KEYWORDS
Osteoarthritis of the
knee;
Complementary
therapies;
Tai Chi;
Meta-analysis;
Systematic review
Summary
Objectives: This paper aimed to systematically review and meta-analyze the effectiveness of
Tai Chi for osteoarthritis of the knee.
Methods: MEDLINE, the Cochrane Library, EMBASE, Scopus, PsycInfo and CAMBASE were screened
through April 2013. Randomized controlled trials (RCTs) comparing Tai Chi to control conditions
were included. Two authors independently assessed risk of bias using the risk of bias tool recommended by the Cochrane Back Review Group. Outcome measures included pain, physical
functional, joint stiffness, quality of life, and safety. For each outcome, standardized mean
differences and 95% condence intervals were calculated.
Results: 5 RCTs with a total of 252 patients were included. Four studies had a low risk of
bias. Analysis showed moderate overall evidence for short-term effectiveness for pain, physical
function, and stiffness. Strong evidence was found for short-term improvement of the physical
component of quality of life. No long-term effects were observed. Tai Chi therapy was not
associated with serious adverse events.
Conclusion: This systematic review found moderate evidence for short-term improvement of
pain, physical function and stiffness in patients with osteoarthritis of the knee practicing Tai
Chi. Assuming that Tai Chi is at least short-term effective and safe it might be preliminarily
recommended as an adjuvant treatment for patients with osteoarthritis of the knee. More high
quality RCTs are urgently needed to conrm these results.
2013 Elsevier Ltd. All rights reserved.
Contents
Introduction..............................................................................................................
Methods..................................................................................................................
Protocol and registration ............................................................................................
Eligibility criteria....................................................................................................
Corresponding author at: Knappschafts-Krankenhaus, Am Deimelsberg 34a, 45276 Essen, Germany. Tel.: +49 201 174 25054;
fax: +49 201 174 25000.
E-mail address: r.lauche@kliniken-essen-mitte.de (R. Lauche).
0965-2299/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2013.06.001
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Literature search....................................................................................................
Study selection......................................................................................................
Data collection ......................................................................................................
Outcomes.....................................................................................................
Risk of bias in individual studies ..............................................................................
Data analysis ........................................................................................................
Assessment of overall effect size .............................................................................
Assessment of heterogeneity .................................................................................
Subgroup and sensitivity analyses.............................................................................
Risk of bias across studies ....................................................................................
Results ...................................................................................................................
Study selection......................................................................................................
Study characteristics ................................................................................................
Setting and participant characteristics .......................................................................
Intervention characteristics ..................................................................................
Outcome measures ...........................................................................................
Risk of bias in individual studies ..............................................................................
Analyses of overall effects....................................................................................
Sensitivity analyses of overall effects.........................................................................
Risk of bias across studies ....................................................................................
Safety ........................................................................................................
Discussion ................................................................................................................
Summary of main results ............................................................................................
Applicability of evidence ............................................................................................
Quality of evidence .................................................................................................
Agreements and disagreements with other systematic reviews ......................................................
Strengths and weaknesses ...........................................................................................
Conclusion ...............................................................................................................
Source of funding ........................................................................................................
Conicts of interest ......................................................................................................
References ...............................................................................................................
Introduction
Osteoarthritis of the knee is one of the most common chronic
diseases among older adults with high impact on physical function1 ; about one fourth of people over 55 years
will report a signicant episode of pain in the knee in the
last year.2 Osteoarthritis of the knee is a condition which
is associated with articular cartilage destruction in addition to underlying bony changes at the joint margins.3 Main
complaints include pain and functional impairment during
everyday activities which severely affects quality of life in
these patients.4
Symptomatic therapeutic approaches mainly consist of
physiotherapy, pharmacological therapy or, if therapies fail,
joint replacement therapy.5,6 Patients are also encouraged
to use some kind of joint-friendly strengthening and aerobic
exercises,6,7 as it may reduce pain, increase function and
reduce the progression of the osteoarthritis.
