds, ""The theory behind yoga practice is that the union of mind and spirit in exercise brings balance to the body and promotes healing ." And there she goes astray.

Bill H.: "The problem with taijiquan for health benefits is that any benefits that accrue beyond simple movement only begin when someone brings a level of personal commitment, intellectual rigour, and, self-awareness beyond the abilities of the vast majority of people. It is an elitist practice."

Bonus points for honesty.

"As a result, it cannot be studied using standard scientific protocols"

Bzzzt! Negative points for standard "your science cannot evaluate my woo" rejoinder.

I see no reason why studies comparing outcomes with tai chi to those experienced with other forms of gentle exercise are not feasible.*

*unless the vastly superior intellectual and spiritual qualities of the tai chiers are a hopeless confounder. :)

By Dangerous Bacon (not verified) on 31 May 2016 #permalink

No, it's not a "“your science cannot evaluate my woo” rejoinder." Its an awareness that you cannot easily select an accurate sample of expert "taiji practitioners". Do you know how to separate people who are expert or even fairly good taiji practitioners from people who are crappy players? If a researcher doesn't know, then how can they construct an experiment that accurately evaluates the practice?

Practising a martial art as a form of personal practice is not the same as doing basic exercises while being yelled at by a drill sergeant. Nor it is the same thing as having someone else move your body for you---which is what a lot of physiotherapy seems to be to me. (I'm willing to be corrected on this last thing----I don't know anything about physio-therapy.) It is a very complex activity that to do well requires a depth of self-awareness that is orders of magnitude greater than simply jerking your muscles in time to music, being chased around an obstacle course by a drill instructor, or, having your legs flexed by a therapist.

To cite an analogy, how could someone evaluate medical professionals if there was no objective criteria for separating them from the general population except self-description? How could you evaluate the efficacy of modern medicine if the sample you were evaluating included MDs, RNs, Naturopaths, Homeopaths, and, Psychic-Surgeons----and you had no way of separating one from the other?

Stop trying to pigeon-hole me into the slot of defending "woo". I have practised taijiquan for 30 years, but I also have a Masters in Philosophy, have taught logic at the university level, and, taken courses on the philosophy of science. I AM NOT ARGUING THAT THERE IS SUCH A THING AS QI OR THAT TAIJIQUAN TEACHES YOU HOW TO SHOOT LIGHTNING BOLTS OUT OF YOUR ASS----I AM QUESTIONING THE IDEA THAT IT IS POSSIBLE TO CREATE AN EXPERIMENT THAT COULD SAY ONE WAY OR THE OTHER THAT TAIJI IS OR IS NOT MUCH GOOD FOR FIXING ARTHRITIS.

By Bill Hulet (not verified) on 31 May 2016 #permalink

Bill @20: I can't speak for anyone else, but when I went to PT for knee issues I was given a collection of exercises to do at home (after they showed me and I practiced in front of them).

(For what it's worth, I feel like you're saying that Taijouan requires a huge amount of commitment and some native skill beyond most exercises, and so in order to test it scientifically you're really looking for Olympic-caliber athletes for both the test and control. I don't agree, but I don't think that's woo.)

By JustaTech (not verified) on 31 May 2016 #permalink

"I AM QUESTIONING THE IDEA THAT IT IS POSSIBLE TO CREATE AN EXPERIMENT THAT COULD SAY ONE WAY OR THE OTHER THAT TAIJI IS OR IS NOT MUCH GOOD FOR FIXING ARTHRITIS."

Then what the heck is the point?

Do you or do you not offer something to benefit the common folk, and if so, how do we peons one figure out who is a good practitioner of it? And if we can, why can't a researcher? In addition, why isn't your secret society trying to get rid of the less than great practitioners of it? I would think they would tarnish your brand.

Fair disclosure: I don't know s*it but am trying to figure it out using logic.

By Not a Troll (not verified) on 31 May 2016 #permalink

JustaTech:
There is a basic minimal value in exercise that accrues to intro taijiquan. But if you want to see if there is something beyond that, you have to approach it the same way that an Olympic calibre athlete does. This doesn't mean that there is no real value in the practice, just that it is inherently elitist in nature. This makes it what is called a "state specific" practice, which means that it can only be practised by a small percentage of the population. This means that it can only be studied anecdotally instead of experimentally.

There is this notion in the Eastern civilizations that people can develop unique abilities through long periods of hard study---"kung fu". It is something that really jars Western sensibilities. It is not the same thing as "woo", but it has some superficial similarities, such as the problems involved in studying it experimentally.

Perhaps an example would help. One of the things you have to learn how to do in the set is to consciously control your glut max muscles independently. You put all your weight on one leg, tuck under your glut, stretch the tendons and muscles down your back, while stretching out your other leg. At the same time, you tighten in your lower abdomen, expand your upper chest to breathe---while keeping the lower part of your adomen (the tan tien) relaxed. At the same time, you keep your body vertical. At the same time, you have to memorize the exact place you are in, in set that has well over 100 moves. Once you get good at that, then you might be asked to do the move backwards, or on the side of a 30 degree slope, or in an area limited to four feet by four feet. The only way you can remember to do all this stuff is by quieting the mind and learning to not be distracted by random thoughts that flow through your self-consciousness. It gets more complicated after that---.

