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Critical review

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For citation purposes: Chapple W. Examining the evidence for medical Qigong exercise in the context of clinician recommendations and health system implementation: a critical review. OA Alternative Medicine 2013 Nov 20;1(3):23. Co

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Examining the evidence for medical Qigong exercise in the context of clinician recommendations and health

system implementation: a critical reviewW Chapple*

AbstractIntroductionThe purpose of this critical review is to summarise the current evidence for clinicians of both traditional Chi-nese and Western medicines in order to facilitate informed recommenda-tions and decision-making about qigong.Materials and Methods‘Qigong’ was queried on PubMed with appropriate filters. Eleven sys-tematic reviews were chosen to dem-onstrate the best evidence for qigong.ResultsFive clinically relevant conclusions were made based on current evi-dence for qigong. (1) Qigong seems to be at least equivalent to exercise in multiple randomised controlled trials for diabetes, hypertension, de-pression and pulmonary function. (2) Qigong is a good joint-healthy option for patients who have diffi-culty exercising or who are at risk for exercise-related injury; it should es-pecially be considered in the elderly population. (3) Since qigong appears to be more effective than walking or conventional exercise for depression and is additive to usual treatment, it is a good choice of exercise modal-ity for patients with a comorbidity of depression. (4) Qigong appears to be a good option for patients not wishing to add a second antihyper-tensive medication or who want to obtain tighter control of their blood

pressure. (5) The evidence for qi-gong is good but not firm. Given that the adverse events from qigong is exceedingly minimal, and given the relatively low cost, the threshold for clinical recommendations should be lower than the threshold for more risky therapies.ConclusionThere is good evidence support-ing the health benefits of qigong for many conditions, but it may never be firm evidence. Qigong also has ben-efits beyond regular exercise and can be a valuable tool when formulating treatment plans for patients with multiple comorbidities. Clinicians need to make the decision about qi-gong recommendations based on the available data and weigh that with risks and costs.

IntroductionUnifying principles of qigongEntire books have been devoted to de-scribing the depth and breadth of qi-gong, but only a brief overview will be discussed here. There are a variety of qigong techniques, forms and styles, which fall under the general heading of ‘qigong’. This is important because a patient may need a different tech-nique (sitting or standing forms for example) from day to day1. However, in general there are basic principles that all qigong follows. Each person practicing qigong tries to harmonise the mind, breath and body. Qigong is often called a walking meditation, which embodies the natural ele-ments of form, force and substance with gentle, slow and sometimes repetitive movements. With prac-tice, the qigong practitioner seeks

to balance the Yin and Yang aspects of the four principles of qigong. The Yin aspect of the mind is tranquility; it is balanced with the Yang aspect of the mind, which is concentration. The Yin aspect of the body is relaxa-tion; it is balanced with the Yang as-pect of the body, which is motion2. Qigong can be practiced alone or in groups, indoors or outside. Qigong is always done to better one’s health, and thus the practice should never push beyond one’s comfort level or physical endurance. For this reason, the author is unable to find any ad-verse events from qigong reported in the literature beyond initial mus-cle stiffness similar to starting other new exercises3,4. The cost of learn-ing qigong in a class or from a video is relatively low, and once learned it can be practiced for free at home for a lifetime. Figure 1 briefly demon-strates the variety of movements in qigong.

Qigong in researchPrevious systematic reviews were marred by the low number of study participants, a small amount of tri-als and the poor study designs5. The quality and quantity of research on qigong has markedly improved in the last few years and will contin-ue to improve each year. Over half the systematic reviews and meta-analyses used in this critical review were published in the last 3 years and were good-quality reviews with strict inclusion and exclusion cri-teria. A meta-analysis for qigong’s effect on essential hypertension is based on 903 cases from nine ran-domised controlled trials (RCTs)3.

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* Corresponding author Email: [email protected]

University of Wisconsin School of Medicine and Public Health MD Program. Madison, WI, USA 53703

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included three RCTs and 230 patients in total. There was a statistically sig-nificant improvement in depression in the qigong group compared to ex-ercise or walking. There appears to be an extra benefit to qigong beyond its physical exercise component, which is likely its focus on a meditative state of mind and synchronous breathing. To answer the second question, two RCTs comprising 120 patients com-pared qigong to newspaper reading followed by discussion. The results showed that the benefits of qigong were due to more than being in a group setting alone.