Tai Chi, developed as martial art in China, has been practiced for centuries. After introduction in Europe and America
the perception of Tai Chi shifted and it is nowadays regarded
a form of exercise or gymnastics. Tai Chi typically includes
a series of dance-like movements that combine to postures
or forms. The forms are executed using slow and smooth
movements that ow into each other. Tai Chi not only is a
movement therapy, but it also includes meditative aspects.8
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Methods
Protocol and registration
The review was planned and conducted in accordance with
the PRISMA guidelines for systematic reviews and metaanalyses12 and the recommendations of the Cochrane Back
398
Review Group.13,14 The protocol had not been registered
prior to conducting the review.
Eligibility criteria
The following conditions had to be met in order to include
a study into this review:
1) Types of studies. Only randomized controlled trials
(RCTs) were considered eligible.
2) Types of participants. Studies of adults (18 years of age
and older) with osteoarthritis of the knee were eligible. Diagnosis had to be based on valid instruments, such
as the Classication Criteria of the American College of
Rheumatology,3,15 radiographic or laboratory evidence,
or medical records. No further restriction regarding disease duration and intensity were applied.
3) Types of interventions. Studies that compared Tai Chi
with no treatment, usual care, placebo or any active
treatment were eligible. No restrictions were made
regarding details of Tai Chi protocol. Co-interventions
were allowed.
4) Types of outcome measures. Studies were eligible if
they assessed at least one patient-centered outcome,
namely 1) pain, 2) physical functional, or 3) stiffness.
If available, data on quality of life, and safety served as
secondary outcomes measures.
5) Length of follow-up. Studies were eligible if they
assessed outcomes at least once, either directly at the
end of the program (short-term effects), or closest to 6
months (long-term effects) following treatment.
Studies were only eligible if they were published as full
paper. All types of languages were eligible. No restriction
regarding publication date was applied.
Literature search
The following electronic databases were searched from
their inception through 04/15/2013: Pubmed/Medline,
Embase, PsycInfo, Scopus, the Cochrane Library and CAMBASE. The literature search was constructed around search
terms for Tai Chi and search terms for osteoarthritis of
the knee and adapted for each database as necessary.
For Pubmed/Medline, the search strategy was the following: (tai ji [MeSH Terms] OR tai ji [Title/Abstract]
OR tai chi [Title/Abstract] OR tai chi [Title/Abstract])
AND (osteoarthritis [MeSH Terms] OR arthritis [MeSH
Terms] OR arthralgia [MeSH Terms] OR joint disease [MeSH
Terms] OR osteoarthritis [Title/Abstract] OR osteoarthrosis [Title/Abstract] OR gonarthrosis [Title/Abstract]
OR degenerative arthritis [Title/Abstract] OR arthritis
[Title/Abstract]).
The reference lists of identied original or review articles
were searched manually for further articles.
Study selection
After duplicate removal the abstracts of all identied records were each screened by two reviewers and
R. Lauche et al.
hardcopies of those studies that were found potentially eligible were obtained. The full articles were then read in detail
and those eligible were included in the systematic review
and meta-analysis.
Data collection
Two reviewers independently extracted data on study
characteristics such as participants, interventions, control
conditions, co-interventions, outcome measures and results.
Disagreements were rechecked with a third reviewer and
resolved by discussion.
Outcomes
The outcomes were dened as follows.
1) Pain intensity had to be measured on a visual analog scale, on a numerical rating scale or on the pain scale
of the Western Ontario and McMaster Universities Arthritis Index (WOMAC). 2) Physical function was included when
measured on a visual analog scale, a numerical rating scale,
the WOMAC physical function scale or the Knee injury and
Osteoarthritis Outcome Score Physical Function Short
Form (KOOS-PS). 3) Stiffness was included when measured
on a visual analog scale, a numerical rating scale or the
WOMAC stiffness scale. 4) Quality of life was included when
assessed using a validated generic measure, e.g. the SF-36,
or a validated specic measure. 5) Safety was included when
measured as the number of adverse events during the study
or the number of drop-outs due to health problems.