Any ability to help with arthritis is going to be very different with someone who has approached the art this way than it is for someone who goes to a class at the Y and follows along as best they can.

Not a Troll:
There are things in this world that are damned hard to study scientifically---if not impossible. That doesn't mean that they don't have value, just that you cannot evaluate them scientifically. Once in a while you come across something that just doesn't fit the scientific method and you have to accept it. That's all I'm trying to say. Think of it as something like Godel's proof---there are some logically true statements that simply cannot be proved to be true.

Science is a wonderful thing. But there are things in the world that it doesn't seem to be able to deal with directly. I would suggest that taijiquan is one of them. This isn't because it is based on occult powers, just because it is something that depends too much on the individual personality of the practitioner.

This is all I'm going to say on this. I was trying to help, but I've just awakened some troll-like behaviour and it has pissed me off more than I want. As far as I'm concerned the difficulty I've had getting my point across is just more evidence of the issue I'm trying to identify in the first place.

By Bill Hulet (not verified) on 31 May 2016 #permalink

There is this notion in the Eastern civilizations that people can develop unique abilities through long periods of hard study—“kung fu”. It is something that really jars Western sensibilities.

And the separation between siddhis is what, precisely?

Once in a while you come across something that just doesn’t fit the scientific method and you have to accept it. That’s all I’m trying to say.

The No True Scotsman fallacy?

Think of it as something like Godel’s proof—there are some logically true statements that simply cannot be proved to be true.

Not without a consistent axiomatic system first, thanks.

^ "between this and siddhis"

Bill Hulet,

No, still not a troll. It's just that your comments pushed a few of my buttons (that I won't go into) and I was harsh in return.

And for that, you have my apologies.

By Not a Troll (not verified) on 31 May 2016 #permalink

Well, now that the Cubs have lost, I'll add one more item to Mr. Hulet's leaving in a huff and strangely accusing the RIgulars of being "troll-like":

Science is a wonderful thing. But there are things in the world that it doesn’t seem to be able to deal with directly. I would suggest that taijiquan is one of them. This isn’t because it is based on occult powers, just because it is something that depends too much on the individual personality of the practitioner.

What's the dividing line between esoteric and occult? What is this "personality"? Are you talking plural minds? You're engaged in special pleading, but vagaries don't make much specialness.

If tai chi practitioners/adherents limited themselves to saying that their practices made them spiritually more aware and in tune to their surroundings, that would fall under the heading of something not measurable by science - in effect, a form of religion.

But once you start claiming myriad health benefits for tai chi, you properly face scrutiny to demonstrate that evidence supports you. And that requires well-designed studies, which are certainly doable. Just bring on your accepted tai chi experts (even if the only criterion for "experts" is "I know them when I see them"), randomize similar groups to undergo either tai chi or some other form of low-impact exercise, and evaluate results according to measurable outcomes (i.e. blood pressure, adverse events, work days lost to injury etc.), not nebulous things like "increased awareness".

Bill H.: "Once in a while you come across something that just doesn’t fit the scientific method and you have to accept it. That’s all I’m trying to say."

Nope. I don't have to accept any health claim that relies on anecdotes. By relying on such a standard, you ally yourself with a ton of disreputable woo.

These days I do a lot of fast walking and treadmill workouts. That does not require exquisite control of certain muscles, a doctorate in philosophy or other attainments that only a small percentage of the populace is supposedly capable of achieving. But I'd stack up the physical benefits I'm seeing* against what the tai chiers get (and I don't look anywhere near as ridiculous).

*plus what's backed up by research.

By Dangerous Bacon (not verified) on 01 Jun 2016 #permalink

@Dangerous Bacon,

Good points.

I agree.Even if there is some putative benefit that the real masters of tai chi receive that can't be achieved by ordinary people doing the exercises, that's no reason to recommend it for ordinary people as therapy for osteoarthritis or anything else.

I started a program of fast walking along with a more controlled diet to lose weight about 5 years ago. The principles were the same ones I used in the Air Force 25 years ago, with the dietary recommendations mainly from the American Diabetes Association.

My weight is now 40 pounds less, my BP and resting pulse are great, and my HDL cholesterol is almost as high as my LDL cholesterol.

My doctor asked me for recommendations to pass on to other patients.

Nothing alternative about it.

By squirrelelite (not verified) on 01 Jun 2016 #permalink

Bill @23: Honestly, I have to firmly disagree with this statement : "There is this notion in the Eastern civilizations that people can develop unique abilities through long periods of hard study—“kung fu”. It is something that really jars Western sensibilities."
To me that sounds a lot like a concert pianist, or a prima ballerina, or a chess master.

