literature review: fitness a comprehensive review of ... · heavenly elixir within.’’ this...

Literature Review: Fitness

A Comprehensive Review of Health Benefits ofQigong and Tai ChiRoger Jahnke, OMD; Linda Larkey, PhD; Carol Rogers, APRN-BC, CNOR, PhD; Jennifer Etnier, PhD;Fang Lin, MS

AbstractObjective. Research examining psychological and physiological benefits of Qigong and Tai

Chi is growing rapidly. The many practices described as Qigong or Tai Chi have similartheoretical roots, proposed mechanisms of action, and expected benefits. Research trials andreviews, however, treat them as separate targets of examination. This review examines theevidence for achieving outcomes from randomized controlled trials (RCTs) of both.

Data Sources. The key words Tai Chi, Taiji, Tai Chi Chuan, and Qigong were entered intoelectronic search engines for the Cumulative Index for Allied Health and Nursing (CINAHL),psychological literature (PsycINFO), PubMed, Cochrane database, and Google Scholar.

Study Inclusion Criteria. RCTs reporting on the results of Qigong or Tai Chi interventionsand published in peer-reviewed journals from 1993 to 2007.

Data Extraction. Country, type and duration of activity, number/type of subjects, controlconditions, and reported outcomes were recorded for each study.

Synthesis. Outcomes related to Qigong and Tai Chi practice were identified and evaluated.Results. Seventy-seven articles met the inclusion criteria. The nine outcome category

groupings that emerged were bone density (n 5 4), cardiopulmonary effects (n 5 19), physicalfunction (n 5 16), falls and related risk factors (n 5 23), quality of life (n 5 17), self-efficacy(n 5 8), patient-reported outcomes (n 5 13), psychological symptoms (n 5 27), and immunefunction (n 5 6).

Conclusions. Research has demonstrated consistent, significant results for a number ofhealth benefits in RCTs, evidencing progress toward recognizing the similarity and equivalenceof Qigong and Tai Chi. (Am J Health Promot 2010;24[6]:e1–e25.)

Key Words: Tai Chi, Taiji, Meditation, Qigong, Mind-Body Practice, Mindfulness,Meditative Movement, Moderate Exercise, Breathing, Prevention Research.Manuscript format: literature review; Research purpose: Setting: health care,community; Health Focus: fitness/physical activity, psychosocial/spiritual health,stress management; Strategy: education, skill building; Target population: all adults,seniors; Target population circumstances: all SES, international, race/ethnicity

INTRODUCTION

A substantial body of publishedresearch has examined the healthbenefits of Tai Chi (also called Taiji), atraditional Chinese wellness practice.In addition, a strong body of researchis also emerging for Qigong, an evenmore ancient traditional Chinese well-ness practice that has similar charac-teristics to Tai Chi. Qigong and Tai Chihave been proposed, along with yogaand pranayama from India, to consti-tute a unique category or type ofexercise referred to currently as med-itative movement.1 These two forms ofmeditative movement, Qigong and TaiChi, are close relatives, having sharedtheoretical roots, common operationalcomponents, and similar links to thewellness and health-promoting aspectsof Traditional Chinese Medicine(TCM). They are nearly identical inpractical application in the health-enhancement context and share muchoverlap in what TCM describes as the‘‘three regulations’’: body focus (pos-ture and movement), breath focus, andmind focus (meditative, mindful com-ponents).1,2

Because of the similarity of Qigongand Tai Chi, this review of the state ofthe science for these forms of medita-tive movement will investigate thebenefits of both forms together. Inpresenting evidence for a variety ofhealth benefits, many of which areattributable to both practices, we willpoint to the magnitude of the com-bined literature and suggest underwhat circumstances Qigong and TaiChi may be considered as potentiallyequivalent interventions, with recom-mendations for standards and furtherresearch to clarify this potential.

Roger Jahnke, OMD, is with the Institute of Integral Qigong and Tai Chi, Santa Barbara,California. Linda Larkey, PhD, Carol Rogers, APRN-BC, CNOR, PhD, and Fang Lin, MS, arewith the Arizona State University College of Nursing andHealthcare Innovation, Phoenix, Arizona.Jennifer Etiner, PhD, is with the University of North Carolina, Greensboro, North Carolina.

Send reprint requests to Linda Larkey, PhD, Arizona State University College of Nursing andHealthcareInnovation, 500 N 3rd Street, Phoenix, AZ 85004; [email protected].

This manuscript was submitted October 13, 2008; revisions were requested June 2, 2009; the manuscript was accepted forpublication July 21, 2009.

Copyright E 2010 by American Journal of Health Promotion, Inc.0890-1171/10/$5.00 + 0DOI: 10.4278/ajhp.081013-LIT-248

July/August 2010, Vol. 24, No. 6 e1

Author PDF.May be distributed widely by e-mail.Posting on Web sites prohibited.

OBJECTIVES

Previously published reviews havereported on specific outcomes of eitherTai Chi or Qigong, mostly addressingonly one of these practices, and rarelytaking into account the similarity of thetwo forms and their similar outcomes.These reviews have covered a widevariety of outcomes, with many focusedon specific diseases or symptoms, in-cluding hypertension,3 cardiovasculardisease,4,5 cancer,6–8 arthritic disease,9

stroke rehabilitation,10 aerobic capaci-ty,11 falls and balance,12,13 bone mineraldensity,14 and shingles-related immuni-ty,15 with varying degrees of supportnoted for outcomes in response toQigong or Tai Chi.

Other reviews have addressed a broadspectrum of outcomes to demonstratehow Qigong16–19 or Tai Chi20–26 hasdemonstrated improvements for par-ticipants with a variety of chronic healthproblems or with vulnerable olderadults. Although many of these reviewshave utilized selection criteria thatrestrict their focus to rigorous empiricalstudies, others have used less stringentcriteria. The purpose of this review is toevaluate the current evidence for abroad range of health benefits for bothQigong and Tai Chi using only ran-domized controlled trials (RCTs), andto evaluate the potential of treatingthese two forms of meditative move-ment as equivalent forms. A completedescription of Qigong and Tai Chi ispresented and the equivalence of theirtheoretical roots and their commonelements of practice are established.Then, the body of evidence for out-comes in response to Qigong and TaiChi is reviewed to examine the range ofhealth benefits. Finally, to more criti-cally evaluate similarities across studiesof the two practices, we discuss thepotential of treating them as equivalentinterventions in research and the in-terpretation of results across studies.

Research question 1: What healthbenefits are evidenced from RCTs ofQigong and Tai Chi?

Research question 2: In examiningthe Qigong and Tai Chi practicesincorporated in research, and theevidence for health benefits commen-surate with each, what claims can bemade for equivalence of these twoforms of practice/exercise that have

typically been considered to be sepa-rate and different?

Overview of Qigong and Tai ChiQigong is, definitively, more ancient

in origin than Tai Chi, and it is theoverarching, more original disciplineincorporating widely diverse practicesdesigned to cultivate functional integ-rity and the enhancement of the lifeessence that the Chinese call Qi. BothQigong and Tai Chi sessions incorpo-rate a wide range of physical move-ments, including slow, meditative, flow-ing, dance-like motions. In addition,they both can include sitting or stand-ing meditation postures as well as eithergentle or vigorous body shaking. Mostimportantly, both incorporate the pur-poseful regulation of both breath andmind coordinated with the regulationof the body. Qigong and Tai Chi areboth based on theoretical principlesthat are inherent to TCM.1 In theancient teachings of health-orientedQigong and Tai Chi, the instructionsfor attaining the state of enhanced Qicapacity and function point to thepurposeful coordination of body,breath, and mind (paraphrased here):‘‘Mind the body and the breath, andthen clear the mind to distill theHeavenly elixir within.’’ This combina-tion of self-awareness with self-correc-tion of the posture and movement ofthe body, the flow of breath, andmindfulness, are thought to comprise astate that activates the natural self-regulatory (self-healing) capacity, stim-ulating the balanced release of endog-enous neurohormones and a wide arrayof natural health recovery mechanismsthat are evoked by the intentful inte-gration of body and mind.

Despite variations among the myriadforms, we assert that health-orientedTai Chi and Qigong emphasize thesame principles and practice elements.Given these similar foundations and thefashion in which Tai Chi has typicallybeen modified for implementation inclinical research, we suggest that theresearch literature for these two formsof meditative movement should beconsidered as one body of evidence.