Risk of bias in individual studies
Risk of bias was assessed independently by two reviewers
using the 2009 Updated Method Guidelines for Systematic
Reviews in the Cochrane Back Review Group.14 These guidelines recommend 12 quality criteria, each of which was rated
with YES, NO or UNCLEAR. These criteria constitute the following risk of bias domains: selection bias, performance
bias, attrition bias, reporting bias, and detection bias. If
study data were inconclusive trial authors were contacted
for further study details. Studies that scored positive on 6
of the 12 criteria at the minimum and had no serious aw
were rated as having low risk of bias. Studies that met fewer
than 6 criteria and/or showed a serious aw were rated as
having high risk of bias.14 This classication as low or high
risk study was used for sensitivity analyses.
Data analysis
Studies were analyzed separately for short-term and longterm effects. Short-term follow-up was dened as measures
taken directly at the end of the intervention, and long-term
follow-up as measures obtained closest to 6 months after
randomization.16
Assessment of overall effect size
If at least two studies were available on an outcome,
meta-analyses were calculated utilizing Review Manager
5 software (Version 5.1, The Nordic Cochrane Centre,
Copenhagen). Standardized mean differences (SMD) with
95% condence intervals (CI) were calculated as the mean
group difference divided by the pooled standard deviation.17
Author, year
Sample size,
No. of groups
Inclusion criteria
Treatment group:
Intervention
Control group:
Intervention
Program length,
duration, frequency
Outcome assessment
a) Short-term
follow-up (at
intervention end)
b) Long-term
follow-up (closest to
12 months)
Outcome measures
1) Pain
2) Physical function
3) Stiffness
4) Quality of life
5) Safety
41, 2
70.8 9.8
(Treatment)
68.8 8.9 (Control)
Attention control
Weeks 16: Health
lectures and
discussions
Weeks 718: no
lectures
18 weeks
a) After intervention
(12 weeks)
b) after 18 weeks
1)
2)
3)
4)
5)
VAS
WOMAC
WOMAC
NA
Adverse events
44, 2
70.2 4.8
(Treatment)
66.9 6.0 (Control)
Wait-list, no
treatment
8 weeks
a) After intervention
(8 weeks)
1)
2)
3)
4)
5)
WOMAC
WOMAC
WOMAC
SF-36
NA
72, 2
64.8 6.0
(Treatment)
62.5 5.6 (Control)
Wait-list, continuing
standard care
12 weeks
a) After intervention
(12 weeks)
1)
2)
3)
4)
5)
WOMAC
WOMAC
WOMAC
NA
NA
55, 2
78.9 6.9
(Treatment)
78.9 8.3 (Control)
Attention control
Health education,
culture-related
activities and social
activities
20 weeks
3 2040 min per
week
a) After intervention
(20 weeks)
1)
2)
3)
4)
WOMAC
WOMAC
WOMAC
Adverse events
40, 2
63.0 8.1
(Treatment)
68.0 7.0 (Control)
Attention control
Wellness education
and stretching,
dietary advices
a) After intervention
(12 weeks)
b) 24 weeks
1)
2)
3)
4)
5)
WOMAC
WOMAC
WOMAC
SF-36
Adverse events
399
Abbreviations: NA, Not assessed; NS, Not signicant; SD, Standard deviation; SF-36, Short Form Health Survey; VAS, Visual Analog Scale; WOMAC, Western Ontario and McMaster Universities
Osteoarthritis Index.
a Signicantly better than.