Another concern is that research on qigong for depression must spec-ify the severity of depression. The authors of the systematic review state that the studies included clini-cal depression (presumably major depressive disorder), depressed el-ders with chronic illnesses, patients with burnout syndrome (which did not show benefit from qigong), adults with depressive mood, women with perimenopausal syndrome and de-pression and patients with depressive symptoms secondary to chronic con-ditions including hypertension, dia-betes mellitus and subhealth status. Only two of the RCTs examined clini-cal depression and did show benefit over usual care alone. The rest of the studies examined patients with de-pression secondary to chronic disease as stated above7. For this reason, the clinical recommendations set forth in Table 2 state that qigong could be rec-ommended at this time for patients with comorbidities of depression.

The systematic reviews for qigong’s effect on hypertension are similar to that of depression. There were two systematic reviews on the subject published. The article in 20076 was only able to state that evidence was encouraging but not conclusive. The meta-analyses in this study strug-gled with different control groups that limited the confidence in the results. Its meta-analysis for qigong plus antihypertensive medication vs.

to closely approximate a patient’s actual experience.

Materials and Methods‘Qigong’ was queried on PubMed with a filter for systematic reviews, guidelines and meta-analyses. Twen-ty publications were considered, and nine were excluded for poor qual-ity. Eleven systematic reviews and meta-analyses were chosen to dem-onstrate the best evidence available for qigong.

ResultsA summary of the results from the 11 systematic reviews and meta-analyses are presented in Table 110–17. Table 2 summarises five clinically relevant recommendations based on the available evidence.

DiscussionAnalysing qigong for depression and hypertensionQigong’s benefit for depression must answer two questions: Are its effects due to exercise alone or is there an ex-tra benefit? Also, does a group setting alone help the depression whether qigong is involved or not? To answer the first question, the meta-analysis

Another literature review for qi-gong’s effect on hypertension in-cluded 12 RCTs and 1218 subjects6. The systematic review and meta-analysis for depression and anxiety is based on 12 RCT’s including 936 participants7. The majority of the re-cent RCTs have resolved the earlier problems8,9 with proper randomisa-tion, proper controls, complete data reporting, power calculation and high-quality study design.

PurposeThe purpose of this critical review is to summarise the current evidence for clinicians of both traditional Chi-nese and Western medicines in order to facilitate informed recommenda-tions and decision making about qigong. This article does not intend to address the large subject of T’ai Chi, external qigong or the physi-ological and cellular changes that occur during qigong training. It also does not intend to cover aspects of medical care where there is a paucity of evidence for qigong. Rather, the focus is on examining systematic re-views and meta-analyses from stud-ies on relevant conditions that are carried out in the general population

Figure 1: Two photos demonstrating the variety of movements in qigong. The physically gentle followed by the physically demanding2. Photos courtesy of Lily Siou of the Tai Hsuan Institute in Honolulu, HI, USA.

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outcome measurements or types of control groups. This heterogene-ity is a classic problem with most meta-analyses and systematic re-views. The second problem is that while there is randomisation, there is no placebo or double-blind con-trolled trials. Most trials involving qigong and even exercise for health benefits have this problem. There is good evidence supporting the health benefits of qigong for many condi-tions, situations and patients that are discussed in this article, but it may never be firm evidence. At some point, clinicians need to make a deci-sion based on the available data and weigh that with the risks and costs.

is supported by these meta-analyses and can be a point of discussion be-tween the patient and physician.

Translating research into clinical decision-makingThe final product of research is to draw a conclusion based on the data collected in the study. The research discussed here has meta-analyses with sample sizes that are sufficient for statistical significance with rea-sonable confidence intervals. Yet the authors of all 11 systematic reviews either cannot draw firm conclu-sions or they do so with caution for two reasons. The first reason is that the studies do not all use the same

antihypertensive medication alone included only 92 subjects total. The second systematic review published in 20083 included 243 subjects in its meta-analysis for qigong plus anti-hypertensive medication vs. antihy-pertensive medication. This article was more confident in its conclusions about qigong’s effect on hypertension. Both systematic reviews concluded that qigong alone was not more effec-tive than exercise or medication but was more effective when compared to no treatment. For this reason, the recommendations in Table 2 specifi-cally recommend its use in combina-tion with medication. Its use as the sole treatment for mild hypertension

Table 1 Results from 11 systematic reviews and meta-analyses showing the effectiveness of qigong

Subject of the systematic reviews

Summary of results from systematic reviews showing statistical significance but which are often in need of more homogenous

outcome measurementsReferences OQAQ* score5

Pain • �External� qigong� is� effective� at� relieving� pain� but� not� internal� qi-gong**