QigongQigong translates from Chinese to

mean, roughly, to cultivate or enhancethe inherent functional (energetic)essence of the human being. It is

considered to be the contemporaryoffspring of some of the most ancient(before recorded history) healing andmedical practices of Asia. The earliestforms of Qigong make up one of thehistoric roots of contemporary TCMtheory and practice.2 Many branches ofQigong have a health and medicalfocus and have been refined for wellover 5000 years. Qigong purportedlyallows individuals to cultivate the nat-ural force or energy (Qi) in TCM thatis associated with physiological andpsychological functionality. Qi is theconceptual foundation of TCM inacupuncture, herbal medicine, andChinese physical therapy. It is consid-ered to be a ubiquitous resource ofnature that sustains human well-beingand assists in healing disease as well as(according to TCM theory) havingfundamental influence on all life andeven on the orderly function of celes-tial mechanics and the laws of physics.Qigong exercises consist of a series oforchestrated practices including bodyposture/movement, breath practice,and meditation, all designed to en-hance Qi function (that is, drawingupon natural forces to optimize andbalance energy within) through theattainment of deeply focused and re-laxed states. From the perspective ofWestern thought and science, Qigongpractices activate naturally occurringphysiological and psychological mecha-nisms of self-repair and health recovery.

Also considered part of the overalldomain ofQigong is ‘‘externalQigong,’’wherein a trained medical Qigong ther-apist diagnoses patients according to theprinciples of TCM and uses ‘‘emittedQi’’ to foster healing. Both internalQigong (personal practice) and externalQigong (clinician-emitted Qi) are seenas affecting the balance and flow ofenergy and enhancing functionality inthe body and themind. For the purposesof our review, we are focused only on theindividual, internal Qigong practice ofexercises performed with the intent ofcultivating enhanced function, inner Qithat is ample and unrestrained. This isthe aspect of Qigong that parallelswhat is typically investigated in Tai Chiresearch.

There are thousands of forms ofQigong practice that have developedin different regions of China duringvarious historic periods and that have

e2 American Journal of Health Promotion


been created by many specific teachersand schools. Some of these forms weredesigned for general health-enhance-ment purposes and some for specificTCM diagnostic categories. Some wereoriginally developed as rituals forspiritual practice, and others to em-power greater skill in the martial arts.An overview of the research literaturepertaining to internal Qigong yieldsmore than a dozen forms that havebeen studied as they relate to healthoutcomes (e.g., Guo-lin, ChunDo-SunBup, Vitality or Bu Zheng Qigong,Eight Brocade, Medical Qigong).2,27–29

The internal Qigong practices gen-erally tested in health research (andthat are addressed in this review)incorporate a range of simple move-ments (repeated and often flowing innature) or postures (standing or sit-ting) and include a focused state ofrelaxed awareness and a variety ofbreathing techniques that accompanythe movements or postures. A keyunderlying philosophy of the practiceis that any form of Qigong has an effecton the cultivation of balance andharmony of Qi, positively influencingthe human energy complex (Qi chan-nels/pathways) that functions as aholistic, coherent, and mutually inter-active system.

Tai ChiTai Chi translates to mean ‘‘Grand

Ultimate,’’ and in the Chinese culture,it represents an expansive philosoph-ical and theoretical notion thatdescribes the natural world (i.e., theuniverse) in the spontaneous state ofdynamic balance between mutuallyinteractive phenomena including thebalance of light and dark, movementand stillness, waves and particles. TaiChi, the exercise, is named after thisconcept and was originally developedboth as a martial art (Tai Chi Chuan ortaijiquan) and as a form of meditativemovement. The practice of Tai Chi asmeditative movement is expected toelicit functional balance internally forhealing, stress neutralization, longevi-ty, and personal tranquility. This formof Tai Chi is the focus of this review.For numerous complex sociological

and political reasons,2 Tai Chi hasbecome one of the best-known formsof exercise or practice for refining Qiand is purported to enhance physio-

logical and psychological function.The one factor that appears to differ-entiate Tai Chi from Qigong is thattraditional Tai Chi is typically per-formed as a highly choreographed,lengthy, and complex series of move-ments, whereas health-enhancementQigong is typically a simpler, easy-to-learn, more repetitive practice. How-ever, even the longer forms of Tai Chiincorporate many movements that aresimilar to Qigong exercises. Usually,the more complex Tai Chi routinesinclude Qigong exercises as a warm-up,and emphasize the same basic princi-ples for practice, that is, the threeregulations of body focus, breath focus,and mind focus. Therefore Qigongand Tai Chi, in the health promotionand wellness context, are operationallyequivalent.

Tai Chi as Defined in theResearch Literature

It is especially important to note thatmany of the RCTs investigating what isdescribed as Tai Chi (for healthenhancement) are actually not investi-gating the traditional, lengthy, com-plex practices that match the formaldefinition of traditional Tai Chi. TheTai Chi used in research on bothdisease prevention and used as acomplement to medical intervention isoften a ‘‘modified’’ Tai Chi (e.g., TaiChi Easy, Tai Chi Chih, or ‘‘shortforms’’ that greatly reduce the numberof movements to be learned). Themodifications generally simplify thepractice, making the movements morelike most health-oriented Qigong ex-ercises that are simple and repetitive,rather than a lengthy choreographedseries of Tai Chi movements that takemuch longer to learn (and, for manyparticipants, reportedly delay the ex-perience of ‘‘settling’’ into the relaxa-tion response). A partial list of exam-ples of modified Tai Chi forms fromthe RCTs in the review is: balanceexercises inspired by Tai Chi,30 Tai Chifor arthritis, five movements from SunTai Chi,31 Tai Chi Six Form,32 YangEight Form Easy,33,34 and Yang FiveCore Movements.34

In 2003, a panel of Qigong and TaiChi experts was convened by theUniversity of Illinois and the Blueprintfor Physical Activity to explore this verypoint.35 The expert panel agreed that it

is appropriate to modify (simplify) TaiChi to more efficiently disseminate thebenefits to populations in need of cost-effective, safe, and gentle methods ofphysical activity and stress reduction.These simplified forms of Tai Chi arevery similar to the forms of Qigongused in health research.

For this reason, it is not onlyreasonable but also a critical contribu-tion to the emerging research dialogueto review the RCTs that explore thehealth benefits resulting from both ofthese practices together, as one com-prehensive evidence base for the med-itative movement practices originatingfrom China.

METHODS

Data SourcesThe following databases were used

to conduct literature searches forpotentially relevant articles: Cumula-tive Index for Allied Health andNursing (CINAHL), psychological lit-erature (PsycINFO), PubMed, GoogleScholar, and the Cochrane database.The key words included Tai Chi, Taiji,Tai Chi Chuan, and Qigong, combinedwith RCT or with clinical researchterms. Additional hand searches(based on word-of-mouth recommen-dations) completed the search forarticles.

Study Inclusion CriteriaCriteria for inclusion of articles

required that they (1) were publishedin a peer-reviewed English-languagejournal between 1993 and December2007; (2) were cited in nursing, med-ical, or psychological literature; (3)were designed to test the effects of TaiChi or Qigong; and (4) used an RCTresearch design. The literature searchresulted in the identification of 576articles to be considered for inclusion.The full texts of 158 articles appearingto meet initial criteria 1 through 4 wereretrieved for further evaluation and toverify which ones were, in fact, RCTs,resulting in a final set of 77 articlesmeeting all of our inclusion criteria.

Data AbstractionArticles were read and results were

entered into a table according tocriteria established by the authors forcategorization and evaluation of thestudies and outcomes. Included in



Table 1 for review and discussion aretype and number of patients random-ized, duration and type of interventionand control condition, measured out-comes, and results. As the informationwas entered into the table, it becameapparent that some of the authorsreported results from the same study inmore than one article. Thus, the 77articles selected actually represented66 unique studies, with one studyreporting a range of outcomes acrossfive articles, and five other studies’results published in two articles each.An additional two articles were notentered into the table36,37 because thesame results were reported in newerarticles. Other than these two droppedarticles, multiple articles are enteredinto the table as representing onestudy (see Table 1) so that the fullrange of outcomes reported across thearticles can be reported without inflat-ing the number of studies.

SynthesisThree authors independently re-

viewed the articles selected for inclu-sion and considered categorizing stud-ies by type of patient or diseaseoutcome. Many of the studies drewparticipants from a general, healthypopulation (n 5 16), so a categoryschema based on patient type ordisease would not have included all ofthe studies. The authors revisited thelong list of health benefits and out-comes assessed across the studies andgenerated broad categories that com-bined related health outcomes intolarger groups. These initial categorieswere defined based on identifying themost frequently measured primaryoutcomes, and then refining thegroups to develop an investigationframework that accommodated all ofthe research outcomes into at least oneof the categories. These categories ofoutcomes related to Qigong and TaiChi practice were discussed and con-tinually reworked until we had clear,nonoverlapping boundaries for eachcategory based on similar symptoms orhealth indicators related to a commonfunction or common target organsystem. These groupings are not in-tended to be conclusive taxonomiesbut rather are used for this review asconvenient and meaningful tools forevaluating similar groups of outcomes.

In this way, examining health out-comes across a variety of study designsand populations (including healthy,diseased, or at-risk patients) waspossible.

