Tai chi as effective as physical therapy while opioids often not cost-effective for knee pain

For relieving pain in patients with knee osteoarthritis, the Chinese mind-body practice of tai chi appears to be as effective as physical therapy, according to a recent study.

In a 1:1 ratio, 204 patients (mean age, 60; 70% female; 53% white) with symptomatic knee osteoarthritis and radiographic evidence of tibiofemoral or patellofemoral osteoarthritis were randomly assigned to tai chi or physical therapy. Those in the tai chi group were further randomized to 1 of 3 trained instructors. Participants were permitted to continue using routine medications and attending their usual physician visits throughout the study. At baseline, mean score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale was 254.8 in the tai chi group and 252.9 in the physical therapy group (range, 0 to 500; higher scores indicate greater pain). Researchers compared the effectiveness of the 2 therapies in a 52-week randomized study. Results were published online on May 17 by Annals of Internal Medicine.

Tai chi sessions lasted 1 hour each and occurred twice per week for 12 weeks, and participants were instructed to practice at home for at least 20 minutes each day. Physical therapy consisted of 30-minute outpatient sessions twice weekly for 6 weeks, followed by 30-minute at-home exercise sessions 4 times per week for 6 weeks. All participants were encouraged to perform 30 minutes of their assigned therapy daily through week 52.

Knee osteoarthritis outcomes were measured at baseline and at 12, 24, and 52 weeks. The primary outcome was the change in WOMAC pain subscale score between baseline and 12 weeks. Both groups had improved WOMAC pain scores at 12 weeks (tai chi, 167 points [95% CI, 145 to 190 points]; physical therapy, 143 points [95% CI, 119 to 167 points]). They showed similar improvements in most secondary outcomes at 12 weeks and in all outcomes at 24 and 52 weeks, and the benefit of tai chi was consistent across instructors.

“Despite the substantial differences in delivering a mind-body intervention to a group and physical therapy to individual persons, both interventions produced similar effects in the treatment of knee osteoarthritis,” the authors concluded, noting that tai chi should be considered an effective therapy. They noted limitations of the study, such as how patients were not blinded to their treatment group assignment and how it was conducted in a single academic center, limiting generalizability.

This study comes on the heels of a cost-effectiveness analysis, published online on April 25 by Arthritis Care & Research, that evaluated the effects of tramadol and/or oxycodone on knee osteoarthritis pain that persisted after conservative treatment with nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections. Using a computer model, researchers calculated how acetaminophen, tramadol, or tramadol followed by oxycodone could be used to provide pain relief until patients died or became willing or eligible to undergo total knee arthroplasty (TKA).

The tramadol and tramadol plus oxycodone strategies delayed TKA by 7 and 9 years, respectively, and led to reduction in TKA utilization by 4% and 10%, respectively, the study found. Compared to acetaminophen, both strategies increased cost and decreased quality-adjusted life-years. The researchers found that tramadol (but not oxycodone) appeared to be an effective and cost-effective treatment for osteoarthritis patients averse to TKA but concluded overall that opioids do not appear to be cost-effective in arthritis patients without comorbidities, principally because of their negative impact on pain relief after TKA.

Because of the pitfalls of opioids and the fact that more research on outcomes is needed, the authors concluded that, in general, clinicians should avoid prescribing opioids in patients with knee osteoarthritis. Limitations to the analysis included the lack of long-term data on the efficacy and toxicity of analgesics and the fact that results cannot be generalized to the entire osteoarthritis population, which includes patients in poorer health.