A Brief Report prepared for Journal of Clinical Rheumatology
November 19, 2001

ABSTRACT

Chronic arthritis pain patients are increasingly seeking alternatives to Western medicine. This open trial was designed to determine if patients with chronic arthritis pain have an improvement in pain, functional movement and mood following external Qigong therapy, a form of traditional Chinese medicine.

An open trial based on volunteer patients in a private rheumatology practice included three Qigong treatments in three days. The Qigong healer administered Qi emission to the area of specific pain for 5 to 10 minutes in three separate days. A follow-up exam was carried out one month later. A total of 10 patients with arthritis pain were recruited to participate in this pilot study, and six of them completed all three treatments. Visual analogue scale (VAS) on pain and mood were used before and after the treatment. Other measures include activity difficulty level scale, Spielberger Anxiety Scale and a swollen/tender joint count to evaluate the effectiveness. All patients reported some degree of relief, reduction in pain and negative mood (except one), decreased anxiety score, and reduced active pain/tender joints (except one), and reduction in movement difficulty scores. Two reported complete relief without any pain even one month after the treatment. Although the results are far from conclusive due to the study design and small sample size, these results suggest that further studies are warranted to determine the efficacy of Qigong treatment of arthritis with a larger sample. The possibility of a placebo or regression effect accounting for our results cannot be excluded and are discussed. The two cases of complete relief in pain are very encouraging and worth further investigation.

Keywords: Qigong therapy, energy medicine, arthritis pain, anxiety, functional movement.

¹ Direct all correspondence to: Dr. Kevin Chen, Department of Psychiatry, UMDNJ - New Jersey Medical School, 30 Bergen Street, ADMC 1419, Newark, NJ 07107. Tel: (973) 972-7225; Fax: (973) 972-8305. Email: chenke@umdnj.edu

External Qigong Therapy for Arthritis Pain: A Pilot Study

INTRODUCTION

About 1 out of 7 people in America have arthritis of some kind. According to the Arthritis Foundation, arthritis is the number one cause of disability in America, and it limits everyday activities for approximately seven millions individuals. Current pharmacological treatments for arthritis are effective to various degrees in controlling the symptoms, but with great drawbacks, including potential toxicity, cost, and potential detrimental effects on both mood and immune function. An effective non-pharmacological therapy for arthritis that returns control to the patients without side effect would have a major impact on arthritis treatment. Qigong therapy from Traditional Chinese Medicine (TCM) shows promise in this direction.

Qigong is a general term for a large variety of forms of traditional energy exercises and therapies. In general, Qigong is considered as the self-training method through Qi (vital energy and Yi (intention and consciousness) cultivation to achieve optimal status of both the mind and body. With constant and unrelenting Qigong practice, the practitioners are said to develop an awareness of Qi sensations in their bodies and use their mind or intention to guide the Qi toward the desired place. Some skillful Qigong practitioners can direct or emit their Qi energy (external Qi) for the purpose of healing others, which is called external Qigong therapy (EQT) or "Qi emission," a process by which Qigong practitioners direct or emit his or her Qi energy to help patients break the blockage of Qi and induce the sick Qi out of body so as to relieve pain, or balance the Qi system to get rid of diseases.

According to TCM, good health is a result of a free flowing, well-balanced Qi (energy) system, while sickness or pain like arthritis is the result of Qi blockage or unbalanced energy in the body. Although the physical nature of Qi remains unknown, there are some intriguing reports that suggest the possibility of physical and/or biochemical alterations induced by "Qi-emission." There is a small but growing body of scientific evidence that suggests the physical existence of Qi, as well as the healing power of Qigong therapy ^[1-6]

Qigong as an alternative therapy has gained increased popularity in the U.S. as well as around the world ^[7-8]. People practice Qigong to treat diseases ranging from hypertension, arthritis to cancer and HIV ^[9-10]. Despite the fact that chronic pain patients are increasingly seeking alternatives to the Western biomedical model, little scientific documentation can be found in Qigong treatment of arthritis pain. The purpose of this open trial of EQT was to determine if subjects with arthritis pain reported a change in pain intensity following three treatments of EQT by a medical Qigong master.

METHODS

Subjects

A total of 10 patients with chronic arthritis pain were recruited from a private rheumatology practice to participate in this open pilot trail. Nine were Caucasian and one Asian with a mean age of 58 (range 20 to 76). Seven were females and three males. Subjects were invited to participate based on the clinician's judgement, convenience and volunteer of the patients. Before the treatment, four subjects were diagnosed with osteoarthritis at knee or hip, one with OA at hand, two with rheumatoid arthritis (at shoulder or knees, both were men), one lumbar spondylosis with multiple sites of OA, one cervical spondylosis with fibromyalgia, and one with spondyloarthropathy on the back. All of them experienced constant or daily pain. Seven had never heard of Qigong before the study.