RESULTS

Study DescriptionA total of 6410 participants were

included across these reported studies.Although some of the studies com-pared Qigong or Tai Chi to otherforms of exercise (n 5 13), manycompared Qigong or Tai Chi to anonexercise treatment control groupsuch as education or usual care (n 543) and some used both exercise andnonexercise comparison groups toevaluate effects of Qigong or Tai Chiinterventions (n 5 11). Many studiesincluded healthy adults (n 5 16studies), while other studies includedparticipants based on specific riskfactors or diagnosis of disease, includ-ing arthritis (n 5 5), heart disease (n5 6), hypertension (n 5 5), osteopo-rosis risk (e.g., perimenopausal status;n 5 3), fall risk determined by age andsedentary lifestyle or poor physicalfunction and balance (n 5 18), breastcancer (n 5 1), depression (n 5 2),fibromyalgia (n 5 2), immune dys-function, including human immuno-deficiency virus/acquired immune de-ficiency syndrome and varicella historyor vaccine response (n 5 3), musculardystrophy (n 5 1), Parkinson’s disease(n 5 1), neck pain (n 5 1), sleepcomplaints (n 5 1), chronic disease (n5 1), and traumatic brain injury (n 51). Some of the studies (n 5 9)monitored adverse effects during theinterventions and none reported anadverse event.

The studies originated from 13 coun-tries (USA, n 5 34; China [includingHong Kong], n 5 9; Korea, n 5 4;Australia and New Zealand, n 5 5;Sweden, n5 4; Great Britain, n5 3; Italyand Taiwan, each n 5 2; Netherlands,Israel, Poland, and Spain, each n 5 1).

OutcomesFrom all of the studies, 163 different

physiological and psychological healthoutcomes were identified. Many of thestudies assessed outcomes across morethan one category (e.g., physical func-tion as well as a variety of psychosocial

and fitness outcomes), so some studiesare discussed in more than one sectionin the review of categories that follows.

The nine outcome category group-ings that emerged are bone density (n5 4); cardiopulmonary effects (n 519); physical function (n 5 16); falls,balance, and related risk factors (n 523); quality of life (QOL; n 5 17); self-efficacy (n 5 8); patient-reportedoutcomes (PROs; n 5 13); psycholog-ical symptoms (n 5 27); and immune-and inflammation-related responses (n5 6). Within each category of out-comes, there were both Qigong andTai Chi interventions represented.

Bone DensityResistance training and other

weight-bearing exercises are known toincrease bone formation38 and havebeen recommended for postmeno-pausal women for that purpose.39

Interestingly, most Qigong and Tai Chipractices involve no resistance and onlyminimal weight bearing (such as gentleknee bends), yet the four RCTs (totalsample size 5 427) included in thisreview reported positive effects onbone health. One study examined theeffect of Qigong40 and three examinedTai Chi.41–43 Bone loss was retardedand numbers of fractures were lessamong postmenopausal women prac-ticing Tai Chi compared to usualcare.41 In another study, bone loss wasless pronounced for postmenopausalfemales practicing Tai Chi or resis-tance training compared to no-exercisecontrols, but this effect was not foundin the older men participating in thestudy.43 Shen et al.42 compared Tai Chito resistance training and reportedsignificant changes in biomarkers ofbone health in both groups. Bonemineral density increased for womenfollowing Qigong exercises as com-pared to no-exercise controls.40 Insummary, current research suggests afavorable effect on bone health forthose practicing Tai Chi or Qigong.

CardiopulmonaryNineteen studies (Qigong, n 5 7;

Tai Chi; n 5 12) reported favorablecardiovascular and/or pulmonary out-comes. Participants in this grouping ofstudies were generally older adults(mean age 5 61.02) and inclusioncriteria varied from history of diseaseto reported sedentary behavior. Mea-



sures of cardiopulmonary functionwere representative of cardiopulmo-nary fitness and cardiovascular diseaserisk and included blood pressure,heart rate, ejection fraction rates,blood lipids, 6-minute walk distance,ventilatory function, and body massindex (BMI).One of the most consistent findings

was the significant reduction in bloodpressure reported in multiple studies,especially when Qigong44,45 or TaiChi46,47 were compared to inactivecontrol groups such as usual care,educational classes, or wait-list con-trols. Even when compared to activecontrol groups such as aerobic exerciseor balance training, Tai Chi showed asignificant reduction in blood pressurein two studies.48,49 Other studies, how-ever, that utilized active control inter-ventions expected to reduce bloodpressure (e.g., low to moderate physicalactivity interventions) showed positivechanges for both groups, but withoutsignificant differences between Qi-gong28 or Tai Chi50,51 and the compari-son group, thus providing preliminaryevidence that these meditative move-ment practices achieve similar results toconventional exercise.Other indicators of cardiac health

have been evaluated. Reduced heartrate is reported49,51,52 as well as in-creases in heart rate variability.53 Thesereported changes in blood pressure,heart rate, and heart rate variabilitysuggest that one or several of the keycomponents of Tai Chi and Qigong—body, breath, and mind—may affectsympathetic and parasympathetic bal-ance and activity.Biomarkers of heart health have

been shown to improve in response toQigong or Tai Chi practice. Yeh et al.34

reported significantly improved serumB-type natriuretic peptide levels inresponse to Tai Chi compared to usual-care controls, indicating improved leftventricular function. Lipid profilesimproved in two studies44,46 comparingQigong and Tai Chi to inactive con-trols, whereas another study of Qi-gong54 reported no change in choles-terol levels compared to inactive (wait-list) controls. Pippa et al.54 also re-ported no change in ejection fractionrates following a 16-week study ofQigong among participants with ahistory of chronic atrial fibrillation.

Urine catecholamine levels were sig-nificantly decreased in participantspracticing Tai Chi compared to wait-listcontrols,45 but a similar trend did notreach significance in another studywith only 15 participants per treatmentcondition.34

A variety of cardiopulmonary fitnessindicators have been examined forboth Qigong and Tai Chi. Participantswith a history of heart failure reportedsignificant improvements in the incre-mental shuttle walk following a com-bined Tai Chi/Qigong interventionimplemented in two studies incorpo-rating inactive control groups.34,55

Women treated for breast cancerachieved significantly increased dis-tances in the 6-minute walk test inresponse to Tai Chi compared to apsychosocial support control interven-tion56 and VO2max increased signifi-cantly more following a Tai Chi inter-vention compared to resistancetraining and usual-care controlgroups.53 In contrast to these consis-tent findings for cardiopulmonarybenefits, one study found no signifi-cant improvement in response toQigong, whereas aerobic training didachieve significant changes. In thissmall (n 5 11 in each arm of study)crossover study of patients with Par-kinson’s disease, participants practicedQigong or aerobic training in randomorder for 7 weeks (with 8 weeks’ rest inbetween intervention periods); resultson the 6-minute walk test, VO2peak, andVO2/Kg ratio were significantly im-proved for those who completed theaerobic exercise protocol, but no sig-nificant effects were found for thosepracticing Qigong.57

Most of the nonsignificant findingshave been found in studies with par-ticipants with some form of chronicillness or recovery from cancer at studyentry. For example, respiratory func-tion improved clinically, but not sig-nificantly, for patients with chronicheart failure practicing Tai Chi com-pared to usual care,34 and, as describedabove, was relatively unchanged for theQigong group with a history of Par-kinson’s disease compared to an aero-bic training control group.57 A groupof patients with muscular dystrophy58

showed a trend for improvement thatdid not reach significance compared toa wait-list control. Further, no change

in cardiovascular function was report-ed for sedentary participants with ahistory of osteoarthritis.59 Aerobic ca-pacity was shown to improve with TaiChi, though not significantly more sothan with inactive controls, in a smallstudy of breast cancer survivors.52,53,56 Itis important to point out that of thesefive studies that failed to demonstratesignificant improvements followingQigong or Tai Chi, four had 31 orfewer participants. It is difficult todiscern whether nonsignificant find-ings in cardiopulmonary fitness arebecause of some pattern of ineffec-tiveness with chronic and debilitatingillness or whether they are a result ofthe limited statistical power.

One of the key risk factors forcardiac disease is obesity. Qigong hasdemonstrated a greater reduction inBMI as compared to an exercisecontrol group in two studies,28,47 butthis difference was not significant.Another study demonstrated amarked but nonsignificant reductionin waist circumference with Tai Chicompared to usual care for olderadults.52 Conversely, one study usingQigong and two with Tai Chi (re-spectively)48,54,59 reported no changein BMI compared to usual care andanother implementing a Qigong in-tervention60 failed to maintain weightloss, suggesting the data are incon-clusive at this point as to whether ornot these practices may consistentlyaffect weight.

A few studies of both Qigong and TaiChi have examined level of intensity,indicating that some forms of thesepractices fall within the moderateintensity level,11,61 but for the mostpart, level of exercise intensity is notreported. Cardiopulmonary benefits ofQigong and Tai Chi may partially beexplained as a response to aerobicexercise, but with the wide range ofspeeds with which these exercises areexecuted, it would be important toassess this factor for a better under-standing of the elements that contrib-ute to outcomes. Regardless of themechanisms, the preponderance ofstudies on cardiopulmonary outcomesshow that Qigong and Tai Chi areeffective compared to inactive controls,or at least approximately equal to theexpected benefits of conventionalexercise.



