Tai Chi, Qigong and the Treatment of Arthritis

Tai chi, also referred to as taiji or taijiquan, is considered both a martial art and a series of low impact exercises. It is also a tool in the toolbox of traditional Chinese medicine (TCM) that has been in existence for hundreds of years, although its philosophical roots go back thousands of years to Confucianism and Taoism [1]. There are five main styles of tai chi. Chen style is the oldest style and originated in the Chen village in China [2]. The second oldest style, and also the most popular style, is the Yang style [3]. Sun style [4] is the newest style of tai chi and has only been in existence for about 100 years. It is known for its high stances, which are especially suited for older people who have balance issues. Wu and Wu Hao [5] are the other main styles of tai chi, which contain elements of both the Yang and Chen styles. Although the styles all differ in some respects, they have more commonalities than differences.


Introduction
Tai chi, also referred to as taiji or taijiquan, is considered both a martial art and a series of low impact exercises. It is also a tool in the toolbox of traditional Chinese medicine (TCM) that has been in existence for hundreds of years, although its philosophical roots go back thousands of years to Confucianism and Taoism [1]. There are five main styles of tai chi. Chen style is the oldest style and originated in the Chen village in China [2]. The second oldest style, and also the most popular style, is the Yang style [3]. Sun style [4] is the newest style of tai chi and has only been in existence for about 100 years. It is known for its high stances, which are especially suited for older people who have balance issues. Wu and Wu Hao [5] are the other main styles of tai chi, which contain elements of both the Yang and Chen styles. Although the styles all differ in some respects, they have more commonalities than differences.

Methodology
The PubMed.gov database [302] and the Europe PMC database [303] were used to find studies on tai chi, qigong and the treatment of arthritis, supplemented by internet searches.

Findings
Marks [304] reviewed, summarized, and synthesized the research involving the use of qigong exercises in the treatment of arthritis. He concluded that mind-body and relaxation techniques such as those practiced in China for centuries may be a useful intervention strategy for adults having various forms of arthritis.
Numerous other studies have been conducted on the effectiveness of tai chi or qigong in general, as well as their effectiveness in the treatment of several specific diseases and ailments. The studies cited in this section examined the effectiveness of these tools of traditional Chinese medicine on various forms of arthritis.

Osteoarthritis of the Knee
Brosseau et al. [305] published clinical practice guidelines for the management of knee osteoarthritis after conducting a systematic study of controlled trials that used mind-body exercise programs for patients having osteoarthritis of the knee. The Ottawa panel of experts reached consensus on a number of issues. The main conclusion was that Sun-style tai chi exercises were effective in pain reduction and improvement of physical function and quality of life for individuals having osteoarthritis of the knee. Another Brosseau et al. study [306] reviewed 26 high-quality studies and identified various effective knee strengthening exercise programs.
Other studies by the Ottawa panel examined the effects of various exercises on arthritis of the hip [307] and hand [308].
Li et al. [309] analyzed the biomechanical response of the meniscus and knee cartilage to the brush-knee and twist-step tai chi movement, and compared the results to walking and jogging.
They found that the tai chi movement resulted in a greater increase in the range of motion, and that stress was more concentrated when walking and jogging than when doing the tai chi movement.
The study concluded that tai chi may have a lower risk of knee joint injury than either walking or jogging.
You et al. [310] studied the effects of tai chi exercises on the improvement of walking function and posture control in elderly patients having osteoarthritis of the knee. After examining the results of 11 trials involving 603 participants, they concluded that the tai chi group had better performance in a six-minute walk test and the time up and go test than did the control group. The study concluded that tai chi could be an excellent way to improve walking function and posture control in elderly adults who have osteoarthritis of the knee. Zeng et al. [311] conducted a review of three random controlled trials (RCT) that indicated that baduanjin qigong exercises may have favorable effects on patients with osteoarthritis of the knee. Baduanjin patients had significantly

better WOMAC (Western Ontario and McMaster Universities
Arthritis Index) scores in some areas than did those of the control group. Significant differences occurred for pain (p < 0.01), stiffness (p< 0.01), and physical function (p < 0.01).
Li et al. [312] conducted a systematic review and meta-analysis Ontario and McMaster Universities Osteoarthritis Index pain score (p = 0.031) for the WQX group. The study concluded that while both WQX and conventional therapy were effective in reducing pain and activity limitations, and promoting muscle power and balance, WQX was significantly more effective in reducing pain and promoting balance than conventional therapy. Lee et al. [314] conducted a pilot, randomized, waiting list-controlled trial to determine whether tai chi exercises could be used to improve the quality of life for patients with osteoarthritis of the knee. The trial included forty-four elderly subjects who had arthritis of the knee.

Osteoarthritis of the Hip
Duan et al. [315] had 12 older, experienced men participate in a study that had them perform the brush knee and twist step tai chi move, along with normal walking. The study concluded that tai chi may result in a better improvement in the hip joint's range of motion and coordination of the neuromuscular system than just walking and is safe and suitable for patients with osteoarthritis of the hip. Zou et al. [316] examined the effect of tai chi practice on attenuating bone mineral density (BMD) loss. They examined the results of 20 randomized controlled trials having a total sample size of 1604. They found that tai chi produced significant benefits on BMD at the lumbar spine (p < 0.0001), femur neck (p < 0.00001), femur trochanter (p = 0.007), and total hip (p = 0.003). They concluded that tai chi is effective in attenuating BMD.
Escalante et al. [317] summarized the evidence of 33 studies that evaluated the effectiveness of various exercise programs on pain for adults with lower limb osteoarthritis. They concluded that tai chi exercise programs achieved better results than strength programs, aerobic programs, hydrotherapy programs or mixed programs. Uhlig [318] found that tai chi and yoga are safe and can be used in the treatment of rheumatologic and musculoskeletal diseases such as osteoarthritis of the knee, hip, and hand, as well as rheumatoid arthritis.

Ankylosing Spondylitis
Xie et al.

Rheumatoid Arthritis
Lee, Pittler and Ernst [320] conducted a systematic review of studies on the effect of tai chi on rheumatoid arthritis (RA) in 2007. They identified 45 potentially relevant studies. Some of the studies they found concluded some positive effects on the use of tai chi to relieve depression and mood of RA patients, while increasing the quality of life. Two studies found that tai chi did not result in any more pain reduction than what could be had with education, stretching exercises, and usual activity control. They concluded that the heterogeneity of the studies prevented any meaningful meta-analysis, and that the studies that were available at that time were of low methodological quality, concluding that whether tai chi was an effective treatment for rheumatoid arthritis remained unproven.
A more recent study by Imoto et al. [321] concluded that tai chi could be a low-cost alternative to other treatments of RA. Their study consisted of a review of three other studies. Those findings indicated that tai chi practice resulted in improvements in mood and depression. Although clinical improvement was achieved with regard to pain and disease pattern, the improvements were not statistically significant. A study by Wang [322] found that the

Concluding Comments
The evidence is clear that tai chi and qigong can have beneficial effects on the treatment of various kinds of arthritis. However, there is room for more research to determine whether, and under what circumstances, these two tools of traditional Chinese medicine are more effective than alternative treatments. One area of research that has been neglected is to compare the various kinds of tai chi and qigong to determine whether one particular set of exercises might be more effective than others in the treatment of various diseases and ailments. For example, is baduanjin more effective in the treatment of X than other qigong sets? Or tai chi? Are some forms of tai chi or qigong more effective in the treatment of arthritis or other diseases than other forms? Is Yang style tai chi more effective in treating X than Sun style tai chi?