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Complementary Therapies in Medicine (2013) 21, 396406

Available online at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/ctim

A systematic review and meta-analysis of


Tai Chi for osteoarthritis of the knee
R. Lauche , J. Langhorst, G. Dobos, H. Cramer
Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine, University of
Duisburg-Essen, Germany
Available online 1 July 2013

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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Tai Chi for osteoarthritis of the knee

397

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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Due to its meditative character it may also reduce stress and


increase psychological well-being.
Patients with osteoarthritis of the knee might benet
from Tai Chi by increasing lower extremity muscular strength
and joint stability,9 for example Tai Chi has been found to
reduce falls in older adults.10 The meditative aspect might
further decrease stress and improve well-being and since
Tai Chi can be offered as group therapy this might foster
contact and social support. Therefore Tai Chi might be a supplementary therapeutic option for patients suffering from
osteoarthritis of the knee.
To our knowledge, a recent review has investigated the
effectiveness of Tai Chi for osteoarthritis in general11 however no long-term effects were evaluated. Therefore, the
aim of this review was to systematically assess and metaanalyze the short- and long-term effectiveness of Tai Chi
therapy for osteoarthritis of the knee.

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

Characteristics of the included studies.


Resultsa
a) Short-term follow-up
b) Long-term follow-up
1) Pain
2) Function
3) Stiffness
4) Quality of life
5) Safety
a) 1) Tai Chi> Attention control
2) Tai Chi> Attention control
3) NS
4) NA
b) 1) NS
2) NS
3) NS
4) NA
5) No serious adverse events
related to Tai Chi

Author, year

Sample size,
No. of groups

Mean age (SD)

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

Brismee et al., 200720

41, 2

70.8 9.8
(Treatment)
68.8 8.9 (Control)

Age > 50 years


Osteoarthritis of the knee
(according to the American
College of Rheumatology)
No bilateral knee arthroplasty

Yang-style Tai Chi


18 weeks
Weeks 16: 3 40 min per
week
Weeks 712: video based
home Tai Chi exercise
Weeks 1318: no exercise

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

Lee et al., 200923

44, 2

70.2 4.8
(Treatment)
66.9 6.0 (Control)

Age: 5080 years


Osteoarthritis of the knee for
more than 6 months
KellgrenLawrence Score > 2
No participation in exercise
program
No injection or surgery < 6
months

Tai Chi Qigong


8 weeks
2 60 min per week

Wait-list, no
treatment
8 weeks

a) After intervention
(8 weeks)

1)
2)
3)
4)
5)

WOMAC
WOMAC
WOMAC
SF-36
NA

a) 1) Tai Chi> Wait-list


2) NS
3) NS
4) Physical component score: Tai
Chi> Wait-list
5) NA

Song et al., 200322

72, 2

64.8 6.0
(Treatment)
62.5 5.6 (Control)

Age > 55 years


Osteoarthritis of the knee
KellgrenLawrence Score > 2
No participation in exercise
program

Sun-style Tai Chi


12 weeks:
Weeks 12: 3 12 Tai Chi
movements per week
Weeks 312: 1 12 Tai Chi
movements per week
+ video based Tai Chi
exercise at home, at least
3 20 min per week

Wait-list, continuing
standard care
12 weeks

a) After intervention
(12 weeks)

1)
2)
3)
4)
5)

WOMAC
WOMAC
WOMAC
NA
NA

a) 1) Tai Chi> Wait-list


2) Tai Chi> Wait-list
3) Tai Chi> Wait-list
4) NA
5) NA

Tsai et al., 201224

55, 2

78.9 6.9
(Treatment)
78.9 8.3 (Control)

Age > 60 years


Osteoarthritis of the knee
(according to the medical
records)
Cognitive impairment
No surgery < 6 months

12-form Sun Style Tai Chi for


arthritis
20 weeks
3 2040 min per week

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

a) 1) Tai Chi> Attention control


2) NS
3) Tai Chi> Attention control
4) No adverse events, but 3 (Tai
Chi) and 2 (Attention control)
drop outs related to health
problems

Wang et al., 200921

40, 2

63.0 8.1
(Treatment)
68.0 7.0 (Control)

Age > 55 years


Osteoarthritis of the knee
(according to the American
College of Rheumatology)
WOMAC > 40
Kellgren-Lawrence Score > 2
No prior Tai Chi or yoga
training
No injection < 3 months
No surgery < 6 months

Yang-style Tai Chi


12 weeks
Weeks 112: 2 60 min per
week
+ 20 min home practice per
day
Weeks 1348: home practice

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

a) 1) Tai Chi> Attention control


2) Tai Chi> Attention control
3) NS
4) Physical component score: Tai
Chi> Attention control
b) 1) Tai Chi> Attention control
2) NS
3) NS
4) NS
5) No serious adverse events
related to Tai Chi

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.