Table

1RandomizedControlledTrials

TestingHealthBenefits

ofQigongandTaiChi

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Audetteetal.5

327(0/27),se

dentary,

71.4

y12wk(60min

33d/wk)

TC

10-m

ove

mentYang

(n5

11)

BW

(n5

8);UC

later

recruite

dandnot

randomized(n

58)

Cardiopulm

onary:VO

2maxq

inTCmore

than

BW

andUC*;

heartrate

variability,high

frequency

qandlow

frequencyQ

inTC

only*nobetweengroupdifference

Falls

andbalance

:strength,handgripand

kneeextensionq

TC

only*andleftkn

ee

extensionq

inTC

more

thanBW*;

flexibility,only

toetouch

flexibility

qin

TC

more

thanBW*;balance

,only

nondominantOLSwith

eye

sclose

dq

inTC

more

thanBW*

Barrow

etal.5

552(42/10),olderadults

with

history

ofch

ronic

heartfailure,69.5

y

16wk(55min

32d/wk)

TC

with

ChiKung

(n5

25)

UC

(n5

27)

Cardiopulm

onary:incrementalshuttle

walkq

inTC

more

thanUC

ns

Patie

nt-reportedoutcomes:

perceived

symptomsofheartfailure

Qin

TC

more

thanUC*

Psy

chological:depress

ion(SCL-90-R

)Q

inTC

more

thanUC

ns;

anxiety

Qin

both

groupsns

Brism

eeetal.1

03

41(7/34),history

ofkn

ee

osteoarthritis,70y

12wkTC

and6wkno

training(40min

33

d/wk,

6wkgrouptraining,

6wkhometraining,6wk

detraining)

TC

Yang24-form

simplified

(n5

18)

6wkofHLfollowed

bynoactivity

same

asexe

rcisegroup

(n5

13)

Phys

icalfunction:WOMAC

qin

TC

more

thanHL*with

Qfordetrainingperiod

Patie


pain

Qin

TC

more

thanHL*;adve

rseoutcomesns

Burinietal.5

726(9/17),history

of

Parkinso

n’s

disease

,65.2

y

7wkeach

ofaerobics

(45min

33d/wk)

and

QG

(50min

33d/wk)

20

sess

ionseach

with

8wk

betweeninterventio

nperiods

QG

(n5

11)

ATse

ssions

(n5

11)

Cardiopulm

onary:6-m

inwalk

andBorg

scale

forbreathless

ness

qandsp

irometryand

cardiopulm

onary

exe

rcisetest

QforAT

more

thanQG*

Patie


Parkinso

n’s

Disease

Questionnairensforboth;Unified

Parkinso

n’s

Disease

Ratin

gSca

lens;

Brown’s

Disability

Sca

lens

Psy

chological:Beck

Depress

ionInve

ntory

ns

Chanetal.4

1132(0/132),history

of

postmenopausa

land

sedentary,54y

12mo(45min

35d/wk)

TC

ChuanYangstyle

(n5

54)

UC

(n5

54)

Bonedensity:fractures(1

TCand3UC)BMD

measu

redbydualenergyx-ray

abso

rptio

metryin

femoralneck

,Q

inTC

less

thanUCnsandtroch

anterQ

both

ns;

peripheralquantitativeco

mputed

tomographyofdistala

ndultradistaltibia

Qless

inTC

thanUC*

Channeretal.5

1126(90/36),history

of

MI,56y

8wk(2

d/wk3

3wk,

then1d/wk3

5wk)

TC

WuChian-C

h’uan

(n5

31)

AE(n

530)orca

rdiac

SG

(n5

4)discu

ssed

risk

factormodifica

tion

andproblemsin

rehabilitatio

n

Cardiopulm

onary:im

mediate

SBPandDBP

QTC

andAEnsandHR

qin

AEmore

thanTC*;ove

rtim

e,SBPQ

both

nsand

DBPandrestingHRQ

inTC

more

than

AE*;SG

toosm

allforco

mpariso

n



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Chenetal.4

087(0/87),history

ofBMD

T§

22.5,45y

12wk(studiedfor

2wk,

then3d/wk)

QG

Baduanjin

(n5

44)

NQ

(n5

43)

Bonedensity:BMD

maintainedin

QG

andQ

inNQ*;

Immune/in

flammatio

n:interleukin-6

Qin

QG

andq

inNQ*

Cheungetal.2

888(37/51),olderadults

inco

mmunity

with

history

ofhyp

ertension,

54.5

y

16wk(120min

32d/wk3

4wkthenmonthly

and

enco

uragedto

practice60

min

inA.M.and15min

in

P.M.3

7d/wk)

QG

Guolin

(n5

47)

E(n

541)

Cardiopulm

onary:BP,HR,waist

circumference

,BMI,totalch

olesterol,

renin,a

nd24-h

urinary

protein

excretio

nQ

QG

andEns;

ECG

QG

andEnc/ns

QOL:SF-36Q

Ens

Psych

ological:Beck

Anxiety

Inve

ntory

Qand

Beck

Depress

ionInve

ntory

q;QG

and

Ens

Choietal.7

359(15/44),livingin

care

facility,

ambulatory

with

history

ofatleast

1fall

risk

factor,

77.8

y

12wk(35min

33d/wk)

TC

Sunstyle(n

529)

UC

(n5

30)

Falls

andbalance

:FALLSns,

butfalls

efficacy

forTC

qandQ

UC*;

kneeand

anklestrength,OLS

eye

sopen,andtoe

reach

qand6-m

walk

Qmore

thanUC*;

OLSeye

sopennc

Self-efficacy:falls

efficacy

forTC

qandQ

UC*

Chouetal.1

08

14(7/7),co

mmunity-

dwellingChinese

,history

ofdepress

ion

from

apsych

ogeriatric

clinic,72.6

y

3mo(45min

33d/wk)

TC

Yangstyle18

form

(n5

7)

WL(n

57)

Psych

ological:CenterforEpidemiological

StudiesDepress

ionSca

leQ

TC

more

thanWL*

Elderetal.6

092(13/79),history

of

completing12-w

kweight

loss

interventionandloss

ofa

tleast3.5

kg,4

7.1

y

24wk(10hove

rallwith

28-m

inQG

sessions)

QG

Emie

ZhenGong

(n5

22)

TAT(n

527)and

SDS(n

524)

Cardiopulm

onary:weightloss

maintenance

forTATandq

QG

andSDS*

Faberetal.3

0238(50/188)frail(51%)

orprefrail(48.9%)

olderadults

livingin

care

facility,

85y

20wk(60min

exe

rcise

and30min

socialtim

e3

1d/wk3

4wkfor

socializatio

n,then3

2d/wkfor16wk)

TC

(BEinsp

iredbyTC)

(n5

80)

FW

(n5

66)or

UC

(92)

Falls

andbalance

:falls

lowerforTC

more

thanFW

andUC

ns;

whenFW

andTC

combined,fallrisk

Qandphys

icalfunction

(6-m

walk,tim

edch

airstand,TUG,and

FICSIT-4)q

comparedto

UC

inprefrail,*

frailns,

alsoTC

comparedto

FW

ns

Patie


Perform

ance

-OrientedMobility

Assess

mentq

forTC

andFW

andexe

rcisegroupsco

mbined

more

thanUC*andprefrail,*frailns;

GroningenActivity

RestrictionSca

leQ

for

FW

more

thanco

ntrol*TC

vs.UC

ns

Franse

netal.3

1152(40/112)olderadults,

history

ofch

ronic

symptomatic

hip

or

kneeosteoarthritis,

70.8

y

12wk(60min

32d/wk)

TC

forArthritis

byDr.Lam

from

SunStyle

24form

s(n

556)

H(n

555)andWL

control(n

541)

Phys

icalfunction:WOMAC:pain

andfunction

QTC

andH

nswith

treatm

enteffect

for

phys

icalfunctionmoderate*;pain

score

QforH

comparedto

WL,*TC

ns;

phys

ical

perform

ance

:TUG,50-footwalk,andstair

clim

bQ

more

forH

thanWL*;tim

edstair

clim

bforQ

TC

andH

ns



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

QOL:SF-12Phys

icalq

Hmore

thanWL*

andTC

more

thanWLborderline*;SF-12

Mentalns

Patie


pain

andfunction

QTC

andH

ns

Psy

chological:Depress

ionAnxiety

&Stress

21Q

inH*andTC

ns

Galantin

oetal.6

638(38/0),history

oflong

term

care

ofHIV/AIDS,

between20and60y

8wk(60min

32d/wk)

TC

(n5

13)

AE(n

513)andUC

(n5

12)

Phys

icalfunction:FR,SR,sit-up,and

phys

icalperform

ance

test

allim

prove

dmore

thanUC*andTCco

mparedto

AEnc

QOL:MedicalOutcomesShortForm

-HIV

improve

dTC

andAEmore

thanco

ntrol*;

spiritu

alwell-beingim

prove

dTC

AEand

UC

ns

Psy

chological:ProfileofMoodStates

improve

dTC

andAEmore

thanco

ntrol*

Gattsand

Woollaco

tt65

19(2/17),balance

-im

pairedse

niors,

77.5

y

3wk(90min

35d/wk)

