Tai chi, a traditional Chinese mind-body exercise, is as effective for chronic insomnia as cognitive behavioral therapy (CBT), results of a randomized noninferiority trial showed.

Among middle-aged and older adults with chronic insomnia, tai chi and CBT were equally effective over the long term in reducing insomnia severity. In addition, both treatments showed similar benefits on participants’ quality of life, mental health, and physical activity.

“Our study supports tai chi as an alternative treatment approach for the long-term management of chronic insomnia in middle-aged and older adults,” the investigators with first author Parco M. Siu, Division of Kinesiology, School of Public Health, Li Ka Shing Faculty of Medicine, University in Hong Kong, Hong Kong, China, wrote.

The study was published online on November 26 in the BMJ.

A Mindfulness Practice

Chronic insomnia affects roughly 1 in 10 adults and is linked to an increased risk for cardiovascular and neurologic diseases. CBT for insomnia (CBT-I) is considered the first-line therapy, but high costs can often be prohibitive for patients.

Tai chi is a slow movement and meditative exercise that stems from ancient Chinese martial art techniques. The practice is becoming increasingly popular in the US. Previous research has demonstrated tai chi as an effective alternative for older adults with insomnia, though direct comparisons with CBT-I are lacking, the investigators noted.

Given tai chi’s low cost and tolerability among older adults, the researchers set out to investigate how the exercise measures up to CBT-I for chronic insomnia.

The trial included 200 participants aged 50 years or older with a diagnosis of chronic insomnia. Individuals who couldn’t walk without assistance, had a condition that could restrict tai chi participation, had already participated in aerobic/mind-body exercise or talk therapy, or had a chronic disease that could affect sleep were excluded.

Participants were randomized in a 1:1 ratio, with 100 receiving tai chi and 100 receiving CBT-I. Over 3 months, the tai chi group attended 24 instructor-led training sessions in the Yang 24 tai chi style. The CBT-I group attended 24 sessions led by therapists over the same period. Outcome assessors were blinded to the treatment groups.

Insomnia severity was assessed after the 3-month intervention and at month 15 using the Insomnia Severity Index (ISI), which measures interference with daily life and sleep pattern satisfaction, among other symptoms.

The researchers used an ISI threshold of four points as the margin to evaluate noninferiority. Insomnia remission rate and treatment response rates were analyzed using logistic regression.

An Accessible Alternative

At the end of treatment, the tai chi group showed a reduction of 6.67 (95% CI, 5.61-7.73) in ISI scores. The CBT-I group had a reduction of 11.19 (10.06-12.32), equaling a between-group difference of 4.52 (-∞ to 5.81).

Since the upper confidence limit was above the noninferiority margin, tai chi was inferior to CBT-I at 3 months.

However, at month 15, the reductions for the tai chi and CBT-I groups were 9.51 (8.47-10.54) and 10.18 (8.97-11.40), respectively, with a between-group difference of 0.68 (−∞ to 2.00). Tai chi was therefore considered noninferior, or comparable, to CBT-I at this point.

Both the tai chi and CBT-I groups showed significant improvements over time for secondary outcomes of anxiety and depression (P < .001), quality of life mentally ( P < .001), physical activity level (P < .001), and subjective sleep quality and quantity (P < .001). 

There were no between group differences in the changes in these outcomes during the study period, indicating that both tai chi and CBT-I groups had similar improvements. 

At month 3, the CBT-I group had a higher insomnia remission rate than tai chi, but rates were similar at month 15 (63.4% for CBT; 76.5% for tai chi; P = .067). The treatment response rates showed a similar pattern at both time points.

No adverse effects were observed among participants. Around a third of the tai chi group continued the exercises on their own after the classes ended, which may be why tai chi showed improvement in reducing insomnia symptoms at follow-up, the investigators noted.

Limitations of the study were that most participants were older adults, and the study was conducted at one research center which could affect the generalizability of results.

This study was supported by General Research Fund of Research Grants Council, Hong Kong University Grants Committee, and Seed Fund for Basic Research of the University of Hong Kong. See article for information on author disclosures.