Tai Chi for osteoarthritis of the knee

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

170 records after


duplicates removed
154 records excluded
after abstract screening
16 full-text articles
assessed for eligibility [20-35]

11 full-text articles excluded


-

3 mixed patient samples [28,31,35 ]


- 5 no RCT [29,30,33,34,36]
- 1 no clinical outcomes [27]
- 1 withdrawn study [32]
- 1 study reported twice [25]

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

Flowchart of the results of the literature search.

Where no standard deviations were available, standard


errors, condence intervals or t values were used to calculate them.
The magnitude of the overall effect size was judged
according to Cohens categories: small effect size:
SMD = 0.20.5: moderate effect size: SMD = 0.50.8 and
large effect size SMD > 0.8: large effect sizes.16
A negative standardized mean difference was dened to
indicate benecial effects of Tai Chi therapy compared to
the control intervention for pain and physical function (i.e.
decreases complaints), for quality of life on the other hand
a positive SMD would correspond with enhanced well-being.
If necessary, scores were inverted and the mean score was
subtracted from the instruments maximum score.13
Levels of evidence were judged using the criteria from
the Cochrane Back Review Group with 1) Strong evidence:
consistent ndings among multiple RCTs with low risk of bias;
2) Moderate evidence: consistent ndings among multiple
high-risk RCTs and/or one low-risk RCT; 3) Limited evidence:
one RCT with high risk of bias; 4) Conicting evidence: inconsistent ndings among multiple RCTs; 5) No evidence: no
RCTs.17

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

heterogeneity, respectively.13 A p value 0.10 from the Chi2


test was dened to indicate signicant heterogeneity.13
Subgroup and sensitivity analyses
If there were at least 2 studies in each subgroup, subgroup
analyses were conducted for type of control treatment (i.e.
no treatment, usual care, placebo or any active treatment).
Sensitivity analyses to test the robustness of signicant
results were conducted by removing studies based on the following methodological quality criterion: quality score < 6.18
If statistical heterogeneity was present in the respective
meta-analysis, the subgroup and sensitivity analyses were
also used to explore the nature of this heterogeneity.
Risk of bias across studies
If at minimum 10 studies were included in a meta-analysis,
risk of publication bias was assessed by visual analysis of funnel plots generated by Review Manager 5.1 software. Nearly
symmetrical funnel plots indicate low risk while asymmetrical funnel plots indicate high risk of publication bias.19

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

Brismee et al., 200720


Lee et al., 2009 23
Song et al., 2003 22
Tsai et al., 2012 24
Wang et al., 200921

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)

Tai Chi for osteoarthritis of the knee

Characteristics of the samples, interventions, outcome


measures and results are shown in Table 1.
Setting and participant characteristics
The trials originated from the US20,21,24 or Korea.22,23
Patients were recruited in an outpatient clinic,22 in senior
centers/senior residential complexes24 or externally by
newspaper announcements.20,21,23
Subjects were aged 50 years,20,23 55 years21,22 or 60
years and older24 and were diagnosed with osteoarthritis
according to the clinical criteria of the American College of Rheumatology,15,20,21 with clinical and radiographic
ndings35 of at least mild to moderate OA.2123 In one
study OA of the knee was conrmed via medical records.24
Patients were excluded if they had undergone bilateral
arthroplasty,20 surgery within the past 6 months21,23,24 or
if they already participated in Tai Chi or an exercise
program.2123
On average patients were in their 60 s and 80 s and female
(86.5%, range from 72.7 to 100.0%). Data on ethnicity were
available only for one study with the majority being Caucasian.
Intervention characteristics
Tai Chi programs lasted 8 weeks,23 12 weeks21,22 or 18
weeks20 or 20 weeks20 with courses offered two times a
week,21,23 three times a week24 or at changing frequencies
after expansion of home practice.20,22 Tai Chi was taught as
the Yang-Style,20,21 the Sun-Style22,24 or as Tai Chi Qigong,23
all including the typical slow, smooth and owing movements of Tai Chi.
Control interventions included a wait-list and an attention control. The wait-list received no treatment23 or
continued standard care,22 the attention control received
health lectures,20 wellness education, stretching and dietary
advice21 or health education and culture-related or social
activities.24
Patients received no co-interventions or received them
to the same extent in 4 studies at least.20,21,23,24
Outcome measures
Pain was assessed in all 5 studies. One of them assessed pain
intensity using a visual analog scale20 and 4 used the WOMAC
pain scale.2124 Physical function was measured with the
WOMAC physical function scale and stiffness was measured
by means of the WOMAC stiffness scale in all studies.2024
Two studies measured quality of life using the SF-36,21,23 and
safety was reported in 3 studies.20,22,24
Short-term effectiveness was evaluated in all studies;
long-term effects (6 months) on the other hand were only
reported in 2 studies.20,21

402

R. Lauche et al.

Figure 2

Forrest plot for short-term effects of Tai Chi on pain, function, stiffness and quality of life.

