Fibromyalgia is a relatively common, chronic, debilitating condition which affects more than 200 million people + worldwide. It is characterized by chronic pain, first and foremost, but individuals also complain of fatigue, stiffness and non-restorative sleep. There is no definitive test for fibromyalgia: blood work and physical exam are normal and the diagnosis is by process of excluding other diseases. Although many physicians question the validity of the diagnosis, for those suffering from fibromyalgia the pain is clearly real, and so is the need to search for mechanisms of relief. Presently, when all other diagnoses are excluded, recommendations include exercise, improved sleep habits and medications. The ideal exercise program is not clear, although many physicians prescribe a mixture of strength and aerobic regimes, perhaps simply covering all the bases. Pharmacologic treatments include amitriptyline (the norephinephrine reuptake inhibitor Elavil), cyclobenzaprine (the muscle relaxant Flexeril), and fluoxitine (the popular seratonin reuptake inhibitor Prozac). More recently the FDA approved three drugs specifically for fibromyalgia: the seratonin/norepinephrine reuptake inhibitors duloxetine (Cymbalta) and milnacipran (Savella), and pregabalin (Lyrica) the anti-convulsive also used for neuropathic pain. Although these drugs do seem to help a percentage of fibromyalgia suffers, the efficacy data is generally disappointing. For example, in a placebo controlled 12 week trial of duloxetine, only 55% of the fibromyalgia sufferers reported a significant reduction in pain compared to 30% of the people treated with placebo (1).
Because of the limited efficacy of available treatments, many individuals are open to unconventional treatment regimes, and there are reports of pain reduction after use of tai chi, yoga, massage and acupuncture. Most of these reports are anecdotal and not randomized or controlled. In this week’s New England Journal of Medicine a group from Tufts Medical Center in Boston reported a 12 week, placebo controlled trial of fibromyalgia patients who underwent either hour long twice weekly sessions of tai chi or wellness education plus stretching as the control treatment (2). 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. Because it combines physical exercise with balance and cognitive tools including internal awareness, tai chi has been investigated as an adjunct therapy for other musculoskeletal conditions including rheumatoid arthritis, osteoarthritis and back pain. The NEJM study reported a significant reduction in pain scores in the tai chi group with fibromyalgia at the end of the 12 week course of tai chi, and this reduction was maintained out to 24 weeks. This assessment, called the Fibromyalgia Impact Questionnaire (FIQ) is a well-validated, multidimensional measure of the overall severity of fibromyalgia as rated by patients. Categories include the intensity of pain, physical functioning, fatigue, morning tiredness, stiffness, depression, anxiety, job difficulty, and overall well-being. Interestingly, several other quality of life scores were investigated, and most were significantly improved in the tai chi group compared to the control group. Outcome measurements which were improved included improved sleep quality, mood, exercise capacity and both the physical and the mental quality of life scores in a commonly used, well validated test called the SF-36 questionnaire.
These results are quite striking, and may indeed change the first line therapy for fibromyalgia. Only 66 patients were enrolled in this study and it is notable that only this many were enrolled from the original 356 telephone calls to pre-screen. It may be concluded that part of the difficulty in enrolling may be due to reluctance to commit to this exercise regime and may predict compliance problems by patients. Another concern with this study is that only one instructor was involved, and so it is possible that the attitude or specific regime of this instructor may have played an important role in the positive results. Finally, it is always extremely difficult to correctly control for this type of intervention. Tai chi is a complex series of mental and physical movements including rhythmic exercise, deep breathing, concentration and balance. Which of these (or was it the motivated instructor) was responsible for the ultimate result, and should we attempt to control for each? This is probably not a productive path to follow, and it is more likely that the physicians who become aware of this result will instead latch on to this interesting potential therapy as a new first line treatment for fibromyalgia, and one with absolutely no adverse side effects.
1. Arnold, L.M., Rosen, A., Pritchett, Y.L. et al. A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder. Pain. 119:5-15. 2005.
2. Wang, C., Schmid, C.H., Rones, R.R., et al. A randomized trial of tai chi for fibromyalgia N Engl J Med. 363:743-754. 2010.
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