Rheumatol Int
DOI 10.1007/s00296-012-2360-1
ORIGINAL ARTICLE
Efficacy and safety of meditative movement therapies
in fibromyalgia syndrome: a systematic review and meta-analysis
of randomized controlled trials
Jost Langhorst Petra Klose Gustav J. Dobos
Kathrin Bernardy Winfried Hauser
Received: 13 August 2011 / Accepted: 18 January 2012
Springer-Verlag 2012
Abstract A systematic review with meta-analysis of the
efficacy and safety of meditative movement therapies
(Qigong, Tai Chi and Yoga) in fibromyalgia syndrome (FMS)
was carried out. We screened Clinicaltrials.Gov, Cochrane
Library, PsycINFO, PubMed and Scopus (through December
2010) and the reference sections of original studies for medi-
tative movement therapies (MMT) in FMS. Randomized
controlled trials (RCT) comparing MMT to controls were
analysed. Outcomes of efficacy were pain, sleep, fatigue,
depression and health-related quality of life (HRQOL). Effects
were summarized using standardized mean differences (SMD
[95% confidence interval]). Outcomes of safety were drop out
because of adverse events and serious adverse events. A total
of 7 out of 117 studies with 362 subjects and a median of 12
sessions (range 824) were included. MMT reduced sleep
J. Langhorst (&)
P. Klose
G. J. Dobos
Department of Internal and Integrative Medicine,
University of Duisburg-Essen, Kliniken Essen-Mitte,
45276 Essen, Germany
e-mail: j.langhorst@kliniken-essen-mitte.de
K. Bernardy
Department of Anaesthesiology, Intensive Care
and Pain Therapy, Saarland University Hospital,
66421 Homburg/Saar, Germany
K. Bernardy
Department of Pain Management,
BG University Hospital Bergmannsheil GmbH,
Ruhr University Bochum, Bochum, Germany
W. Hauser
Department of Internal Medicine I, Klinikum Saarbrucken,
66119 Saarbrucken, Germany
W. Hauser
Department of Psychosomatic Medicine and Psychotherapy,
Technische Universitat Munchen, Munich, Germany
disturbances (-0.61 [-0.95, -0.27]; 0.0004), fatigue (-0.66
[-0.99, -0.34];\0.0001), depression (-0.49 [-0.76, -0.22];
0.0004) and limitations of HRQOL (-0.59 [-0.93, -0.24];
0.0009), but not pain (-0.35 [-0.80, 0.11]; 0.14) compared
to controls at final treatment. The significant effects on
sleep disturbances (-0.52 [-0.97, -0.07]; 0.02) and HRQOL
(-0.66 [-1.31, -0.01]; 0.05) could be maintained after a
median of 4.5 (range 36) months. In subgroup analyses, only
Yoga yielded significant effects on pain, fatigue, depression
and HRQOL at final treatment. Drop out rate because of
adverse events was 3.1%. No serious adverse events were
reported. MMT are safe. Yoga had short-term beneficial
effects on some key domains of FMS. There is a need for high-
quality studies with larger sample sizes to confirm the results.
Keywords Fibromyalgia syndrome
Meta-analysis

Meditative movement therapies
Yoga
Taichi
Qigong

Efficacy
Safety
Randomized controlled trials
CAM
(complementary and alternative medicine)
Abbreviations
FMS Fibromyalgia syndrome
MMT Meditative movement therapies
BAT Body awareness therapies
CAM Complementary and alternative medicine
RCT Randomized controlled trials
HRQOL Health-related quality of life
SMD Standardized mean differences
Introduction
The key symptoms of fibromyalgia syndrome (FMS) are
chronic ([3 months) widespread pain, physical fatigue,
123