TC

TwelveClass

icalTC

Postures(n

511)

TC-base

dandaxial

mobility

program;

samegrouppracticed

TC

afterco

ntroltim

e(n

58)

Falls

andbalance

:TUG

Qmore

forTC

than

control*;F

Rq

forTCandco

ntrol;OLSand

tandem

stance

both

legsq

more

TC

than

control*;tib

ialis

anteriormore

qforTC

thanco

ntrol*;gastrocn

emiusq

only

TC

afterco

ntroltim

e*

Gemmelland

Leathem

96

18(9/9),history

of

traumatic

brain

injury

symptoms,

45.7

y

6wk(45min

32d/wk)

TC

Chenstyle(n

59)

WLUC

(n5

9)

QOL:SF-36andRose

nberg

Self-Esteem

Sca

lenodifferentnsexc

eptrole

emotio

nal

qTC

more

thanUC*

Psy

chological:VisualAnalogueMoodSca

les

improve

dTC

more

thanUC*;

Rose

nberg

Self-Esteem

Sca

lenc,

ns

Greensp

an

etal.3

2

269(0/269),co

ngregate

independentliving,

transitio

nally

frailwith

at

least

1fallin

past

year,

.70yand50%

ove

r80y4

8wk(60increasingto

90min

32d/wk)

TC

6simplifiedform

s(n

5103)

WE

(n5

102)

Phys

icalfunction:Sickn

ess

Impact

Profilefor

phys

icalfunctionandambulatio

nQ

more

TC

thanWE*

Patie


Sickn

ess

Impact

Profileandphysicala

ndambulatio

nperceivedhealth

statusQ

TCmore

than

WE*;se

lf-reportedhealth

ncTCandWEns

Hammondand

Freeman100

133(13/120),history

of

fibromya

lgia

from

arheumatologyoutpatie

nt

department,48.53y

10wk(45min

31d/wk)

TC

forarthritis

(partof

patie

ntED

groupincluding

fibromya

lgia

inform

atio

n,

posturaltraining,stretching,

andweights)(n

552)

RG

(n5

49)

Self-efficacy:Arthritis

Self-Efficacy

Sca

leq

TC

more

thanRG

at4mo*;at8mons

Patie


Fibromya

lgia

Impact

QuestionnaireQ

TC

more

than

RG*at4mo*;at8mons

Psy

chological:Anxiety

anddepress

ionTC

andRG

ns

Hartetal.8

718(16/2),history

ofstroke

,co

mmunity-dwelling,

54.77y

12wk(60min

32d/wk)

TCC

(n5

9)

BE(n

59)

Falls

andbalance

:BBS,OLS,Emory

FractionalAmbulatio

nProfile,Romberg,

TUG

improve

din

BE,*notTCC

ns



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

QOL:Duke

Health

Profileim

prove

dTC,*not

BEns

Hartmanetal.6

733(5/28),co

mmunity-

dwellingwith

lower

extremity

osteoarthritis,

68y

12wk(60min

32d/wk)

TC

9-form

Yang(n

518)

UC

with

phoneca

llseve

ry2wkto

discu

ssissu

esrelatedto

osteoarthritis

(n5

15)

Phys

icalfunction:OLS,50-ftwalk,andch

air

rise

TC

andUC

nswith

smallto

moderate

effect

size

forTC

only

QOL:Arthritis

Impact

Measu

rementSca

leII

(satisfactionwith

life)q

andtensionQ

more

forTC

thanUC*;pain

andmood

both

ns

Self-efficacy:arthritis

self-efficacy

qTC

more

thanUC*

Hass

etal.8

828(notreported),older

adults

transitio

ningto

frailty,

79.6

y

48wk(60min

32d/wk)

TC

8of24simplified

form

s(n

514)

WE(n

514)

Falls

andbalance

:ce

nterofpress

ure

during

S1andS2im

prove

dforTC

more

than

WE*;S3forboth

ns

Irwin

etal.1

10

112(41/71),health

yolder

adults,70y

16wk(40min

33d/wk)

TC

Chih

(n5

59)

HE(n

553)

QOL:SF-36im

prove

dforphys

ical

functioning,b

odily

pain,v

itality,

andmental

health

forTC

more

thanHE*;role

emotio

nalQ

forHEmore

thanTC*;role

phys

ical,generalhealth

,andso

cial

functioningboth

groupsns

Psych

ological:Beck

DepressionSco

req

TC

andHEns

Immune/in

flammatio

n:va

rice

llazo

stervirus

resp

onder-ce

llfrequency

qTC

more

than

HE*

Irwin

etal.9

036(5/13),health

yolder

adults,70.5

y15wk(45min

33d/wk)

TC

Chih

(n5

14)

WL(n

517)

QOL:SF-36only

role

phys

icalandphys

ical

functioningim

prove

dmore

forTC

than

WL*

Immune/in

flammatio

n:va

rice

llazo

stervirus

cell–mediatedim

munity

qmore

forTC

thanWL*

Jin109

96(48/48),TC

practitioners,36.2

yHistory

ofTC

46.4

mo

males/34mofemales2

sessionsofexp

osu

reto

stress

followedby

resp

ectivetreatm

ent

TC

longform

orYangstyle

(n5

24)

BW

(n5

24),TC

M(n

524),andNR

(n5

24)

Psych

ological:ProfileofMoodStates

improve

dalltreatm

ents*with

state

anxiety

Qin

TC

more

thanreading*;BPandHR

qunderstress

forTC

andBW

more

than

MandNR*;

adrenalineQ

more

forTC

thanM*;noradrenalineq

more

forTC

thanNR*;

salivary

cortisolq

allgroups*

Judgeetal.7

421(0/21),se

dentary,

68y

6mo(20min

walkingplus

otherexe

rcise3

3d/wk

forTC

andnoexe

rcisefor

12wk,

then30min

31

d/wkforFT)

TC

simple

with

strength

trainingandwalking

(n5

12)

FT(n

59)

Falls

andbalance

:OLS

qmore

forTC

than

FT

ns;

kneeextensionq

more

forTC

thanFT*;

sittinglegpress

improve

dTC

andFT

ns



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Kutneretal.9

7130(?/?),TC

BTand

control,mostly

women,

health

yolderadults,

76.2

y

15wk(45min

total3

2d/wkTC

and1d/wkBT

andED)

TC

10modifiedform

sfrom

108(n

551)

BT(n

539)andED

control(n

540)

QOL:SF-36allgroupsnc

Self-efficacy:se

lf-co

nfid

ence

qmore

forTC

andBTthanEC*

Psy

chological:Rose

nberg

self-esteem

qmore

TC

thanBTorEC

ns

Lansingeretal.6

4122(36/86)history

of

longterm

nonsp

ecific

neck

pain,43.8

y

3mo(1

h3

1–2d/wk

310–12se

ssions)

QG

Biyun(n

560)

ET(n

562)

Phys

icalfunction:gripstrength

andce

rvical

ROM

qboth

groupsns

Patie


neck

pain

and

Neck

Disability

IndexQ

both

groupsns

Leeetal.4

4,101

36(14/22),history

ofhyp

ertension,53.4

y8wk(30min

32d/wk)

QG

Shuxinpingxu

egong

(n5

17)

WL(n

519)

Cardiopulm

onary

44:(2004a)BPQ

more

inQG

thanWL*;HDLandAPO-A1q

more

inQG

thanWL*;high-density

lipoprotein

andapolipoprotein

A1q

andtotal

cholesterolQ

inQG

pre-post*;

triglyce

ridesQ

inQG

andq

inWLns

Self-efficacy

101:Self-efficacy

andperceived

benefitsq

inQG

andQ

inWL*

Psy

chological101:emotio

nalstate

qin

QG

andQ

inWL*

Leeetal.4

5,107

58(notreported),history

ofhyp

ertension,

56.2

y

10wk(30min

33d/wk)

QG

Shuxinpingxu

egong

(n5

29)

UC

WL(n

529)

Cardiopulm

onary

107:HR

Qmore

inQG

than

WL*;epinephrineandnorepinephrineQ

forQG

andq

forWL*;co

rtisolQ

forQG

andq

forWLns

Psy

chological107:Self-reportstressQ

QG

more

thanWL*;epinephrineand

norepinephrineQ

forQG

andq

forWL*;

cortisolQ

forQG

andq

forWLns

Cardiopulm

onary

45:BPandca

tech

olamines

QforQG

andq

forUC*;ve

ntilatory

functionq

more

forQG

thanUC*

Leeetal.9

1139(45/96),residentof

care

facility,

ambulatory,

Chinese

,82.7

y

26wk(60min

33d/wk)

TC

(n5

66)

UC

(n5

73)