I feel like you're saying that unless someone who dances ballet is Misty Copeland, what they're doing isn't ballet. And I would argue the opposite; whatever your skill level, what you're doing is what you're doing. It's the motions and the mental attitude, not the skill level. And *that* can be measured by science.

I do not need to be a yogi for the practice of yoga to help me touch my toes.

By JustaTech (not verified) on 01 Jun 2016 #permalink

I spent 15 years studying Tai chi and a handful of similar martial arts. As long as you don't drink the kool-aid, it has some nice qualities. In some ways, it's like studying how to improve your golf swing, but in the context of your arms, legs and body.

That said, I think you have to be careful with it. The entire mythos surrounding Tai chi invites you to place it on a pedestal all by itself, which is the foundation of a placebo. If you spend your time looking for it to make you 'better,' you will surely see it making you better. I've met people who have taken the study of these arts so far that they are literally in the process of destroying their knees, backs and shoulders rather than fixing them, or they engage in other physical activities that do damage to their bodies under the delusion that doing Tai chi 'also' will somehow make the self abuse 'okay.' Further, indulging in Tai chi runs the risk of crank magnetism... the slope from Tai chi to accupuncture and from there to things like Reiki, raw foodism and antivaccine views is surprisingly direct.

I do understand what sells people from Tai chi into 'energy medicine' and I wish there was a way to keep it in context. Contemplating your body and understanding how it moves and what it feels can have some very impactful and 'spiritual' experiences (what do you expect? It's the biological equivalent of putting a microphone up to a speaker)... but it also shows that nobody is instantaneously capable of understanding the truth about even something so innocuous as themselves and their own bodies. One of the big things I got from my study of martial arts is a notion of my own limitations and that I could do things that seemed painless and health promoting at the time, which spiraled into real sports injuries later.

I personally have gotten away from studying things like Tai chi because I've found that schools teaching these arts tend elevate the teachers away from mere mortal humanity. It's a recipe for disaster, changing an exercise into a religion. The teacher just has to look impressive and they can sell a majority of their potential students on any old thing. The result is a guru surrounded by true believers... never mind that most of the believers usually don't stop to ask if they should be elevating a functional gym teacher into guru-hood. I won't.

@Bill comment 23

"Science is a wonderful thing. But there are things in the world that it doesn’t seem to be able to deal with directly. I would suggest that taijiquan is one of them. This isn’t because it is based on occult powers, just because it is something that depends too much on the individual personality of the practitioner. "

That's a confirmation bias on your part. A quantitative change in something like health is measurable and comparable to other sources of similar change. If you start arguing that changes are not measurable you're also arguing that they don't actually exist. If it only exists in your mind, how is that not the same thing as a lie? This is why placebo is so dodgy.

Belief has tremendous power --it can totally color your reality and make truth out of falsehood. But, belief isn't always the same thing as truth.

One of the big problems with martial arts like Tai chi is that to get to a high level, it's taught by believers to believers. If you do not sufficiently believe, the teacher won't let you progress until you demonstrate to him or her that you believe what they're shoveling. Unbelievers drop out and go away while believers progress. This situation is intrinsically designed so that if you don't shelve the skepticism, you go nowhere. Worse, at a high level, when it's all believers surrounded by believers, imagination and group think fills in the blanks where reality doesn't actually go and elitism keeps the magic insulated from upset. There is social pressure in that situation to conform to the expectations of your betters or become a pariah. How can science penetrate that?

If you're asking a measurement to go where you think it should, you don't always like where that measurement actually ends up... then, of course science can't measure it. That's a set-up so that it won't ever provide the 'right' measurements to match your expectations. At that point, not only can you _not_ be certain that what you believe is the truth, you also actively want to see what you believe confirmed as truth. Preconfirmed hypotheses are dangerous because a scientist can't let them go when they don't stand up to testing. Claiming that such a preconfirmed hypothesis must not be testable is just a way to decouple it from ever needing to be true.

Ah viggen, you said it far better than I ever could.

It was one of the buttons Bill Hulet pressed - the fact of it being a belief system where if one does not proceed to get better than their attitude, personality, thoughts or their knowledge of the process are lacking.

Honestly, I can not thing of anything more cruel to those who are suffering than to blame them in this way.

By Not a Troll (not verified) on 01 Jun 2016 #permalink

^ Sorry viggen. I think you were making a different point about the belief system yet I think what I described above is another one of the fall-outs from it.

By Not a Troll (not verified) on 01 Jun 2016 #permalink

Tai Chi is a great method. With joints that don't want to behave in my case, this is a great option. Swimming and Yoga as well. I've been into Eugene SIms book How I Achieved Freedom From Arthritis, he was able to avoid knee replacement so I take him at his word and have tried his methods and saw very good changes as far as my mobility goes.

By Annie Romero (not verified) on 24 Jun 2016 #permalink