cognitive disturbances, non-restorative sleep and a high
amount of somatic and psychological distress [1, 2]. The
estimated prevalence of FMS in Western European coun-
tries ranges from 2.2 to 6.6% [3, 4]. Patients with FMS use
many pharmacological and non-pharmacological therapies,
resulting in high costs for health services [5]. In an Internet
survey, 24% of respondents reported use of Qigong, Tai
Chi or Yoga [6].
Qigong, Tai Chi and Yoga can be subsumed as meditative
movement therapies (MMT) [7]. MMT is proposed as a new
category of exercise defined by (a) some form of movement or
body positioning, (b) a focus on breathing and (c) a cleared or
calm state of mind with a goal of (d) deep states of relaxation.
Sign-Chi-Do, Neuromuscular Integrative Action and Eur-
hythmy are other less known forms of MMT [7]. Qigong and
Tai Chi are two traditional Chinese medicine techniques that
incorporate body movement, breath and attentional training to
improve disease symptoms and maintain health [8]. Tai Chi
is, in contrast to Qigong, a martial art. Ai Chi is an adaptation
of land Tai Chi movements to water. Tai chi movements
practiced quickly can provide self-defence and are externally
focused. Qigong cannot and is internally focused. Yoga is an
ancient Indian, non-religious mindbody approach that has
components centreing on meditation, mindfulness, breathing
and activity or postures [8].
Meditative movement therapies had not been included
into evidence-based guidelines on the management of FMS
[911] except a negative recommendation on Tai Chi as
single therapy in the German guideline [11]. A systematic
review on Qigong in chronic pain conditions included four
randomized controlled trials (RCT) and three controlled
trials (search of literature until February 2009). The authors
rated the existing trial evidence as not convincing enough to
suggest that Qigong is an effective modality for pain man-
agement. [12]. A qualitative systematic review of RCTs on
complementary and alternative medicine treatments in FMS
included RCTs evaluating six therapeutic approaches in the
mindbody category (search of literature until February
2007) Qigong only appeared as a cotreatment in the pre-
sented studies and did not prove beneficial [13].
A meta-analysis of the results of RCTs with MMT in
FMS had not been conducted until now. Therefore, we saw
the need to update the search of literature and to perform a
quantitative analysis of efficacy outcomes of MMT in
FMS. Furthermore, we respected a recent topical review on
best practice in reporting of systematic reviews in pain
medicine that recommended not only focus on efficacy, but
also on the safety of a treatment [14]. The aims of this
systematic review were to assess
(a) the efficacy of MMT on the key symptoms of FMS
compared with controls
(b) the safety of MMT
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Rheumatol Int
Materials and methods
The review was performed according to the PRISMA
statement (preferred reporting items for systematic reviews
and meta-analyses) [15] and the recommendations of the
Cochrane Collaboration [16].
Study protocol
Methods of analysis and inclusion criteria were specified in
advance. We used the review protocol of our systematic
review on cognitive behavioural therapies in FMS [17].
Eligibility criteria
Types of interventions
Studies with meditative movement therapies were inclu-
ded. Studies in which MMT were part of a multi-compo-
nent therapy or were combined with mindfulness-based
stress reduction were excluded because it would not be
possible to separate the effects of MMT from the additional
modalities. Studies with body awareness therapies were
excluded because they do not meet all four criteria of
MMT.
Types of studies
A randomized controlled design (RCT) comparing MMT
with controls was demanded. In case of multiple control
groups, we predefined the following order for comparison:
attention control (unspecific elements such as education
and emotional support), treatment as usual, waiting list,
active therapy (any defined pharmacological or non-phar-
macological other than hypnosis/guided imagery). The
studies should be available as a full publication in a peer
reviewed science journal.
Types of participants
Patients diagnosed with FMS on recognized criteria, of any
age, were included.
Types of outcomes measures
Efficacy: Studies should assess at least one key domain of
FMS [pain, sleep, fatigue, health-related quality of life
(HRQOL) and depression] [18]. From each trial, we
selected the measure considered most appropriate for each
of these six outcomes. When there was more than one
measure for an outcome, we gave preference to measures
recommended by OMERACT [18].
Rheumatol Int
Acceptability and safety: Studies should report accept-
ability (total drop out rate) and of safety (serious adverse
events and drop out because of adverse events).
Data sources and searches
The electronic bibliographical databases screened included
the Clinicaltrials.Gov (National Institute of Health),
Cochrane Central Register of Controlled Trials (CEN-
TRAL), PsycINFO, PubMed and Scopus (through
December 31, 2010). The search strategy for PubMed was
as follows: (Breathing Exercises[Mesh] OR Tai Chi OR
Sign-Chi-Do OR Neuromuscular Integrative Action OR
Eurhythmy) AND Fibromyalgia[Mesh] AND ((clini-
cal[Title/Abstract] AND trial[Title/Abstract]) OR clinical
trials[MeSH Terms] OR clinical trial[Publication Type]
OR random*[Title/Abstract] OR random allocation [MeSH
Terms] OR therapeutic use [MeSH Subheading])).
The search strategy was adapted for each database if
necessary. No language restrictions were applied. In addi-
tion, reference sections of original studies, systematic
reviews on MMT [12, 13] and evidence-based guidelines
on the management of FMS [911] were screened
manually.
Study selection
Two authors (JH and WH) independently screened the
titles and abstracts of potentially eligible studies identified
by the search strategy as above. The full-text articles were
then examined independently by two authors (KB and PK)
to determine whether they met the inclusion criteria.
Data collection process
Two authors (JL and PK) independently extracted the data
using standard extraction forms. Discrepancies were
rechecked and consensus achieved by discussion. If nee-
ded, a third author (GD) reviewed the data to reach a
consensus. Where outcomes, means or standard deviations
were missing, attempts were made to obtain these data by
contacting four trial authors. Additional data were provided
by three authors (see Table 1).
Data for study settings, participants, exclusion criteria,
interventions, cotherapies, attendance rates, reported side
effects and outcomes sought are listed in Table 1.
Risk of bias in individual studies
To ascertain the internal validity of the eligible RCT, two
pairs of reviewers (KB, WH; JL, PK) working indepen-
dently determined the adequacy of randomization, con-
cealment of allocation, blinding of outcome assessors and
adequacy of data analysis (Was intention-to-treat analysis
performed?). We calculated a risk of methodological bias
score with a range of 03 (0 = adequate, 1 = unclear or
inadequate for each item).
The same pairs of reviewers checked the settings of the
studies, the means of referral to the RCT, the demo-
graphical data of the study samples and if patients with
frequent comorbidities of FMS, namely depressive disor-
ders and inflammatory rheumatic diseases, were included
to assess whether study samples were representative FMS
patients of clinical practice (external validity).
Summary measures
Data entry (WH) was checked by another author (KB).
Discrepancies were resolved by consensus. Meta-analyses
were conducted using RevMan Analysis software (RevMan
5.0.24) of the Cochrane Collaboration [19]. Standardized
mean differences (SMD) were calculated by means and SD
or change scores for each intervention. Examination of the
combined results was performed by a random-effects
model (inverse variance method), because this model is
more conservative than the fixed-effects model and incor-
porates both within study and between-study variance
[20]. The SMD used in Cochrane reviews is the effect
size known as Hedges (adjusted) g. We used Cohens
categories to evaluate the magnitude of the effect size,
calculated by SMD, with g [ 0.20.5 = small effect size,
g [ 0.50.8 = medium effect size and g [ 0.8 = large
effect size [21].
Planned methods of analysis
Heterogeneity was tested using the I2 statistic, with I2
values over 50% indicating strong heterogeneity. Tau-
squared was used to determine how much heterogeneity
was explained by subgroup differences [16].
Risk of bias across studies
Publication bias was assessed by Eggers intercept test [22]
and Beggs rank correlation test [23] at the significance
level p \ 0.05.
Additional analyses
Subgroup analysis
If there were at least two studies available, subgroup
analyses were prespecified for type of MMT and of control
group. These subgroup analyses were also used to examine
potential sources of clinical heterogeneity.
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 Table 1 Main study characteristics

123
Author Mean age Exclusion of somatic Diagnosis of Study population Treatment group Control group Both groups Outcomes used for
Country Women % diseases and mental FMS meta-analysis
Year Race % disorders N screened/ N/completing N/completing (%) Kind of treatment Kind of treatment Comedication allowed Latest follow-up
Setting Randomized End of therapy (%) End of therapy Duration treatment Duration treatment Attendance rates (all
Referral (%) N/completing (%)End of sessions)
therapy Side effects
Drop out due to side
effects in
experimental group