QOL:health

-relatedQOLq

TC

more

than

UC*

Psy

chologicalsy

mptoms:

self-esteem

qTC

more

thanUC*

Lietal.3

348(notreported),older

adults,68.88y

3mo(3

d/wk)

TC

Yang8-form

easy

TC

(n5

26)

SC

(n5

22)

Falls

andbalance

:OLSim

prove

dTC

more

thanSC*

Phys

icalfunction:SF-12phys

ical,

instrumentalactivitiesofdaily

living,50-ft

walk,andch

airrise

allim

prove

dTC

more

thanSC*

Psy

chological:SF-12mentalq

more

TC

thanSC*



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Lietal.1

05

118(22/96),history

ofmoderate

sleep

complaints

and

community-dwelling

adults,75.4

y

24wk(60min

33d/wk)

TC

Yang(n

562)

EC

(n5

56)

Phys

icalfunction:OLSandSF-12phys

icalq

andch

airrise

and50-ftwalk

QTC

more

thanEC*

Patie

nt-reportedoutcomes:sleepduratio

nand

efficiency

qandsleepquality,

latency,

duratio

n,anddisturbance

s,Epworth

Sleepiness

Sca

le,andPittsb

urg

Sleep

QualityIndexQ

more

forTC

thanEC*;

sleepdysfunctionboth

andmedicatio

nQ

TC

only

ns

Psych

ological:SF-12mentalq

both

nsLietal.7

5,99

256(77/179),se

dentary

77.48y

6mo(60min

32d/wk)

TC

Yangstyle24form

s(n

5125)

SC

(n5

131)

Falls

andbalance

75:fewerfalls

andfewer

injuriousfalls

forTC

thanSC*;andBBS,

Dyn

amic

GaitIndex,

FR,andOLSq

and

50-ftwalk

andTUG

Qmore

forTC

than

SC*allsu

stainedat6mofollow-up

Falls

andbalance

99:activities-sp

ecific

balance

qmore

forTC

thanSC*

Self-efficacy

99:falls

self-efficacyq

(mediator)

andfearoffalling(SAFFE)Q

more

forTC

thanSC*

Psy

chological:fearoffalling(SAFFE)Q

more

forTC

thanSC*

Lietal.6

8,70,92,112,123

6401(9/85),se

dentary,

72.8

y6mo(60min

32d/wk)

TC

Yangstyle24form

s(n

549)

WL(n

545)

Phys

icalfunction68:SF-20phys

icalfunction

qamongTC

more

thanWLove

rtim

e*r

scores

Self-efficacy

68:se

lf-efficacy

qamongTC

more

thanWLove

rtim

e*rsc

ores

QOL92:SF-20(generalhealth

survey)

qmore

forTC

thanWL*;TC

with

lower

leve

lsofhealth

perceptio

n,phys

ical

function,andhighdepress

ionatbase

line

andmove

mentco

nfid

ence

q5

qphys

icalfunction*

Psy

chological112:Phys

icalfunctionse

lf-esteem

andRose

nberg

self-esteem

qmore

forTC

thanWL*

Self-efficacy

123:barrierandperform

ance

self-

efficacy

qTC

more

thanWL*;exe

rcise

adherence

qTC

thanWL*;andSE

conditionsrelatedto

adherence

forTC

Maciaszeketal.7

649(49/0),se

dentary,history

ofosteopenia

or

osteoporosis,

70.2

y

18wk(45min

32d/wk)

TC

24form

(n5

25)

UC

(n5

24)

Falls

andbalance

:Posturographic

Platform

(tim

eQ;%

task

perform

ance

andtotal

length

ofpath

qforTC*;and%

task

perform

ance

andtotallength

ofpath

qmore

forTC

thanUC*



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Mannerkorpiand

Arndorw

69

36(0/36),history

of

fibromya

lgia,45y

3mo(20min

31d/wk)

QG

with

Body

Awareness

(n5

19)

UC

(n5

17)

Phys

icalfunction:ch

airstandandhandgrip

TC

andUC

ns

Patie


bodyawareness

qTC

more

thanUC*;fib

romya

lgia

symptomsTC

andUC

ns

Manza

neque

etal.1

13

29(14/15),health

yyo

ung

adults,18–21y

1mo(30min

35d/wk)

QG

EightPiece

sofBroca

de

(low

intensity)(n

516)

UC

(n5

13)

Immune/inflammation:leuko

cytes,

eoso

inophils,monocytes,

andC3leve

lsQ

TCthanUC*;trendforneutrophils;total

lymphocytes,

Tlymphocytes,

thelper

lymphocytes,

conce

ntrationsofco

mplement

C4orim

munoglobulinsns

McG

ibbonetal.8

536(16/20),history

of

vestibulopathy,

59.5

y10wk(70min

31d/wk)

TC

Yang(n

519)

VR

(n5

17)

Falls

andbalance

:gaitsp

eedq

TCmore

than

VR*;steplength

qforTC

andVR*;stance

duratio

nQ

VR*more

thanTC;stepwidth

qVR

andTC

ns:

mech

anicale

nergy

exp

enditu

re(hipQ

TCmore

thanVR*;ankle

qmore

forTCthanVR*;kn

eeandlegboth

ns);peaktrunkforw

ard

velocity

qTCmore

thanVR*;forw

ard

velocity

rangeandpeak

orrangeoflateraltrunkve

locity

TC

andVR

ns;

peaktrunkangularve

locity

qmore

for

VRthanTC*;trunkangularve

locityinfrontal

planeandch

angeinpeakandrangeTCand

VR

ns;

trunkve

locity

peakandrange

positivelyco

rrelatedwith

changein

leg

mech

anicale

nergyexp

enditu

reforTC*and

VR

negativerelatio

nsh

ipMcG

ibbon

etal.8

6

26(11/15),history

ofve

stibulopathy,

56.2

y10wk(70min

31d/wk)

TC

Yang(n

513)

VR

(n5

13)

Falls

andbalance

:gaze

stability

qmore

for

VRthanTC*;whole-bodystability

andfoot

fallstability

qmore

forTC

thanVR*;

correlatio

nbetweench

angein

gaze

stability

andwhole-bodystability

,andfoot-

fallstability

andgaze

stability

forVR

not

TC*;co

rrelatio

nbetweenfoot-fallstability

andwhole-bodystability

forVR

andTC*

Motivala

etal.5

032(14/18),outof

63whoco

mpletedRCT

forherpeszo

sterrisk

inagingstudy,

68.5

y

37wkTC

(?min

31d/wk)

TC

Chih

(n5

19)

PR

andslow

movingphys

ical

move

ment

(n5

13)

Cardiopulm

onary:pre-ejectionperiodq

posttask

more

forTCthanPR*;BPandHR

TC

andPR

ns

Mustian

etal.5

6,93

21(0/21),history

ofbreast

cance

r52y

12wk(60min

33d/wk)

TC

YangandChi

Kung(n

511)

PS(n

510)

Cardiopulm

onary

56:6-m

inwalkq

forTC

and

QforP

S*;aerobicca

pacityq

forT

CandQ

forPSns

Phys

icalfunction56:(2006)musc

lestrength

(handgripq

forTC

andQ

forPS*);and

flexibility

(abductionq

TCandPS,fle

xion,

extension,horizo

ntaladductionand

abductionq

more

forTC

thanPS*;and

bodyfatmass

QforTC

andq

forPSns



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

QOL93:health

-relatedQOLq

forTC*andQ

PSns

Psy

chological93:Self-esteem

qforTC

and

QforPS*

Nowalk

etal.8

4110(15/95),longterm

care

residents,84y

13–28mo(3

d/wk)

TC

with

behavioral

component(n

538)

Phys

icaltherapyweight

training(n

537)and

ED

Control(n

535)

Falls

andbalance

:falls

nodifference

between

groups

Pippaetal.5

443(30/13),history

ofstable

chronic

atrialfib

rillatio

n,

68y

16wk(90min

32d/wk)

QG

(n5

22)

WLco

ntrol

(n5

21)

Cardiopulm

onary:6-m

inwalk

qforQG

and

QforWL*;Ejectionfraction,BMI,

cholesterolns

Sattin

etal.7

7311(20/291),transitiona

llyfrailwith

history

of1or

more

falls

inpa

stye

ar(55

AfricanAmericans),80

.1y

48wk(60–90min

32d/wk)

TC

6of24Sim

plified

(n5

158)

WE

(n5

153)

Falls

andbalance

:activities-sp

ecific

balance

qmore

amongTC

thanWE*

Psy

chological:Falls

Efficacy

Sca

leQ

more

amongTC

thanWE*

Shenetal.4

228(7/21),se

dentary

from

ase

niorlivingfacility,

79.1

y

24wk(40min

33d/wk)

TC

YangStyle

Sim

plified24form

s(n

514)

RT(n

514)