Table 1
400
R. Lauche et al.
270 records identified
through database searching
-
83
1
0
9
126
51
2 of additional records
identified through other sources
Pubmed/Medline
Cochrane
Cambase
PsycInfo
Embase
Scopus
5 of studies included
in qualitative synthesis [20-24]
0 full-text articles excluded
5 of studies included
in quantitative synthesis
(meta-analysis) [20-24]
Figure 1
Assessment of heterogeneity
Statistical heterogeneity between studies was quantied
by determination of I2 . I2 > 30%, I2 > 50% and I2 > 75% were
dened to indicate moderate, substantial and considerable
Results
Study selection
Literature search retrieved 272 records, 102 of them
were duplicates (Fig. 1). Sixteen full-text articles were
assessed for eligibility2036 (Fig. 1). Eleven full text articles were excluded because they investigated mixed patient
samples,28,31,35 were not randomized,29,30,33,34,36 did not
measure relevant outcomes27 or were withdrawn.32 Another
study was published twice,23,25 they were reported as 1 study
only.23 Five studies, involving a total of 252 patients, were
included in qualitative and quantitative analysis.2024
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Adequate
outcome
assessor
blinding
Yes
Yes
Unclear
Yes
Yes
Yes
Unclear
Unclear
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Unclear
Yes
Yes
No
Yes
No
Yes
Yes
Inclusion of an
intention-totreat
analysis
No
Yes
No
Yes
Yes
Acceptable
and described
drop-out rate
Acceptable
compliance
Similar or no
cointerventions
Similar
baseline characteristics
Adequate
random
sequence
generation
Yes
Yes
Yes
Yes
Yes
Adequate
allocation
concealment
Adequate
participant
blinding
Adequate
provider
blinding
Attrition bias:
Performance bias:
Selection bias:
Risk of bias assessment of the included studies using the Cochrane risk of bias tool.
Bias
Author, year
Table 2
401
Study characteristics
Reporting
bias:
No selective
outcome
reporting
Detection bias:
Similar timing
of outcome
assessment
7
9
4
9
10
Total risk:
(max. 12)
402
R. Lauche et al.
Figure 2
Forrest plot for short-term effects of Tai Chi on pain, function, stiffness and quality of life.
Outcome
Pain
Time frame
Short-term
Study
Brismee et al., 200720
Lee et al., 200923
Song et al., 200322
Tsai et al., 201224
Wang et al., 200921
Total
Overall effect
Heterogeneity
Mean (control)
3.37
0.2
0.61
1.02
38.45
Long-term
3.46
131.55
2.45
97.99
3.19
64.6
Short-term
31.82
9.4
11.09
6.82
506.75
14.0
14.4
12.0
8.87
286.12
Long-term
38.61
440.5
Short-term
Long-term
QOL Physical
Short-term
QOL Mental
Short-term
Physical Function
Stiffness
SD (Tai Chi)
2.05
4.1
3.9
2.55
97.99
Weight
15.7%
19.6%
20.9%
26.5%
17.2%
100.0%
1.97
97.99
13
20
33
48.3%
51.7%
100.0%
37.77
2.7
1.33
1.3
182.15
119
11.22
10.8
10.6
6.04
286.12
13
15
21
27
20
96
15.8%
19.8%
20.2%
26.5%
17.6%
100.0%
0.45
0.49
0.84
0.71
1.11
0.72
15.62
286.12
38.58
257.3
13.12
286.12
13
20
33
46.6%
53.4%
100.0%
4.7
1.2
0.91
1.79
73.05
1.66
2.1
1.6
1.34
45.53
20
29
22
28
20
119
Test for overall effect: Z = 2.91 (P = 0.004)
Heterogeneity: Chi2 = 8.02, df = 4 (P = 0.09); I2 = 50%
4.67
0.3
0.23
0.22
50.15
1.4
1.4
1.8
1.14
45.53
13
15
21
27
20
96
18.0%
20.0%
20.5%
21.6%
20.0%
100.0%
5.28
65.0
1.53
45.53
4.54
50.2
1.51
45.53
13
20
33
47.2%
52.8%
100.0%
17.1
11.57
14.9
7.46
5.6
4.14
12.9
7.46
15
20
35
51.0%
49.0%
100.0%
19.2
2.14
15.9
9.59
9.1
1.93
10.3
9.59
15
20
35
49.2%
50.8%
100.0%
20
20
40
Test for overall effect: Z = 0.74 (P = 0.46)
Heterogeneity: Chi2 = 2.64, df = 1 (P = 0.10); I2 = 62%
20
29
22
28
20
SD (control)
1.78
1.8
5.1
1.69
97.99