Calandre 50 years Concomitant disease ACR 1990 90/81 81/66 42/32 AI Chi (Tai Chi Movements in water) Active control: Yes, without changes Pain VAS 010*
Spain 90% female worsen with warm (90) (81) (76) 6 weeks, 3 times, 60 min Stretching NR Sleep PSQI*
water exercise
2009 NR (?9 drop outs during (?3 drop outs during Total: 18 h 6 weeks, 3 times, 60 min NR Fatigue VAS 010*
University follow-up) follow-up Total: 18 h 2/32 Pain exazerberation Depression BDI*
University 39/34 1/32 Chlorine HRQOL FIQ total*
outpatient (87) hypersensitivity 3 months
pain unit
attendants (?6 drop outs during
follow-up)
Carson 53,7 years Suicidal risk, physically ACR 1990 64/53 53/48 25/22 Yoga of Awareness Delayed treat-ment Yes, without changes Pain VAS 010
USA 100% female disabled (83) (91) (88) (yoga ? meditation ? breathing control 88% Sleep VAS 010
2010 92,5% white exercises ? group discussion) 28/27 NR Fatigue VAS 010
University 8 weeks, 1 time, 120 min group class (93) 0/25 Depression VAS
University Total: 16 h 010

center ? DVD daily HRQOL FIQR total

database 2040 min home training No follow up

Haak 53 years Severe depression or NR 75/57 (76) 57/53 (93) 29/28 (97) Qi Gong Delayed treatment NR Pain NRS 17
Sweden 100% female diseases, 7 sessions internal Qi Gong (lotus method) control NR Sleep quality NRS
psychosis,suicidal still and dynamic 28/25 17
2008 NR risk, drugs, alcohol 92.80%
University 2 sessions external Qi Gong (89) 0/29 Fatigue NA

Local press, 7 weeks, 9 group sessions Depression BDI

Nat. Care Total: 11,5 h HRQOL

Centers, ? tape home training 2 9 20 min per day WHOQOL
Patients BREF
Asso- No follow-up
ciations,
Family
doctors,
Insurance
companies
Ide NR Musculoskeletal, ACR 1990 NR 40/35 20/18 (90) Yoga breathing exercises in warm water Treatment as usual NR Pain VAS 010
Brazil 100% female respiratory, (87.5) 4 weeks, 4 9 60 min/week 20/17 (85) NR Sleep PSQI
neurological,
2008 NR cardiovascular, skin Total: 16 h NR Fatigue VAS 010
University disease 0/20 Depression VAS
NR Hydrophobia 010
HRQOL FIQ Total
Rheumatol Int
 Table 1 continued
Author Mean age Exclusion of somatic Diagnosis of FMS Study population Treatment group Control group Both groups Outcomes used for
Country Women % diseases and mental meta-analysis
Year Race % disorders N screened/ N/completing N/completing (%) Kind of treatment Kind of treatment Comedication allowed Latest follow-up
Setting Randomized (%) End of therapy (%) End of therapy Duration treatment Duration treatment Attendance rates (all
Rheumatol Int

Referral N/completing (%)End of sessions)

therapy Side effects
Drop out due to side
effects in
experimental group

Manner-kopi 45 years NR ACR 1990 NR 36/22 19/12 Body Awareness Therapy Treatment as usual Yes, no changes Pain VAS 010*
Sweden 100% female (61) (63) 14 group sessions, 12 weeks, 17/10 (59) 58% at least 50% of Sleep NA
2004 NR 90 min treatments Fatigue VAS 010*
University Total: 18 h 6/19 Increased pain Depression NP
? tape low back and hips
HRQOL FIQ total
1/19 Muscle
inflammation No follow-up

1/19 Increase of pain

Stephens 13,2 years Comorbidity ACR 145/30 30/24 14/12 Qi Gong Active control: Aerobics Yes, IR Pain VAS 0-10
USA 73% female NR (21) (80) (86) 12 group sessions, 12 weeks, 12 group sessions,12 NR Fatigue Peds QL
2008 NR 1 time, 30 min weeks, 1 time, 30 min 64% Sleep NA
District hospital Total: 6 h Total: 6 h None Depression CDI
Rheumatology and ? video training twice ? video training twice a 0/12 HRQOL VAS 010
pain clinics a week week
No follow-up
16/12
(75)
Wang 50,1 years Serious medical ACR 90/66 66/61 33/32 Yang-Style Tai Chi Active control: No changes Pain VAS 010
USA 86% female condition, medical Yes (73) (92) (97) 24 group sessions, 12 weeks, Wellness Education ? 77% treatment Sleep PSQI
conditions 2 times, 60 min stretching (2/3
2010 56% white contributing to FMS, (? 2 drop outs 70% control Fatigue VAS 010*
during follow-up) Total:24 h didactic lesson,
Tertiary Care low score in Mini- 1/3 exercises) None Depression CES-D
Academic Hospital Mental Test ? DVD after intervention 0/33 HRQOL FIQ total
24 group sessions,
12 weeks, 2 times, 6 months
60 min
Total: 24 h
33/29 (88)

The order of the presented studies is arranged according to alphabetic order

ACR American College of Rheumatology, BDI Beck Depression Inventory, CDI Childrens Depression Inventory, CES-D Center for Epidemiological Studies Depression Scale, FIQ Fibromyalgia Impact Questionnaire, FIQR Fibromyalgia Impact Questionnaire revised,
HRQOL Health-related quality of life, JPMF Juvenile Primary Fibromyalgia, NA Not assessed, NP Not provided on request, NR Details not reported, PedsQOL Pediatric Quality of Life Inventory, PSQI Pittsburgh Sleep Quality Index, VAS Visual Analogue Scale
* Data provided on request, ** Only follow-up values reported

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Sensitivity analyses screening, 84 records were excluded: 25 did not evaluate