Bonedensity:se

dentary

olderadults

onbone

metabolism

(serum

bone-specific

alkaline

phosp

hatase

/urinary

pyridinoline)q

more

forTCthanRTat6

wk*

andTCreturnedto

base

lineandRTless

thanbase

line*;

parathyroid

horm

oneq

more

forTC

than

RTat12wk*;se

rum

1,25-vita

min

D3TC

andRTns;

serum

calcium

qmore

forTC

thanRTat12wkco

mparedto

6wk*;

urinary

calcium

QforTC*notRT;se

rum

andurinary

PiTC

andRTns

Songetal.5

9,104

43(0/72),history

of

osteoarthritis

andno

exe

rcisefor

1yprior,63y

12wk(60min

33d/wkfor2wkthen

31d/wkfor10wk)

TC

SunStyle

modified

forarthritics(n

522)

UC

(n5

21)

Cardiopulm

onary

59:BMI,13-m

inergometer

TC

andUC

ns

Falls

andbalance

59:OLS,trunkfle

xionand

sit-upsq

more

forTC

thanUC*;fle

xibility

andkn

eestrength

TC

andUC

ns

Patie

nt-reportedoutcomes1

04:pain

and

stiffness

Qandperceivedbenefitsq

more

forTCthanUC*;TCperform

edmore

health

behaviors

thanUC*

Stenlundetal.8

295(66/29),history

ofco

ronary

artery

disease

,77.5

y

12wk(60min

QG

and

120min

discu

ssionon

variousthemes)

QG

(TC

&Medicinsk

QG)(n

548)

UC

(n5

47)

Falls

andbalance

:Falls

Efficacy

Sca

le,

tandem

standing,O

LSleft,c

limbboxe

sleft

TC

andUC

ns;

OLSrightandclim

bboxe

srightq

more

forTC

thanUC*;and

coordinatio

nQ

more

forUCthanTC*;and

self-reportedactivity

leve

lq

forTC

more

thanUC*

Pys

chological:fearoffallingbetweenTC

and

UC

ns



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Thomasetal.5

2207(113/94),health

y,co

mmunity-dwelling,

68.8

y

12mo(60min

33d/wk)

TC

Yangstyle24

form

s(n

564)

PS(n

565)or

UC

(n5

78)

Cardiopulm

onary:energyexp

enditu

req

for

TC

andRTmore

thanUC

ns;

waist

circumference

andHRQ

more

TCandRT

thanUC

ns;

insu

linse

nsitivity

Qmore

for

RTthanUC*andmore

forTCthanUCns;

BMI,bodyfat,BP,ch

olesterol,and

gluco

seTC,RT,andUC

ns

Tsa

ietal.4

676(38/38),se

dentary

with

prehyp

ertension

orstageI,52y

12wk(50min

33d/wk)

TC

Yang(n

537)

UC

(n5

39)

Cardiopulm

onary:BPandtotalc

holesterolQ

forTC*andq

forUC

ns;

BMIandHR

TC

andUCns;

triglyce

rideQ

TC*andq

UC*;

LDLQ

TC*andq

UC

ns;

high-density

lipoprotein

qTC*andQ

UC

ns

Psy

chological:traitandstate

anxiety

QTC*m

ore

thanUC

ns

Tsa

ngetal.9

582(16/66),history

ofdepress

ionand

chronic

illness,

82.4

y

16wk(30–45min

33d/wk)

QG

Baduanjin

(n5

48)

NR

groupwith

same

intensity

(n5

34)

QOL:personalwell-beingq

forQG

andQ

NR*;generalhealth

questionnaireQ

QG

andq

NR*;andse

lf-co

nce

ptQ

more

TC

thanNR*

Self-efficacy

:Chinese

GeneralSelf-Efficacy

andPerceivedBenefitsQuestionnaireq

more

forQG

thanNR*

Psy

chological:Geriatric

Depress

ionSca

leQ

more

forQG

thanNR*

Tsa

ngetal.9

450(26/24),history

of

chronic

disease

,74.6

y12wk(60min

32d/wk)

QG

Eight-SectionBroca

des

(n5

24)

BR

activities(n

526)

QOL:phys

icalhealth

,activitiesofdaily

living

psy

chologicalhealth

andso

cial

relatio

nsh

ipsim

prove

dforQG*;se

lf-co

nce

ptandWHOQOL-BREFQG

and

BR

ns

Psy

chological:Geriatric

Depress

ionSca

leQ

TC

andBR

ns

Tsa

ngetal.7

238(8/30),se

dentary,

community-dwelling,type

2diabetics,

65.4

y

16wk(45min

32d/wk)

TC

fordiabetes(12-

move

menthyb

rid

from

YangandSun)

(n5

17)

Sham

exe

rcise(seated

calisthenics

andstretching)

(n5

20)

Phys

icalfunction:6-m

inwalk,habitu

aland

maximalgaitsp

eed,musc

lestrength,and

peakpowerq

TC

more

thanSEns;

endurance

Qmore

forSEthanTCns;

and

habitu

alp

hys

icala

ctivity

qTCandQ

SE*

Falls

andbalance

:balance

indexQ

TC

and

SEns;

OLSopenq

TC

andncSEns;

OLSclose

dandtandem

walk

QTC

and

SEns;

Falls

0–2TC

andSEns

QOL:SF-36(exceptSocialFunctionq

for

TC

andQ

SE*)

andDiabetesIntegratio

nSca

leTC

andSEns



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Vouke

latos

etal.7

8

702(112/590)co

mmunity

dwelling,69y

16wk(60min

31d/wk)

TC

38programsmostly

Sun-style

(83%)Yang

(3%)(n

5271)

WL(n

5256)

Falls

andbalance

:sw

ayonflo

orandfoam

mat,lateralstability,co

ordinatedstability,

andch

oicesteppingreactiontim

eim

prove

dTC

more

thanWL*;maximal

leaningbalance

rangeq

TC

more

than

WLns;

fallratesless

forTC(n

5347)than

WL(n

5337)*

Wangetal.7

120(5/15),co

mmunity-

dwellingwith

rheumatoid

arthritis

class

IorII,

49.5

y

12wk(60min

32d/wk)

TC

Yangstyle(n

510)

StretchingandWE

(n5

10)

Phys

icalfunction:ch

airstandand50-ftwalk

qTC

andWEns;

America

nCollegeof

Rheumatology20Q

TC

more

thanWE*;

handgripnotreported;H

ealth

Ass

essment

Questionnaireq

more

TCthanWE*;ESR

andC-reactiveprotein

ns

QOL:SF-36q

more

TC

thanWEwith

only

vitality*

Patie


pain

QTC

and

qWEns

Psy

chological:CenterforEpidemiological

StudiesDepressionSca

leq

more

TC

thanWE*

Immune/in

flammatio

n:ESR

andC-reactive

protein

ns(note

TC

higherleve

lat

base

line)

Wenneberg

etal.5

8

36(19/17),history

of

musculardys

trophy,

55.3

y

12wk(w

eeke

ndim

mersion,

then45–50min

31d/wk

for4wk,

theneve

ryother

weekfor8wk)

QG

(n5

16)

WLco

ntrol(n

515)

Cardiopulm

onary:Forcedvitalca

pacity

and

exp

iratory

volumeQ

QG

andWLns

Falls

andbalance

:BBSunch

angedforQG

andQ

WLnsforinterventio

nperiod;

subgroupA

QOL:SF-36generalh

ealth

unch

angedforQG

andQ

WL*andotherdim

ensionsns;

Ways

ofCopingpositivereappraisalcopingQ

for

QG

andunch

angedforWL,*co

nfrontative

copingq

QG

andQ

WLns,

andother

dim

ensionsns

Psy

chological:Montgomery

Asb

erg

Depress

ionRatin

gSca

leQG

andWLns

Winsm

ann106

47(47/0),ve

terans.