10,11 7,5

Diabetes • �Qigong�exercise�is�effective�at�improving�multiple�measures�of��diabetic�control�alone�or�in�conjunction�with�medication.�It�is�not�more�effective�than�regular�exercise�for�diabetic�patients

12 N/A

Cancer�Care • �Qigong�in�cancer�care�shows�a�consistent�trend�towards�improved�immune�function�and�inconsistent�improvement�in�psychosocial�benefits

13,14 N/A,5

High�blood�pressure • �Qigong�combined�with�medication�is�effective�at�reducing�mortal-ity,�stroke�and�systolic�blood�pressure�by�12–18�mmHg�in�hyperten-sive�patients�compared�to�medication�alone.�Qigong�alone�is�not�statistically�different�than�exercise�or�medication

3,6 7,6

Depression • �Qigong�is�as�effective�as�cognitive�behavioural�therapy�for�depres-sion,�is�additive�to�usual�care�and�appears�more�effective�than�ex-ercise�for�depression.�Qigong�does�not�improve�anxiety�symptoms

7 N/A

Fall�risk • �Qigong�and�Tai�Chi�both�show�a�decrease�in�fear�of�falling�in�the�elderly�population.�Only�Tia�Chi�directly�assessed�number�of�falls�with�beneficial�findings�in�the�elderly�population

15 N/A

Lung�function • �Qigong�and�Tai�Chi�improve�pulmonary�function�tests,�6-min��walking�test,�lung�function�and�quality�of�life�in�COPD�patients.�It�is�not��superior�to�other�forms�of�exercise��

16 N/A

Cardiac�Rehab • �Qigong�is�effective�at�improving�multiple�parameters�of�cardiac�rehabilitation�after�a�variety�of�cardiac�disease.��It�is�well�tolerated�in�patients�with�chronic�heart�disease�

17 N/A

*The�Overview�Quality�Assessment�Questionnaire�(OQAQ)�gives�a�score�from�1�to�7;�<3�=�extensive�or�major�flaws;�>5�=�minor�or�minimal�flaws5.�N/A=�Not�available.**External�qigong�involves�a�practitioner�directing�qi�over�an�area�of�concern�with�their�hands,�while�internal�qigong�is�equivalent�to�qigong�exercise�with�movement.

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also suggests that qigong has ben-efits beyond regular exercise and can be a valuable tool when formulating treatment plans for complicated pa-tients with multiple comorbidities. Clinicians are encouraged to examine the evidence and recommendations set forth here and throughout the literature.

Abbreviation listRCT, randomised controlled trial.

References1. Shinnick P. Qigong: where did it come from? Where does it fit in science? What are the advances? J Altern Complement Med. 2006 May;12(4):351–3.2. Siou L. Ch’I Kung: the art of mastering the unseen life force. Hong Kong: Tuttle. 1988;pp.47–9.3. Guo X, Zhou B, Nishimura T, Teramukai S, Fukushima M. Clinical effect of qigong practice on essential hypertension: a meta-analysis of randomized controlled trials. J Altern Complement Med. 2008 Jan–Feb;14(1):27–37.4. Ritter C, Aldridge D. Qigong Yangsheng as a therapeutic approach for the treat-ment of essential hypertension in com-parison with a western muscle relaxation therapy: a randomized, controlled pilot. Chinesische Medizin. 2001;16:48–63. In German.5. Lee MS, Oh B, Ernst E. Qigong for healthcare: an overview of systematic re-views. JRSM Short Rep. 2011 Feb;2(2):7.6. Lee MS, Pittler MH, Guo R, Ernst E. Qigong for hypertension: a systematic review of randomized clinical trials. J Hy-pertens. 2007 Aug;25(8):1525–32.7. Wang CW, Chan CL, Ho RT, Tsang HW, Chan CH, Ng SM. The effect of qigong on depressive and anxiety symptoms: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2013.8. Xin L, Miller YD, Brown WJ. A quali-tative review of the role of qigong in the management of diabetes. J Altern Complement Med. 2007 May;13(4): 427–33.9. Lee MS, Ernst E. Qigong for move-ment disorders: a systematic review. Mov Disord. 2009 Jan;24(2):301–3.10. Lee MS, Pittler MH, Ernst E. External qigong for pain conditions: a systematic

often heavily persuaded by a doctor’s recommendations.

Health system implementationThere is a role for qigong, and indeed any form of exercise, in a system of care and prevention of illness. The upfront cost of implementation and side-effect profile of qigong are low, making it an ideal option for third-party payers who are increasingly becoming more invested in cost containment. It is likely that a com-bined popularity among patients and increasing recommendation from clinicians will one day influence widespread health system imple-mentation of qigong classes.