We post hoc decided to reanalyse the data excluding two
studies in warm water because the effects on the outcomes
might have been partially due to the positive effects of
balneotherapy on FMS [24].
Metaregression analyses
We a priori decided to metaregress SMDs with the meth-
odological quality score and for potential sources of
methodological heterogeneity and with number of treat-
ment sessions and total treatment duration for potential
sources of clinical heterogeneity. Metaregression was
performed using the mixed effects model. Tau2 variance
was calculated by the method of unrestricted maximum
likelihood by Comprehensive Meta-analysis software [25].
MMT in FMS, 38 were review articles, 13 were case
reports, conference papers or commentaries, seven studies
were not completed, and one study was only available as
abstract. Sixteen full-text articles assessed for eligibility;
nine full-text articles were excluded for the following
reasons: two studies with Tai Chi part of multi-component
therapy [26, 27], three studies with Yoga combined with
mindfulness-based stress reduction [2830], one study
comparing Yoga with Yoga combined with Tui Na without
adequate control group [31], one study because of lacking
randomization [32], one study comparing two types of
body awareness therapies (BAT) [33] and one non-ran-
domized study with Feldenkrais therapy [33]. Finally,
seven studies were included into analysis [3440] (Fig. 1).
Study characteristics

Results Setting, referral and diagnostic criteria

Search results Three studies were conducted in North America, three in

Europe and one in South America. Patients were recruited
The literature search produced 120 citations; 20 were by registers of hospitals, referral (general practitioner,
double hits (study found in at least two data sources). By rheumatologist and departments of hospitals), local self-

Fig. 1 PRISMA flow diagram

Search of electronic databases 3 of additional records identi-
10 Central fied by other searches
10 NIH
20 Pubmed
4 PsycINFO
73 SCOPUS

20 of records after duplicates removed

100 of records screened 84 of records excluded

16 of full-text articles as- 9 full-text articles excluded:

sessed for egilibility
7 of studies included in
qualitative synthesis
3 Yoga part of Mindfulness based stress
reduction
2 Tai Chi part of multicomponent therapy
1 Two types of MMT compared without
control group
1 No randomisation
1 with two types of Body Awareness ther-
apy
1 with Feldenkrais therapy

7 of studies included in
meta-analysis

123
Rheumatol Int
help groups, insurance companies and newspaper adver-
tisements. Six studies were conducted within the setting of
a university and one within a district hospital. All studies
were single-centre based. FMS was diagnosed in five
studies by the criteria of the American College of Rheu-
matology [41] and in one study with adolescents by the
Juvenile Primary Fibromyalgia criteria [42]. One study did
not report the diagnostic criteria used.
Participants
The median of the mean age of participants was 50 (range
1354) years. The median percentage of women was 100
(range 73100)%.
Interventions
Data are reported as median (range): five studies reported
the number of persons screened which were subsequently
randomized with a percentage of 76 (2190)%. The num-
ber of patients with MMT was 25 [1941] and controls 28
[1638]. 181 patients each were in MMT and control
groups.
Two studies each offered Tai Chi and Yoga, and three
studies offered Qi Gong. In three studies, the controls
received another active therapy (stretching, education,
physiotherapy and moderate aerobic exercise), and in two
studies, each delayed treatment control or treatment as
usual (Table 1). The number of sessions was 12 [824].
The total treatment time was 18 (648) h.
Two studies performed follow-ups after 4.5 [36]
months.
Outcomes
There was some variety of outcomes measures. Pain was
assessed by all studies by a visual or numeric rating scale.
HRQOL was assessed by five studies by the total score of
the Fibromyalgia Impact Questionnaire. Two studies used
other validated composite HROL scores. Sleep distur-
bances were assessed by a single-dimension rating scale in
two studies and by the Pittsburgh Sleep Quality Index in
two studies. Fatigue was assessed by three studies by a
single-dimension rating scale and in one study by a vali-
dated composite score. Depression was assessed by four
studies by three different validated depression question-
naires and in one study by a single-dimension rating scale.
Risk of bias within studies
The risk of bias score was 2 (03) (see Table 1). One study
did not report the exclusion criteria. All other studies
excluded patients with severe somatic diseases (but not for
inflammatory rheumatic disease). One study excluded
patients in case of severe depression. Two studies excluded
patients with unresolved litigation.
Results of individual studies
The means, SD, sample sizes and effect estimates at final
treatment and at follow-up of each study can be seen in the
forest plots (Fig. 2).
Synthesis of results
Data are reported as follows: standardized mean differ-
ence, 95% confidence interval and p value of test for
overall effect. MMT reduced sleep disturbances (-0.61
[-0.95, -0.27]; 0.0004), fatigue (-0.66 [-0.99, -0.34];
\0.0001), depression (-0.49 [-0.76, -0.22]; 0.0004)
and limitations of HRQOL (-0.59 [-0.93, -0.24];
0.0009) compared to controls at final treatment. There
was no significant effect on pain (-0.35 [-0.80, 0.11];
0.14). Based on Cohens categories, the effects were
medium for sleep disturbances fatigue and HRQOL and
small for depression.
MMT did not reduce pain (-0.17 [-0.88, 0.55]; 0.65),
fatigue (-0.63 [-1.46, 0.20] and depression (-0.27
[-0.67, 0.14]; 0.19), but sleep disturbances (-0.52 [-0.97,
-0.07]; 0.02) and restrictions of HRQOL (0.66 [-1.31,
-0.01]; 0.05) at follow-up (see Table 2).
Four studies reported on adverse events. Two studies
mentioned that no adverse events occurred. One study
reported that 6/12 patients reported an increase of pain.
Three studies reported a total drop out of 6/191 (3.1%) due
to adverse events (three because an increase of pain, one
because of muscle inflammation and one because of chlo-
rine hypersensitivity) in the MMT groups. No serious
adverse events were reported (see Table 3).
Risk of bias across studies and additional analyses
There was substantial heterogeneity in the comparisons of
the outcomes pain and HRQOL at final treatment and of
pain, fatigue and HRQOL at follow-up. Most notably, there
was no substantial heterogeneity in the comparisons with a
significant effect except HRQOL at final treatment and at
follow-up.
Subgroup analysis
Statistical heterogeneity of analysis was substantially
reduced in case of yoga trials for the outcomes pain and
HRQOL. A significant effect on pain, fatigue, sleep,
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Pain final treatment

Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 Mean
Calandre 2009 Ai Chi 6.2 2.2 32 6.6 2.1 34 16.0% -0.18 [-0.67, 0.30]
Carson 2010Yoga Awareness 4.1 2.1 25 5.1 2.3 28 15.3% -0.45 [-0.99, 0.10]
Haak 2000 Qigong 3.3 0.8 28 4.2 0.9 28 15.1% -1.04 [-1.60, -0.48]
Mannerkorpi 2004 BAT 7.9 2.4 11 7.6 1.8 10 11.6% 0.13 [-0.72, 0.99]
Stephens 2008 Qi-Gong 6.1 2.3 16 3.7 2.5 14 12.6% 0.98 [0.21, 1.74]
Subtotal (95% CI) 112 114 70.6% -0.16 [-0.76, 0.45]
Heterogeneity: Tau = 0.36; Chi = 18.85, df = 4 (P = 0.0008); I = 79%
Test for overall effect: Z = 0.51 (P = 0.61)

1.1.2 Mean Change

Ide 2008 Water Yoga -2.8 3 18 -1 2.1 17 13.6% -0.68 [-1.36, 0.01]
Wang 2010 Tai Chi -2.5 1.8 33 -0.6 2.4 33 15.8% -0.89 [-1.39, -0.38]
Subtotal (95% CI) 51 50 29.4% -0.81 [-1.22, -0.40]
Heterogeneity: Tau = 0.00; Chi = 0.23, df = 1 (P = 0.63); I = 0%
Test for overall effect: Z = 3.90 (P < 0.0001)

Total (95% CI) 163 164 100.0% -0.35 [-0.80, 0.11]

Heterogeneity: Tau = 0.28; Chi = 23.81, df = 6 (P = 0.0006); I = 75%
-4 -2 0 2 4
Test for overall effect: Z = 1.49 (P = 0.14) Favours experimental Favours control
Test for subgroup differences: Chi = 4.72, df = 1 (P = 0.03), I = 78.8%

Sleep final treatment

Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.6.1 Mean
Calandre 2009 Ai Chi 11.9 4.9 32 14 5 34 22.6% -0.42 [-0.91, 0.07]
Carson 2010Yoga Awareness 5.7 3.1 25 6.1 2.9 28 20.5% -0.13 [-0.67, 0.41]
Haak 2000 Qigong -4 1.1 28 -3.4 1.1 28 20.7% -0.54 [-1.07, -0.00]
Subtotal (95% CI) 85 90 63.8% -0.37 [-0.67, -0.07]
Heterogeneity: Tau = 0.00; Chi = 1.17, df = 2 (P = 0.56); I = 0%
Test for overall effect: Z = 2.41 (P = 0.02)

1.6.2 Mean change

Ide 2008 Water Yoga -3.2 5.2 18 2.1 4.3 17 14.7% -1.08 [-1.80, -0.37]
Wang 2010 Tai Chi -3.6 3.5 33 -0.7 2 33 21.5% -1.01 [-1.52, -0.49]
Subtotal (95% CI) 51 50 36.2% -1.03 [-1.45, -0.61]
Heterogeneity: Tau = 0.00; Chi = 0.03, df = 1 (P = 0.86); I = 0%
Test for overall effect: Z = 4.84 (P < 0.00001)

Total (95% CI) 136 140 100.0% -0.61 [-0.95, -0.27]

Heterogeneity: Tau = 0.07; Chi = 7.60, df = 4 (P = 0.11); I = 47%
-4 -2 0 2 4
Test for overall effect: Z = 3.52 (P = 0.0004) Favours experimental Favours control
Test for subgroup differences: Chi = 6.41, df = 1 (P = 0.01), I = 84.4%

Fatigue final treatment

Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.2.1 Mean
Calandre 2009 Ai Chi 7.3 2.7 32 7.8 2.1 34 22.2% -0.21 [-0.69, 0.28]
Carson 2010Yoga Awareness 4.8 2.5 25 6.7 1.6 28 18.7% -0.90 [-1.47, -0.33]
Mannerkorpi 2004 BAT 8.7 1.1 11 8.9 1 10 10.7% -0.18 [-1.04, 0.68]
Stephens 2008 Qi-Gong 811 247 16 1,025 432 14 13.5% -0.60 [-1.34, 0.13]
Wang 2010 Tai Chi 4.5 2.8 33 6.7 2.3 33 21.3% -0.85 [-1.35, -0.34]
Subtotal (95% CI) 117 119 86.4% -0.58 [-0.89, -0.26]
Heterogeneity: Tau = 0.03; Chi = 5.46, df = 4 (P = 0.24); I = 27%
Test for overall effect: Z = 3.60 (P = 0.0003)

1.2.2 Mean change

Ide 2008 Water Yoga -2.8 3.4 18 0.3 0.6 17 13.6% -1.22 [-1.95, -0.49]
Subtotal (95% CI) 18 17 13.6% -1.22 [-1.95, -0.49]
Heterogeneity: Not applicable
Test for overall effect: Z = 3.29 (P = 0.001)

Total (95% CI) 135 136 100.0% -0.66 [-0.99, -0.34]

Heterogeneity: Tau = 0.06; Chi = 8.13, df = 5 (P = 0.15); I = 39%
-4 -2 0 2 4
Test for overall effect: Z = 4.01 (P < 0.0001) Favours experimental Favours control
Test for subgroup differences: Chi = 2.67, df = 1 (P = 0.10), I = 62.6%

Fig. 2 Forest plots of the effect estimates (standardized mean differences) of meditative movement therapies versus controls on outcomes at
final treatment and at follow-up. CI = Confidence interval; IV = inverse variance

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Depression final treatment

Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.3.1 Mean
Calandre 2009 Ai Chi 16.8 10.4 32 18 8.5 34 20.9% -0.13 [-0.61, 0.36]
Carson 2010Yoga Awareness 1.7 2 25 3.8 2.8 28 16.8% -0.84 [-1.41, -0.28]
Haak 2000 Qigong 12.9 7.5 28 17.1 8 28 18.2% -0.53 [-1.07, -0.00]
Stephens 2008 Qi-Gong 8 6.3 16 7.7 8.2 14 11.6% 0.04 [-0.68, 0.76]
Subtotal (95% CI) 101 104 67.5% -0.38 [-0.76, -0.01]
Heterogeneity: Tau = 0.06; Chi = 5.28, df = 3 (P = 0.15); I = 43%
Test for overall effect: Z = 2.00 (P = 0.04)