Effect sizes of Tai Chi on selected study outcomes.

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 (Tai Chi)


2.41
2.2
2.45
2.6
157.25

No. of patients (Tai Chi)


20
29
22
28
20
119
Test for overall effect: Z = 5.01 (P < 0.00001)
Heterogeneity: Chi2 = 2.55, df = 4 (P = 0.64); I2 = 0%

Mean (control)
3.37
0.2
0.61
1.02
38.45

Long-term

Brismee et al., 200720


Wang et al., 200921
Total
Overall effect
Heterogeneity

3.46
131.55

2.45
97.99

3.19
64.6

Short-term

Brismee et al., 200720


Lee et al., 200923
Song et al., 200322
Tsai et al., 201224
Wang et al., 200921
Total
Overall effect
Heterogeneity

31.82
9.4
11.09
6.82
506.75

14.0
14.4
12.0
8.87
286.12

Long-term

Brismee et al., 200720


Wang et al., 200921
Total
Overall effect
Heterogeneity

38.61
440.5

Short-term

Brismee et al., 200720


Lee et al., 200923
Song et al., 200322
Tsai et al., 201224
Wang et al., 200921
Total
Overall effect
Heterogeneity

Long-term

Brismee et al., 200720


Wang et al., 200921
Total
Overall effect
Heterogeneity

QOL Physical

Short-term

Lee et al., 200923


Wang et al., 200921
Total
Overall effect
Heterogeneity

QOL Mental

Short-term

Lee et al., 200923


Wang et al., 200921
Total
Overall effect
Heterogeneity

Physical Function

Stiffness

SD (Tai Chi)
2.05
4.1
3.9
2.55
97.99

No. of patients (control)


13
15
21
27
20
96

Weight
15.7%
19.6%
20.9%
26.5%
17.2%
100.0%

SMD [95% CI]


0.48 [1.19,
0.56 [1.20,
0.66 [1.28,
0.72 [1.26,
1.19 [1.87,
0.72 [1.00,

1.97
97.99

13
20
33

48.3%
51.7%
100.0%

0.12 [0.58, 0.81]


0.67 [1.31, 0.03]
0.29 [1.06, 0.48]

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%

0.00 [0.71, 0.72]


0.63 [1.26, 0.01]
0.33 [0.95, 0.28]

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%

0.02 [0.68, 0.72]


0.47 [1.10, 0.17]
0.66 [1.27, 0.04]
1.24 [1.82, 0.66]
0.49 [1.12, 0.14]
0.59 [0.99, 0.19]

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%

0.47 [0.25, 1.20]


0.32 [0.94, 0.31]
0.06 [0.72, 0.83]

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%

0.79 [0.14, 1.44]


0.98 [0.32, 1.64]
0.88 [0.42, 1.34]

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%

0.69 [0.05, 1.34]


0.02 [0.60, 0.64]
0.35 [0.31, 1.01]

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]

Tai Chi for osteoarthritis of the knee

Table 3

0.26]
0.14]
0.22]
0.17]
0.44]
0.44]

Test for overall effect: Z = 5.05 (P < 0.00001)


Heterogeneity: Chi2 = 2.52, df = 4 (P = 0.64); I2 = 0%
18
20
38
Test for overall effect: Z = 1.06 (P = 0.29)
Heterogeneity: Chi2 = 1.67, df = 1 (P = 0.20); I2 = 40%

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.

Tai Chi vs. Wait-list

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

Effect sizes of Tai Chi versus controls.

Risk of bias across studies


Since less than 10 studies were included in each metaanalysis, funnel plots were not analyzed.

Table 4

Sensitivity analyses of overall effects


After exclusion of the high risk RCT22 the results for pain,
physical function and stiffness remained signicant, the
effect size was approximately the same.
Subgroup analyses. Subgroup analyses were conducted for
the comparisons Tai Chi vs. wait-list and Tai Chi vs. attention
control, see Table 4.
Tai Chi vs. wait-list. Limited evidence was found for shortterm effects on pain, physical function and stiffness of Tai
Chi compared to wait-list. Effect sizes were moderate, see
Table 4. No long-term effects were evaluated.
Sensitivity analyses of Tai Chi vs. wait-list. No sensitivity
analysis could be conducted for the comparison Tai Chi vs.
Wait-list because only 2 RCTs were available for the comparison, 1 low risk and 1 high risk RCT. Results of the low
risk RCT however showed no signicant effect in favor of Tai
Chi.
Tai Chi vs. attention control:. Moderate evidence was
found for short-term effects of pain and physical function with large and moderate effect size respectively, see
Table 4.
Sensitivity analyses of Tai Chi vs. attention control. No
sensitivity analysis for the comparison Tai Chi vs. attention
control was necessary, because all trials had low risk of bias.

