Fibromyalgia is a vexing clinical problem. Characterized by chronic, widespread musculoskeletal pain, the management of this syndrome is complicated by its uncertain pathophysiology and a scarcity of highly effective treatments. When the best-known combination of education, exercise, cognitive behavioral therapy, and medications offer incomplete relief, patients and physicians are often left to wonder: Can anything further be done?
In this week’s issue of NEJM, Wang et al report on a randomized, single-blind trial comparing tai chi training to a control intervention of wellness education and stretching for the treatment of fibromyalgia. Sixty-six patients at Tufts Medical Center were randomized to undergo twice-weekly sessions in either the tai chi or control intervention arm over a twelve-week period. Changes to a well-validated patient-rated severity index, the Fibromyalgia Impact Questionnaire (FIQ) score, served as the primary outcome measure for the trial.
At the conclusion of the training program, the patients assigned to the tai chi intervention demonstrated a substantially greater improvement in FIQ scores than those in the control group, a finding that was sustained at a planned follow-up evaluation at 24 weeks. Significantly superior improvements at the 12- and 24-week evaluations were also demonstrated for secondary endpoints, including patient and physician global assessment scores, the Pittsburgh Sleep Quality Index, and physical and mental quality-of-life components of the SF-36. In short, the intervention was a success.
So should physicians have their pens poised to prescribe tai chi for all of their fibromyalgia patients? In an accompanying editorial, Drs. Yeh, Kaptchuk, and Shmerling suggest perhaps not – or at least not yet. Although this rigorously performed trial is encouraging, both the authors and editorialists point out that it is difficult to eliminate the possibility that the placebo effect biased evaluations in favor of the tai chi intervention. The complex, multi-dimensional nature of tai chi makes the identification of the ‘active ingredient’ difficult, and the construction of a simple – but adequate – control intervention virtually impossible.
“Fibromyalgia is a challenging condition with uncertain pathogenesis and few effective treatment options,” says NEJM Editor Dr Mary Beth Hamel. “In this trial, patients experienced clinically-significant benefits from a treatment that has few recognized adverse effects. Although replication in larger, longer, multi-site trials is warranted, these results are encouraging.”