The duration of pain ranged from 2 months to 20 years (mean=6.1). Five patients were currently married, three widowed and two never married. Six of the patients had a reported a family history of chronic pain. Eight of them considered themselves religious, six have prayed for their health and four have meditated for health purpose. All of them believed at least a little in the effectiveness of the complementary and alternative medicine, but only two of them used something alternative previously. This study was approved by the Institutional Review Board of UMDNJ - New Jersey Medical School. The informed consent form explained that Qigong is a form of traditional Chinese energy medicine, but not an approved treatment in the U.S.; hopefully this open trial will not interrupt the participant's normal treatment or therapy.

Protocol

After informed consent was obtained and a short questionnaire completed the patients were examined by the physician to confirm the diagnosis with the criteria set by American Reumatology College. Then the patient was seated in a quite treatment room along with the Qigong healer, and the translator (KC). Treatment consisted of the Qigong healer administering Qi (the bio-energy) emission for 5 to 10 minutes. The process of treatment is said to emit Qi, a form of healing energy, to the area of specific joint(s) pain to break the Qi blockage. The location and length of treatment varied by patients, depending upon the type of pain and the healer's perception of Qi blockage. The patient was touched from time to time to pinpoint the pain area and lightly massage the pain area. At times the Qigong healer uttered words in Chinese climaxing in a shout, which was supposed to be a discharge of strong Qi. After that, the healer used his hands to induce the sick Qi out of the body from the bottom of feet or the fingertip of the hand at a distance of 10-15 cm from the patient. The healer spoke no English.

A total of three treatments were given in three continuous days. However, two subjects could not come back for the follow-up treatment due to a schedule conflict, and two dropped out after the second treatments without giving a reason. Six of the ten subjects completed all three treatments with both before and after evaluations, and were followed-up for an additional examination one month after the treatment.

Measures

The measurement used to evaluate the improvement include visual analogue (VAS) pain and mood scales (100 mm line with verbal anchors of zero as "no pain" and 100 as the "worst possible pain), VAS "relief" scale (anchored by "no relief of pain" and "complete relief of pain); activity difficulty level scale ^[11] (ten items for daily activity), Spielberger State-Trait Anxiety Scale ^[12] (state part only, 20 items), and a swollen/tender joint count (by the same physician all the time). In addition, a categorical pain scale was employed ^[13]. The scale consists of eight verbal descriptors ranging from "no pain" to "excruciating." The mood scale was anchored by the "best I could feel" (0) and "worst I could feel" (100).

RESULTS

Table 1 presents the results of VAS pain, mood and relief scores among all 10 subjects immediately prior and after the first treatment. Before the Qigong treatment, subjects' VAS pain score ranged from 11 to 87 (mean=55.0, standard deviation (SD) = 26); and the VAS negative mood scores ranged from 16 to 56 (mean=41.5; SD=15). As described above, the pain-relief oriented treatment by the Qigong healer lasted about 5 to 10 minutes. The relief scores were determined immediately after the first treatment. All subjects reported various degree of relief after the first treatment (mean = 63.7 and SD=25). When the pre- and post-treatment VAS scores were compared, we found that eight subjects reported some degree of mood improvement (mean reduction =18, SD=17; p < .05); nine of 10 subjects reported some reduction in pain, ranging from 9 to 63 (mean reduction =27, SD=23; p < .01), and one reported more pain in VAS scale, but reduced pain in word description (a contradiction).

Table 1. VAS Pain, Mood, and Relief Scores
Immediately Prior and After the First Treatment

Using non-parametric statistics to test the difference between positive (pain reduction) and negative response (pain increase), in 9 out of 10 trials the patients reported reduction in pain. This could occur by chance only at p < .01 in a cumulative binomial probability distribution.

Two of the patients reported "no-pain" in categorical word description after the first treatment (data not shown).

Only six of the ten subjects completed all three treatments with both before and after evaluation, and were followed-up for an additional examination one month after the treatment. Table 2 presents the results of VAS pain, mood and relief scores at the 4 points of the study. After the third treatment, all six patients still reported a reduction in VAS pain, ranging from 11 to 62 (mean reduction=34.7), and increased relief scores. Five of the 6 patients reported a reduced negative mood scores. The one-month follow-up examination showed that two of the patients (both OA) reported no pain at all, i.e., a complete relief, even though some patients reported slight increase in pain in comparison to the previous measurement after the treatment.