No. of patients
(control)

Analyses of overall effects


Meta-analyses (Fig. 2, Table 3) revealed moderate evidence
for short-term effects on pain (SMD = 0.72; 95% CI 1.00 to
0.44; P < 0.00001), physical function (SMD = 0.72; 95% CI
1.01 to 0.44; P < 0.00001) and stiffness (SMD = 0.59; 95%
CI 0.99 to 0.19; P = 0.004). Strong evidence was found
for physical component of quality of life (SMD = 0.88; 95%
CI 0.42 to 1.34; P < 0.0001), but no evidence for the mental
component. No evidence was found for long-term effects.
Based on Cohens categories, the short-term effects were
of moderate size, and the effect on the physical component
of quality of life was large.

SMD (95% CI)

Heterogeneity I2 ; Chi2 ; P

Risk of bias in individual studies


Four of 5 studies had low risk of bias,20,21,23,24 see Table 2.
All studies had low risk of selection bias with only Brismee
et al.20 not reporting allocation concealment. Risk of performance bias mainly was high, mostly due to lack of blinding of
patients and care providers. Risk of attrition bias was mixed;
only 3 studies had acceptable dropout rates and included
intention-to-treat analyses.21,23,24 Risks of reporting bias and
detection bias were low in general.

62%, 2.64; 0.10


0%; 1.84; 0.40
40%; 1.67; 0.20
74%; 7.76; 0.02
62%; 2.64; 0.10
0%; 0.05; 0.82
0%; 0.60; 0.44
0%; 0.18; 0.67

R. Lauche et al.

6%; 2.13; 0.34

404

Tai Chi for osteoarthritis of the knee

405

no adverse events occurred. No other serious adverse events


were reported.

falling.10 The meditative aspect of Tai Chi can reduce stress


and increase psychosocial well-being.

Discussion

Strengths and weaknesses

Summary of main results

This review and meta-analysis included only randomized


controlled trials and evaluated long-term effects of Tai Chi.
Patient-centered outcomes were used for meta-analyses
as recommended by the task force of the Osteoarthritis
Research Society.40
The primary limitation of this review is the total number
of eligible trials. Therefore, sensitivity analyses for subgroup
comparisons were partly impossible. More studies that compare Tai Chi therapy to guideline endorsed therapies; other
forms of exercises or placebo are urgently needed. The number of trials also limits judgment on side effect of Tai Chi.
Although no adverse events were associated with Tai Chi
denite conclusions are not possible here. It only can be
assumed that Tai Chi is a treatment with low risk of injury.
Overall risk of bias was low but 1 out of 5 studies had a
high risk of bias. Statistical heterogeneity was not present
in the meta-analyses. Another limiting factor is the short
follow-up time frame. Only 2 studies evaluated long-term
follow-up and the longest follow-up was conducted at 24
weeks. Recommendations of the Osteoarthritis Research
Society International include longer time frames40,41 which
should be considered in following studies.

This meta-analysis found moderate overall evidence for


short-term improvement of pain, physical function and stiffness, and strong evidence for short-term improvement of the
physical component of quality of life. Compared to attention
control, Tai Chi showed moderate evidence for short-term
improvement of pain and physical function, and compared to
wait-list there was limited evidence for short-term improvement of pain, physical function and stiffness, however due
to the high risk of bias the results of the latter might be due
to bias alone. Available safety data suggest that Tai Chi was
not associated with serious adverse events.

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.

Agreements and disagreements with other


systematic reviews
Systematic reviews are available for Tai Chi in the treatment
of osteoarthritis in general.11,37 One review also included
a meta-analysis,11 which found encouraging effects for
osteoarthritis of the knee regarding pain and function. However this meta-analysis did not cover the long-term effects
and further included a study31 that was later withdrawn
because there was considerable doubt on the authenticity
of the data.38,39 After exclusion of the study from Ni et al.,31
inclusion of the recent study results by Tsai et al.24 and under
consideration of the long-term effects the results are more
differentiated than reported there.11 Altogether short-term
effects were only found when compared to attention control. Compared to wail-list controls the effects could not be
distinguished from bias.
The modes of action are not known in detail, but it
can be assumed that Tai Chi acts like other kinds of physical exercises.11 Physical movement can increase muscular
strength and exibility, and stabilize the knee joint.9 It
may also help to improve balance and reduce the risk of

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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