ConclusionQigong research continues to im-prove in quality and quantity every year. There are a multitude of RCTs, meta-analyses and systematic re-views that examine qigong’s effect on specific diseases. The major limi-tation to most of the research is the lack of a possible placebo and the het-erogeneity of controls used. However, despite these shortcomings, there is still good evidence that qigong is ef-fective at improving patient health in certain conditions. The evidence

Customising treatment plans for patientsIt is also important to integrate the complexity of an individual patient into the treatment modality deci-sion. For example, qigong may be the most appropriate exercise modality for a type II diabetic with hyperten-sion, arthritis and depression. Any exercise will be beneficial and will be included as an important part of the treatment plan for all the above issues. Qigong should be recom-mended as a joint healthy exercise with likely benefits for depression beyond other exercise modalities, such as walking, swimming or sta-tionary bikes. Patient acceptance is also an important issue when dis-cussing treatment modalities dur-ing a clinic visit. A recent study from Utah showed improvement in fatigue and stress in older men with prostate cancer with attendance of a qigong class compared to a stretching class. The study also showed a statistically significant higher rate of class at-tendance for qigong as opposed to stretching18. These results suggest that patient acceptance of qigong among older men is not unreason-able to expect. It is also important to remember that patient acceptance is

Table 2 Five clinically relevant conclusions based on the current body of evidence for qigong1.��Qigong�seems�to�be�at�least�equivalent�to�exercise�in�multiple�RCTs�for�diabe-

tes,�hypertension,�depression�and�pulmonary�function2.��Qigong�is�a�good�joint-healthy�option�for�patients�who�have�difficulty�exercis-

ing�or�who�are�at�risk�for�exercise-related�injury;�it�should�especially�be�consid-ered�in�the�elderly�population

3.��Since�qigong�appears�to�be�more�effective�than�walking�or�conventional�ex-ercise�for�depression�and�is�additive�to�usual�treatment,�it�is�a�good�choice�of�exercise�modality�for�patients�with�a�comorbidity�of�depression�

4.��Qigong�appears�to�be�a�good�option�for�patients�not�wishing�to�add�a�second�antihypertensive�medication�or�who�want�to�obtain�tighter�control�of�their�blood�pressure

5.��The�evidence�for�qigong�is�good�but�not�firm.�Given�that�the�adverse�events�from�qigong�is�exceedingly�minimal,�and�given�the�relatively�low�cost,�the�threshold�for�clinical�recommendations�should�be�lower�than�the�threshold�for�more�risky�therapies�

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review of randomized clinical trials. J Pain. 2007 Nov;8(11):827–31.11. Lee MS, Pittler MH, Ernst E. Internal qigong for pain conditions: a systematic review. J Pain. 2009 Nov;10(11):1121–7.12. Freire MD, Alves C. Therapeutic Chi-nese exercises (Qigong) in the treatment of type 2 diabetes mellitus: a systematic review. Diabetes Metab Syndr. 2013 Jan–Mar;7(1):56–9.13. Chan CL, Wang CW, Ho RT, Ng SM, Chan JS, Ziea ET, et al. A systematic review of the effectiveness of qigong exercise in

supportive cancer care. Support Care Cancer. 2012 Jun;20(6):1121–33.14. Lee MS, Chen KW, Sancier KM, Ernst E. Qigong for cancer treatment: a systemat-ic review of controlled clinical trials. Acta Oncol. 2007;46(6):717–22.15. Rogers CE, Larkey LK, Keller C. A re-view of clinical trials of tai chi and qigong in older adults. West J Nurs Res. 2009 Mar;31(2):245–79. 16. Ding M, Zhang W, Li K, Chen X. Effective-ness of T’ai Chi and qigong on chronic ob-structive pulmonary disease: a systematic

review and meta-analysis. J Altern Com-plement Med. 2014 Feb;20(2):79–86. 17. Chan CL, Wang CW, Ho RT, Ho AH, Ziea ET, Taam Wong VC, et al. A systematic re-view of the effectiveness of qigong exer-cise in cardiac rehabilitation. Am J Chin Med. 2012;40(2):255–67.18. Campo RA, Agarwal N, Lastayo PC, O’Connor K, Pappas L, Boucher KM, et al. Levels of fatigue and distress in senior prostate cancer survivors enrolled in a 12-week randomized controlled trial of Qi-gong. J Cancer Surviv. 2014 Mar;8(1):60–9.

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