[1.15,
[1.13,
[1.47,
[1.26,
[1.78,
[1.01,
0.23]
0.07]
0.05]
0.17]
0.51]
0.44]
Table 3
0.26]
0.14]
0.22]
0.17]
0.44]
0.44]
18
20
38
Test for overall effect: Z = 0.14 (P = 0.89)
2
Heterogeneity: Chi = 2.64, df = 1 (P = 0.10); I2 = 62%
29
20
49
Test for overall effect: Z = 3.74 (P = 0.0002)
Heterogeneity: Chi2 = 0.15, df = 1 (P = 0.69); I2 = 0%
29
20
49
Test for overall effect: Z = 1.05 (P = 0.29)
Heterogeneity: Chi2 = 2.19, df = 1 (P = 0.14); I2 = 54%
Abbreviations: CI, Condence interval; df, degrees of freedom; N, Number of patients; QOL, Quality of life; SD, Standard deviation; SMD, standardised mean difference
403
0.46
<0.0001
0.29
0.11
0.89
0.007
0.003
0.01
0.29 [1.06, 0.48]
0.76 [1.12, 0.40]
0.33 [0.95, 0.28]
0.59 [1.31, 0.13]
0.06 [0.72, 0.83]
0.61 [1.06, 0.17]
0.67 [1.12, 0.23]
0.56 [1.01, 0.12]
Abbreviations: CI, Condence interval; SD, Standard deviation.
a Outcomes are only shown if sufcient data for meta-analysis were available.
b No sensitivity analysis possible due to the lack of low risk studies.
2
3
2
3
2
2
2
2
Long-term: Pain
Short-term: Function
Long-term: Function
Short-term: Stiffness
Long-term: Stiffness
Short-term: Painb
Short-term: Functionb
Short-term: Stiffnessb
40
68
38
68
38
51
51
51
33
60
33
60
33
36
36
36
<0.0001
0.79 [1.16, 0.43]
3
Short-term: Pain
Tai Chi vs. Attention
control
68
60
P
No. of patients
(Tai Chi)
No. of studies
Outcomea
Comparison
Safety
Adverse events were reported in 3 studies.20,21,24 Brismee
et al.20 found sporadic complaints of minor muscle soreness
and foot and knee pain at the beginning of the intervention, Wang et al.21 found temporarily increased knee pain.
She also reported two serious adverse events, namely newly
diagnosed breast and colon cancer, which obviously were
not related to Tai Chi. These adverse events occurred in the
intervention and the control group. Tsai et al.24 stated that
Table 4
No. of patients
(control)
Heterogeneity I2 ; Chi2 ; P
R. Lauche et al.
404
405
Discussion
Applicability of evidence
Trials were conducted with outpatients or externally
recruited patients in the US or Korea. The vast majority of
participants were female with an average age between 60
and 80 years. The studies included patients with at least mild
to moderate osteoarthritis according to radiographic evidence. The results of the studies might or might not apply to
the majority of osteoarthritis patients; there are not enough
studies for conclusive judgment.
Quality of evidence
There was some variability of the methodological quality of
studies; the effects on pain, physical function and stiffness
were robust against potential methodological biases. The
results of the comparisons Tai Chi vs. wait-list could not be
separated from bias.
Conclusion
This systematic review found moderate evidence for shortterm improvement of pain, physical function and stiffness
in patients with osteoarthritis of the knee practicing Tai
Chi. Assuming that Tai Chi is at least short-term effective
and safe it might be preliminarily recommended as an adjuvant treatment for patients with osteoarthritis of the knee.
More high quality RCTs are urgently needed to conrm these
results.
Source of funding
This review was supported by a grant from the Rut- and
Klaus-Bahlsen-Foundation. The funding source had no role
in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the
decision to submit the manuscript for publication.
Conicts of interest
The authors declare that no nancial or non-nancial conict of interest exists.
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