In comparison of the physical exam results (swollen/tender joint counts), 4 of the 6 subjects had reduced active pain/tender joints (as much as a reduction of 26 active joints) immediately after the treatment, 1 had no change and 1 had slightly more active pain joints (see Table 3). One month later, 4 of the 6 patients reported a reduction in active pain/tender joints. One who had more active pain/tender joints was a female patient diagnosed as Lumbar Spondylosis; the other who had more active pain/tender joints was the one who was diagnosed as rheumatoid arthritis on the shoulder and back in the first treatment (with only two-month pain history), but the final diagnosis was revised as undifferentiated connective tissue diseases in the follow-up exam, not the general arthritis pain that this study was designed to treat.

As to the movement difficult score, the mean was reduced from 11 prior treatment to 7.2 immediately after the treatment (p < .10), and further to 5.8 one month later, which was about 50% reduction of the overall score of movement difficulty (p < .05). This indicator may be a more objective improvement than pain score since the treatment really help the patients to gain control to themselves and move around more freely. All six patients reported some degree of reduction in movement difficulty one month after the treatment. One patient originally diagnosed as CREST syndrome and osteoarthritis on hands and feet (age 53) reported no difficulty in movement at all after reporting a complete relief and no pain in the follow-up exam.

Table 3 also presents the scores of the Spielberger Anxiety Scale (state only) before and after the treatment, and at follow-up. There is a general trend of reduction in anxiety after the Qigong treatment among all patients. The mean score at one month later (26.5) is much smaller than that immediately after the treatment (p < .05), which implies that the long-term effect (one month later) is greater than the short-term effect in terms of reduction of anxiety.

DISCUSSION

This is a preliminary open trial designed to explore the pain-relief effect of Qigong treatment for Western arthritis pain patients. Our results indicate that, like many treatment experiences, external Qigong treatment has some effect on pain-relief for most of our participants. All participants who underwent the complete 3 treatments reported some improvement in pain and anxiety, as well as the improvement in active pain/tender joints and. Two of the patients (1/3 of the samples) reported complete relief without pain even at one month after the treatment. One of them came to the clinic with a cane, and walked out to her car without the cane dramatically after the first EQT treatment. She wrote in her evaluation, "don't know what happened, glad about the opportunity. Noticed the difference in left knee." Although we cannot eliminate the possibility of placebo effect or suggestibility in these cases due to lack of control, we have observed encouraging and lasting effectiveness of EQT therapy for reduction in arthritis pain and related anxiety symptoms. The positive response we observed from most of our patients suggests further examination of Qigong be warranted.

One of the interesting findings in this pilot study is the effect of external Qigong therapy on reduction of anxiety. Our results show that, one month after the intervention, the mean score of anxiety was even lower than that immediately after the treatment, which implies the possible long-lasting effect of Qigong therapy on negative mood. Dr. Wu of UMDNJ ^[3] also observed the similar result of long-term effect of Qigong therapy on anxiety in their study of Qigong treating late-stage reflex sympathetic dystrophy.

We cannot exclude the possibility of non-specific treatment effects such as placebo or psychological effect accounting for our results. As yet, the mechanism of the placebo effect is unspecified. It has been suggested that it depends on the disease, the treatment, the patient, or all three. Other such effects include the statistical phenomenon of regression toward the mean accounting for apparent improvement. Statistical regression occurs when extreme scores that are invariably measured imperfectly (e.g., pain symptom severity scores) move closer to their mean or average level when measurement is repeated ^[14]. For example, a person selected to participate in a study of hypertension, will tend to have slightly lower blood pressure at a second, later measurement. Further, in an open trial such as this, patients may be motivated to please the master and their treating clinician. Moreover, only patients thought to be willing to participate, i.e., sympathetic to alternative medicine, were approached or agreed for this trial. Of 12 approached 10 agreed who were also able to be present on that specific day of the study. Clearly these patients were motivated and curious about alternative methods for their chronic arthritis pain.

Perhaps even more than with acupuncture, we are confronted with the challenge that a control treatment is difficult to design and implement since Qigong therapy is, in essence like psychotherapy, the interaction between the therapist, here the Qigong master, and the patient. Sham masters have been employed in Qigong studies of non-humans and in cell lines ^[2]. It is more difficult in human studies given the confidence and strong presence the master exudes. In any case, this first trial was necessary in order to establish an effect before more ambitious and properly controlled studies are justified.

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