1.3.2 Mean change

Ide 2008 Water Yoga -2.1 3.9 18 -0.1 0.2 17 12.5% -0.70 [-1.38, -0.01]
Wang 2010 Tai Chi -8.1 8.2 33 -2.3 8.3 33 20.1% -0.69 [-1.19, -0.20]
Subtotal (95% CI) 51 50 32.5% -0.70 [-1.10, -0.29]
Heterogeneity: Tau = 0.00; Chi = 0.00, df = 1 (P = 1.00); I = 0%
Test for overall effect: Z = 3.39 (P = 0.0007)

Total (95% CI) 152 154 100.0% -0.49 [-0.76, -0.22]

Heterogeneity: Tau = 0.03; Chi = 6.81, df = 5 (P = 0.24); I = 27%
-4 -2 0 2 4
Test for overall effect: Z = 3.53 (P = 0.0004) Favours experimental Favours control
Test for subgroup differences: Chi = 1.53, df = 1 (P = 0.22), I = 34.6%

Quality of life final treatment

Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.4.1 Mean
Calandre 2009 Ai Chi 49.1 15.9 32 55.7 15.1 34 17.2% -0.42 [-0.91, 0.07]
Carson 2010Yoga Awareness 35.5 17.6 25 48.7 18.9 28 15.6% -0.71 [-1.27, -0.15]
Haak 2000 Qi Gong -3.4 0.7 28 -2.8 0.9 28 15.9% -0.73 [-1.28, -0.19]
Mannerkorpi 2004 Qi Gong 7.3 0.9 12 7.1 1.7 10 10.3% 0.15 [-0.69, 0.99]
Stephens 2008 Qi Gong -6.5 1.3 16 -6.8 2.5 14 12.3% 0.15 [-0.57, 0.87]
Subtotal (95% CI) 113 114 71.3% -0.39 [-0.74, -0.05]
Heterogeneity: Tau = 0.06; Chi = 6.48, df = 4 (P = 0.17); I = 38%
Test for overall effect: Z = 2.23 (P = 0.03)

1.4.2 Mean change

Ide 2008 Water Yoga -2.1 2.1 18 0 1 17 12.1% -1.24 [-1.97, -0.51]
Wang 2010 Tai Chi -27.8 17.6 33 -9.4 17.6 33 16.5% -1.03 [-1.55, -0.52]
Subtotal (95% CI) 51 50 28.7% -1.10 [-1.52, -0.68]
Heterogeneity: Tau = 0.00; Chi = 0.20, df = 1 (P = 0.66); I = 0%
Test for overall effect: Z = 5.12 (P < 0.00001)

Total (95% CI) 164 164 100.0% -0.59 [-0.93, -0.24]

Heterogeneity: Tau = 0.12; Chi = 13.70, df = 6 (P = 0.03); I = 56%
-4 -2 0 2 4
Test for overall effect: Z = 3.31 (P = 0.0009)
Favours experimental Favours control
Test for subgroup differences: Chi = 7.02, df = 1 (P = 0.008), I = 85.8%

Pain follow-up
Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
2.1.1 Mean
Calandre 2009 Ai Chi 6.9 3 32 7.1 2.2 34 50.5% -0.08 [-0.56, 0.41]
Subtotal (95% CI) 32 34 50.5% -0.08 [-0.56, 0.41]
Heterogeneity: Not applicable
Test for overall effect: Z = 0.31 (P = 0.76)

2.1.2 Mean change

Wang 2010 Tai Chi -2.4 2.1 33 -0.7 2.1 33 49.5% -0.80 [-1.30, -0.30]
Subtotal (95% CI) 33 33 49.5% -0.80 [-1.30, -0.30]
Heterogeneity: Not applicable
Test for overall effect: Z = 3.12 (P = 0.002)

Total (95% CI) 65 67 100.0% -0.43 [-1.14, 0.28]

Heterogeneity: Tau = 0.20; Chi = 4.15, df = 1 (P = 0.04); I = 76%
-4 -2 0 2 4
Test for overall effect: Z = 1.20 (P = 0.23) Favours experimental Favours control
Test for subgroup differences: Chi = 4.15, df = 1 (P = 0.04), I = 75.9%

Fig. 2 continued

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Sleep follow-up
Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
2.5.1 Mean
Calandre 2009 Ai Chi 12.9 4.3 32 14.2 4.5 34 50.9% -0.29 [-0.78, 0.19]
Subtotal (95% CI) 32 34 50.9% -0.29 [-0.78, 0.19]
Heterogeneity: Not applicable
Test for overall effect: Z = 1.18 (P = 0.24)

2.5.2 Mean change

Wang 2010 Tai Chi -4.2 4.5 33 -1.2 3.3 33 49.1% -0.75 [-1.25, -0.25]
Subtotal (95% CI) 33 33 49.1% -0.75 [-1.25, -0.25]
Heterogeneity: Not applicable
Test for overall effect: Z = 2.94 (P = 0.003)

Total (95% CI) 65 67 100.0% -0.52 [-0.97, -0.07]

Heterogeneity: Tau = 0.04; Chi = 1.67, df = 1 (P = 0.20); I = 40%
-4 -2 0 2 4
Test for overall effect: Z = 2.25 (P = 0.02) Favours experimental Favours control
Test for subgroup differences: Chi = 1.67, df = 1 (P = 0.20), I = 40.1%

Fatigue follow-up
Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
2.2.1 Mean
Calandre 2009 Ai Chi 7.6 1.9 32 8 1.8 34 50.6% -0.21 [-0.70, 0.27]
Wang 2010 Tai Chi 4.4 2.8 33 7.1 2.2 33 49.4% -1.06 [-1.58, -0.54]
Subtotal (95% CI) 65 67 100.0% -0.63 [-1.46, 0.20]
Heterogeneity: Tau = 0.29; Chi = 5.48, df = 1 (P = 0.02); I = 82%
Test for overall effect: Z = 1.49 (P = 0.14)

