A Mind-Body Approach to Chronic Pain

A little more compliance, a little less pain; how can that be bad?

Posted Mar 31, 2018

Yes, there have been small studies praising tai chi as an alternative treatment for fibromyalgia; however, virtually all of those studies concluded that more robust studies were needed.

It may be that the most recent publication of the British Medical Journal has finally given us the robustness we all deserve when considering so-called alternative therapies for fibromyalgia.

Published results of a 52-week single-blind trial show that, in addition to fibromyalgia symptom relief, tai chi was associated with greater improvements in depression, anxiety, self-efficacy, and the mental component of the Short-Form Health Survey (SF-36) quality-of-life measure.

For those fibromyalgia patients trying to avoid the almost-inevitable polypharmacy that goes with many chronic conditions, perhaps this is one non-pharmaceutical prescription that will be used with some consistency; unfortunately, while aerobic exercise is recommended as a standard treatment for fibromyalgia to virtually all fibromyalgia patients, many patients find it difficult to exercise because of fluctuations in symptoms. 

You try exercising when it hurts.  Suddenly, that exercise recommendation becomes one more psychological burden.

This study included 226 individuals with fibromyalgia who were randomly assigned to receive supervised aerobic exercise for 24 weeks, twice weekly (75 subjects), or one of four Yang-style supervised tai chi interventions, for 12 or 24 weeks once or twice weekly (151 subjects).  Participants in the study were followed for 52 weeks. Investigators report adherence was "rigorously" encouraged in person and by telephone.  As a result of this rigor, a total of 183 participants (81%) completed the 24-week evaluation.

The study's primary outcome was changed in the revised Fibromyalgia Impact Questionnaire (FIQR) scores at 24 weeks compared with baseline. Secondary outcomes included changes of scores in patients' global assessment, anxiety, depression, self-efficacy, coping strategies, physical functional performance, functional limitation, sleep, and health-related quality of life as measured by the SF-36.

Each supervised session lasted one hour, and all participants were encouraged to include at least 30 minutes of tai chi or aerobic exercise in their daily routine during the intervention period. The researchers also asked participants to continue their exercise routines for up to the 52-week follow-up.

Research staff who were blinded to group assignment measured body mass index, treatment expectations, adherence, safety, and physical performance on the 6-minute walk test.  (Of course, subjects could not be blinded as to whether they were or were not participating in tai chi—but how could this ever be blinded?)

Those assigned to the tai chi groups attended 62% of classes versus 40% of participants in the aerobic exercise group, reflective perhaps of the more gentle (both physical and mental) and thus tolerable nature of tai chi.

Subjects in all five groups demonstrated a similar reduction in the use of pain medications, antidepressants, and muscle relaxants over time.  And speaking of time, the duration of tai chi mattered, with individuals in the 24-week groups reporting greater improvements in FIQR scores compared with those in the 12-week groups.  And for the motivationally-challenged fibromyalgia patient, when the investigators looked at the frequency of tai chi, they found no significant difference in effectiveness at 24 weeks between those who participated in tai chi once a week and those participating twice a week, suggesting tai chi once a week may be sufficient to see the reported improvements. 

Chronic widespread pain is a complex biopsychosocial medical condition that is associated with substantial mental health comorbidities, such as depression and anxiety. Tai chi has the potential to address the physical, psychosocial, and behavioral elements that contribute to chronic pain, and may be especially suited to tackling both the psychological and somatic symptoms associated with chronic pain.

This trial found that tai chi mind-body intervention results in similar or greater symptom improvement compared with aerobic exercise, the current most commonly prescribed non-drug treatment for patients with fibromyalgia.

Substantial evidence in the past several decades has suggested aerobic exercise (on land and in water) and its combinations effectively treat fibromyalgia and other chronic musculoskeletal pain disorders. Continuing exercise maintains positive effects on pain, depressed mood, physical fitness, and health-related quality of life. However, some patients with fibromyalgia have difficulties adhering to exercise programs, indicating a need for other effective therapeutic options.

In this study, participants assigned to the mind-body therapy maintained higher and more consistent attendance than those assigned to aerobic exercise. In other words, patient compliance may be greater with mind-body therapies.

When we in the health care profession dealing with chronic conditions, compliance often becomes one more patient aliment that needs our attention; compliance can translate to less pain in those with chronic pain.

For fibromyalgia patients, there is now a little more validation for a treatment that carries with it a little more compliance and results in a little less pain.

You can’t say anything bad about that.

References

Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial BMJ 2018;360:k851  (Published 21 March 2018)