2.2.2 Mean change

Subtotal (95% CI) 0 0 Not estimable
Heterogeneity: Not applicable
Test for overall effect: Not applicable

Total (95% CI) 65 67 100.0% -0.63 [-1.46, 0.20]

Heterogeneity: Tau = 0.29; Chi = 5.48, df = 1 (P = 0.02); I = 82%
-4 -2 0 2 4
Test for overall effect: Z = 1.49 (P = 0.14) Favours experimental Favours control
Test for subgroup differences: Not applicable

Depression follow-up
Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
2.3.1 Mean
Calandre 2009 Ai Chi 17 9.4 32 17.6 9.2 34 50.5% -0.06 [-0.55, 0.42]
Subtotal (95% CI) 32 34 50.5% -0.06 [-0.55, 0.42]
Heterogeneity: Not applicable
Test for overall effect: Z = 0.26 (P = 0.80)

2.3.2 Mean change

Wang 2010 Tai Chi -6.5 8.5 33 -2.4 8.5 33 49.5% -0.48 [-0.97, 0.01]
Subtotal (95% CI) 33 33 49.5% -0.48 [-0.97, 0.01]
Heterogeneity: Not applicable
Test for overall effect: Z = 1.91 (P = 0.06)

Total (95% CI) 65 67 100.0% -0.27 [-0.67, 0.14]

Heterogeneity: Tau = 0.02; Chi = 1.38, df = 1 (P = 0.24); I = 28%
-4 -2 0 2 4
Test for overall effect: Z = 1.30 (P = 0.19) Favours experimental Favours control
Test for subgroup differences: Chi = 1.38, df = 1 (P = 0.24), I = 27.8%

Fig. 2 continued

depression and HRQOL was only detectable in Yoga Sensitivity analysis

trials and on sleep only in Tai Chi trials. A significant
effect on sleep and fatigue was only detectable if
compared with active controls, on depression only
if compared with delayed treatment control and on
HRQOL only if compared with treatment as usual (see
Table 4).
After removing the two studies in warm water, the signif-
icant effects of MMT remained on fatigue (-0.73 [-1.04,
-0.42]; \0.0001), sleep (-0.56 [-1.06, -0.07]; 0.03),
depression (-0.56 [-0.89, -0.24]; 0.0007) and HRQOL
(-0.51 [-0.95, -0.06]; 0.02).

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Quality of life follow-up

Meditative Movement Therapies Controls Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
2.4.1 Mean
Calandre 2009 Ai Chi 52.9 13.4 32 57.5 13.7 34 50.8% -0.34 [-0.82, 0.15]
Subtotal (95% CI) 32 34 50.8% -0.34 [-0.82, 0.15]
Heterogeneity: Not applicable
Test for overall effect: Z = 1.35 (P = 0.18)

2.4.2 Mean change

Wang 2010 Tai Chi -28.6 18.2 33 -10.2 18.2 33 49.2% -1.00 [-1.51, -0.49]
Subtotal (95% CI) 33 33 49.2% -1.00 [-1.51, -0.49]
Heterogeneity: Not applicable
Test for overall effect: Z = 3.81 (P = 0.0001)

Total (95% CI) 65 67 100.0% -0.66 [-1.31, -0.01]

Heterogeneity: Tau = 0.16; Chi = 3.38, df = 1 (P = 0.07); I = 70%
-4 -2 0 2 4
Test for overall effect: Z = 1.99 (P = 0.05)
Favours experimental Favours control
Test for subgroup differences: Chi = 3.38, df = 1 (P = 0.07), I = 70.4%

Fig. 2 continued

Table 2 Risk of
Author Adequate Adequate concealment Blinding of the Intention-to-
methodological bias score of the
reference randomisation of treatment allocation outcome assessor treat-analyse
studies
Calandre [34] Yes No Unclear Yes
Carson [35] Yes Yes Yes Yes
Haak [37] Unclear Unclear Unclear Yes
Ide [36] Yes Unclear Yes No
Mannerkorpi [38] Unclear Unclear Yes No
Stephens [39] Yes Yes Yes Yes
Wang [40] Yes Unclear Unclear Yes

Table 3 Effect sizes of

Outcome Number Number Effect size Test for overall Heterogeneity I2
meditative movement therapies
title of studies of patients (SMD [95% CI]) effect p value (%); Tau2
on selected outcome variables
Final treatment
01 Pain 7 327 -0.35 [-0.80, 0.11] 0.14 75; 0.28
02 Fatigue 6 271 -0.66 [-0.99, -0.34] \0.0001 39; 0.06
03 Sleep 5 276 -0.61 [-0.95, -0.27] 0.0004 47; 0.07
04 Depression 6 306 -0.49 [-0.76, -0.22] 0.0004 27; 0.003
05 HRQOL 7 328 -0.59 [-0.93, -0.24] 0.0009 56; 0.11

Follow up
01 Pain 2 132 -0.43 [-1.14, 0.28] 0.23 76; 0.20
02 Fatigue 2 132 -0.63 [-1.46, 0.20] 0.14 82; 0.29
HRQOL health-related quality 03 Sleep 2 132 -0.52 [-0.97, -0.07] 0.02 40; 0.04
of life, SMD standardised mean 04 Depression 2 132 -0.27 [-0.67, 0.14] 0.19 28;0.02
difference; CI confidence 05 HRQOL 2 132 -0.52 [-0.97, -0.07] 0.05 70; 0.16
interval

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Table 4 Subgroup analysis of the effect size on selected outcomes at final treatment

Outcome title Number of Number of Effect size SMD (95% Test for overall effect Heterogeneity I2 [%];
studies patients CI) p value Tau 2

Pain

Types of MMT
BAT 1 21 Not calculated
QiGong 2 94 0.05 [ 2.03, 1.93] 0.96 94; 1.92
Tai Chi 2 132 0.53 [ 1.22, 0.16] 0.13 74; 0.18
Yoga 2 88 0.54 [ 0.96, 0.11] 0.01 0; 0

Sl e e p

Types of MMT
BAT 0
QiGong 1 56 Not calculated
Tai Chi 2 132 0.71 [ 1.28, 0.13] 0.02 62; 0.12
Yoga 2 88 0.58 [ 1.51, 0.35] 0.22 75 0.35
Fatigue

BAT 1 21 Not calculated

QiGong 1 30 Not calculated
Tai Chi 2 133 0.52 [ 1.15, 0.11] 0.10 69; 0.14
Yoga 2 88 1.02 [ 1.47, 0.58] <0.0001 0; 0
Depression

BAT 0
QiGong 2 86 0.30 [ 0.85, 0.25] 0.29 37; 0.06
Tai Chi 2 133 0.41 [ 0.96, 0.15] 0.15 61; 0.10
Yoga 2 88 0.78 [ 1.22, 0.35] <0.0001 0; 0

Quality of life
BAT 2 41 0.78 [ 0.53, 2.09] 0.24 74; 0.67
QiGong 2 86 0.32 [ 1.19, 0.54] 0.46 73; 0.28
Tai Chi 2 133 0.72 [ 1.32, 0.12] 0.02 65; 0.12
Yoga 2 88 0.92 [ 1.42, 0.41] 0.0003 20; 0.03

Fatigue

Type of control
group
Delayed treatment 1 53 Not calculated
Treatment as usual 2 56 0.73 [ 1.75, 0.29] 0.16 70; 0.38
Active control 3 162 0.54 [ 0.95, 0.12] 0.01 39; 0.05
Depression
Type of control
group
Delayed treatment 2 109 0.68 [ 1.07, 0.29] 0.0004 0; 0
Treatment as usual 1 35 Not calculated
Active control 3 162 0.30 [ 0.74, 0.14] 0.19 47; 0.07
CI confidence interval, MMT meditative movement therapy, SMD standardized mean difference
CI confidence interval, MMT meditative movement therapy, SMD standardised mean difference

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Metaregression analyses
Simple linear regressions showed that no significant asso-
ciations between the effect size on HRQOL at final treat-
ment and risk of bias score ( = -0.27, p = 0.32), number
of treatment sessions ( = 0.29, p = 0.51) and duration of
therapy ( = -1.0, p = 0.07).
Publication bias
In the Eggers test, the intercept of the effect size on
HRQOL was 4.2 and t = 1.0 (two-tailed p = 0.28). In the
Beggs test, kendalls tau without continuity correction was
0.33 and Z = 1.0 (p = 0.29). Both tests were not indicative
for a publication bias.
Discussion
Summary of evidence
MMT reduced sleep disturbances, fatigue, depressed mood
and restrictions of HRQOL at final treatment and sleep
disturbances and restrictions of HRQOL at follow-up. In
subgroup analyses, only Yoga yielded significant effects on
pain, fatigue, depression and HRQOL. Tai Chi was only
effective on sleep at final treatment. The acceptance of
MMT was moderate. The safety of MMT was high.
Applicability of evidence
The study samples, with a preponderance of middle-aged
women, were representative for clinical populations with
FMS in the America and Europe. The study settings with a
majority of tertiary care centres were not representative for
the care of most FMS patients.
Limitations
The reliability of the overall results and of all sensitivity
and subgroup analyses is limited because the analyses were
underpowered due to the small number of included studies
and patients.
However, it is hardly possible to reach the recom-
mended 200 patients per treatment arm in non-pharmaco-
logical studies to drop the risk of bias [14].
Although every effort was made to obtain missing data
from authors, it was not possible in every case to do so.
Therefore, some studies are not represented fully in our
meta-analysis.
The methodological quality of the studies varied.
However, the effect sizes were not afflicted by method-
ological quality. Considerable heterogeneity existed for
the outcomes of pain and HRQOL at final treatment and
at follow-up which could not be explained by clinical and
methodological differences between the studies. Respon-
ses in studies in patients with chronic pain are frequently
not Gaussian, but with a split between responders and
non-responders. No study assessed predefined response
rates (e.g. 30% pain reduction). Therefore, the core out-
comes of a 30 and 50% pain reduction [14] could not be
analysed.
Agreements with other systematic reviews on MMT
in chronic pain
Our results confirm the conclusions of a systematic review
that evidence as not convincing enough to suggest that Qi
Gong is an effective modality for pain management [12]. A
systematic review on Tai Chi in chronic musculoskeletal
pain (arthritis) found a pain reduction, butin line with
our resultsno improvement of HRQOL [43].
Conclusions
Implications for clinical practice
We cannot recommend all types of MMT for the man-
agement of FMS. We found evidence of a short-term relief
of four key domains of FMS by Yoga and of one key
domain by Tai Chi. We found no evidence of the efficacy
of Qi Gong. However, the acceptance and safety of all
types of MMT were highcompared to pharmacological
therapies [44]. Therefore, the use of MMT within a multi-
component approach including aerobic exercise and psy-
chological therapy can be considered. Furthermore, special
context factors like expertise, qualification and charisma of
the performing instructor may be of special importance for
the success of a treatment modality.
Implications for research
Further studies with multi-site recruitment producing ade-
quate sample sizes are necessary to allow for stronger tests
of treatment efficacy and for examination of individual
(e.g. gender, age and treatment expectation) differences in
treatment response. The decreased effects of the interven-
tions with follow-up, which might be due to a wearing off
or a lack of continued practice should be addressed. Most
importantly, MMT should be compared with established
therapies such as aerobic exercise or antidepressants if it
provides any advantages regarding efficacy, acceptability
and safety. The use of a core set of outcome measures
including response rates would improve the internal
validity of MMT studies. Adverse events such as
123

worsening of physical or psychological symptoms should
be documented.
Acknowledgments J.L. has received congress travel grant by Eli
Lilly. K.B. has received congress travel grant by Pfizer. W.H. has
received honoraria for educational lectures from Eli Lilly, Janssen-
Cilag and Mundipharma, consulting fees from Eli Lilly and Pfizer,
and a congress travel grant by Eli Lilly.
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