49.55y

4wk(75min

32d/wk)

TC

ChuanYangStyle

(n5

23)

UC

includedgroup

therapy(n

524)

Patie


Disso

ciative

Exp

erience

sandSym

ptom

Check

list9

0Q

TC

more

thanUC

ns

Wolfetal.4

7311(20/291),transitio

nally

frailwith

ave

rageof5.6

comorbidities,

80.9

y

48wk(60–90min

32d/wk)

TC

6of24simplified

form

s(n

5158)

WE

(n5

153)

Cardiopulm

onary:BMIQ

TC

andq

WE*;

SBPandHR

QTC

andq

WE*;DBPQ

TC

more

thanWE*

Physicalfunction:gaitsp

eedandFRq

TC

andWEns;

chairstandsQ

12.3%

TC

and

q13.7%

WE*;360uturn

andpickupobject

similarch

angeTC

andWEns;

OLSnc



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Wolfetal.7

9286(17/269),transitio

nally

frailwith

ave

rageof5.6

comorbidities,

80.9

y

48wk(60–90min

32d/wk)

TC

6of24simplified

form

s(n

5145)

WE(n

5141)

Falls

andbalance

:TC

lowerrisk

forfalls

from

mo4to

12;R

Rfalls

TCandWE0.75(C

I50.52–1.08)ns

Wolfetal.8

072(12/60),

sedentary,77.7

y15wk(60min

32d/wkTC

group)

TC

108form

ssimplified

to10form

s(n

519)

BT(n

516)andED

control(n

519)

Falls

andbalance

:balance

:dispersionfor

OLS(eye

sopen),toesup(eye

sopenand

close

d),ce

nterofbalance

Xwith

toesup

(eye

sopen)andce

nterofbalance

Y(O

LS

eye

sopenandclose

d)Q

more

BTthan

ED

andTC*;dispersionfortoesup(eye

sopen),ce

nterofb

alance

XOLS(eye

sopen

andclose

d)andtoesup(eye

sclose

d),and

centerofb

alance

Yfortoesup(eye

sopen

andclose

d)TC,BT,a

ndEDns

Psy

chological:fearoffallingQ

more

forTC

thanBTandED*

Wolfetal.4

9200(39/161),co

mmunity-

dwelling,76.2

y15wk(45min

31

d/wkin

class

plus

15min

23

daily)

TC

(n5

72)

BT(n

564)and

ED

control

(n5

64)

Cardiopulm

onary:BPQ

more

forTC

thanBT

andED*;12-m

inwalkq

0.01mile

forBT

andEDandQ

0.02forTC*;body

compositio

nch

angesforTC,B

TandEDns

Phys

icalfunction:lefthandgripstrength

Qmore

inBTandED

thanTC*;strength

of

hip,kn

eeandankleviaNicholasMMT

0116musc

letester,lowerextremity

ROM

changesTC,BT,andED

ns

Falls

andbalance

:intrusive

nessQ

more

for

TCthanEDns;

RRforfalls

inTC0.632(C

I0.45–0.89)*usingFICSIT

falldefin

ition;for

BTandotherfalldefin

itionsns

Psy

chological:fearoffallingQ

more

forTC

thanBTandED*

Wooetal.4

3180(90/90),co

mmunity-

dwelling,68.91y

12mo(?

min

33d/wk)

TC

Yangstyle24

form

s(n

558)

RT(n

559)andUC

(n5

59)

Falls

andbalance

:muscle

strength

(grip

strength

andquadrice

ps)

ns;

balance

(SMARTBalance

Master,stance

time,gait

velocity,andbendreach

)andfalls

forTC,

RTandUC

ns

Bonedensity:women:BMD

loss

athip

less

forTC

andRTthanUC*;BMD

loss

at

spineless

forTCandRTthanUCns;

men:

nodifference

in%

changein

BMD

Yangetal.8

349(10/39),health

yadults,

80.4

y6mo(60min

33d/wk)

QG

(sittingandstanding)

andTaijiChenstyle

Essentia

l48form

(n5

33)

WL(n

516)

Falls

andbalance

:Senso

ryOrganizatio

nTest

vestibularratio

sandbase

ofsu

pport

measu

resq

more

forTC

thanWL*q

;Senso

ryOrganizatio

nTest

visu

alratio

sandfeetopeningangle

forTC

andWLnc



Table

1,Continued

Source

Subjects:

No.(M

ale/Female),

Description,MeanAge

ExerciseDuration

ExerciseGroup

ControlGroup

ReportedOutcomes

Yangetal.1

14

50(13/37),history

of

rece

ivedflu

immunizatio

nandse

dentary,77.2

y

20wk(60min

33d/wk)

QG

(sittingandstanding)

andTaijiChenstyle

Ess

entia

l48form

(n5

27)

WL(n

523)

Immune/in

flammatio

n:hemagglutin

atio

ninhibitionass

ayq

109%

forQG

compared

to,10%

forWL*

Yehetal.3

430(19/11),history

ofc

hronic

stable

heartfailure,64y

12wk(60min

32d/wk)

TC

Yang-style

5co

remove

ments

(n5

15)

UC

including

pharm

aco

logic

therapy

anddietary

and

exe

rciseco

unse

ling

(n5

15)

Cardiopulm

onary:peakO2uptake

qTC

and

QUC

ns;

6-m

inwalk

qTC

andQ

UC*;

serum

B-typ

enatriuretic

peptid

eQ

TCand

qUC*;

plasm

anorepinephrineq

TC

more

thanUC

ns;

nodifference

sin

incidence

ofarrhythmia

betweengroups

QOL:Minneso

taLivingwith

HeartFailure

QTC

andqUC*

Youngetal.4

862(13/49),history

ofBP

between130and159

andnottaking

medicatio

nsfor

hyp

ertensionorinsu

lin(45.2%

black

),66.7

y

12wk(60min

32

d/wkclass

with

goal

of30–45min

34–5

d/wk)

TC

Yangstyle13

move

ments

(n5

31)

AEclass

at40%–60%

HR

rese

rve(n

531)

Cardiopulm

onary:BPQ

TC

andAE*;BMIq

slightly

TC

andAEns;

timein

moderate

activity,weeklyenergyexp

enditu

re,and

leisurely

walkingq

forAEmore

than

TC

ns

Zhangetal.8

147(25/22),history

ofpoorbalance

,70.4

y8wk(60min

37d/wk)

TC

simplified24

form

sZhou

(n5

24)

UC

(n5

23)

Falls

andbalance

:OLS,trunkandfle

xion

more

TCthanUC*;10-m

inwalkQ

TCand

UC

ns

Psy

chologicalsym

ptoms:

Falls

Efficacy

Sca

leq

more

TC

thanUC*

!TC

indicatesTaiC

hi;BW,brisk

walking;UC,usu

alcare;q

,increase

insc

ore;Q

,decrease

insc

ore;OLS,1-legstance

;ns,

scoresnotsignifica

ntly

differentbetweengroups;

HL,health

lecture;W

OMAC,W

estern

OntarioandMcM

asterUniversitiesOsteoarthritis

Index;

QG,Q

igong;A

T,a

erobictraining;B

MD,b

onemarrowdensity;A

E,a

erobicexe

rcise;S

G,s

upportgroup;M

I,myo

cardialinfarctio

n;SBP,sy

stolic

bloodpress

ure;DBP,diastolic

bloodpress

ure;HR,heartrate;NQ,noQigong;E,exe

rcise;BP,bloodpress

ure;BMI,bodymass

index;

ECG,

electroca

rdiogram

up;nc,

noch

angein

scores;

QOL,qualityoflife;WL,waitlist;TAT,Tapasacu

press

ure

tech

nique;SDS,se

lf-directedsu

pport;BE,balance

exe

rcises;

FW,functional

walking;TUG,tim

edupandgo;FICSIT,FrailtyandInjuries:

CooperativeStudiesonInterventio

nTech

niques;

H,hyd

rotherapy;

HIV/AIDS,humanim

munodeficiency

virus/acq

uired

immunodeficiency

syndrome;F

R,functionalreach

;SR,s

itandreach

;WE,w

ellness

educa

tion;E

D,e

duca

tion;R

G,relaxa

tiongroup;B

BS,B

erg

Balance

Sca

le;T

CC,T

aiC

hichuan;H

E,h

ealth

educa

tion;M,medita

tion;NR,neutralreading;FT,fle

xibility

training;BT,balance

training;ET,exe

rcisetherapy;

ROM,rangeofmotio

n;HDL,high-density

lipoprotein;APO-A1,apolipoprotein

A1;SC,stretchingco

ntrol;EC,e

xerciseControl;SAFFE,SurveyofActivitiesandFearofFallingin

theElderly;

VR,ve

stibularrehabilitatio

n;RCT,randomizedco

ntrolledtrial;PR,pass

iverest;

PS,psy

choso

cialsu

pport;RT,resistance

training;NR,newsp

aperreading;BR,basicrehabilitatio

n;WHOQOL-BREF,WorldHealth

Organizatio

nQualityofLife

:AbbreviatedVersion;ESR,

erythrocy

tese

dim

entatio

nrate.

*p#

0.05betweengroups.



Physical FunctionDecreased physical activity is related

to declining physical function in allpopulations, and that decline is com-pounded by the natural process ofaging.62,63 Changes in physical functionwere assessed in 16 studies (Qigong, n5 2; Tai Chi, n 5 14). Most of thestudies were conducted with olderadults (i.e., studies in which mean age5 55 years or older, n 5 13) andseveral recruited specifically for partic-ipants with chronic pain (e.g., osteo-arthritis, neck pain, or fibromyalgia, n5 5). A number of behavioral mea-sures of physical function performancewere included in this category ofoutcomes, which also includes self-reported responses on scales repre-senting physical function. Althoughfitness outcomes, such as the 6-minutewalk test, might also be seen asassessing overall physical function, wedid not include tests already discussedin the cardiopulmonary fitness catego-ry, but rather focused on functionaltests that are usually used to assesscapacity for daily living. Studies thatassessed changes in overall physicalactivity levels are also included as anoutcome pertaining to physical func-tion.

Physical function measured with awide variety of performance indica-tors, including chair rise, 50-ft walk,gait speed, muscle contractionstrength, hand grip, flexibility, andfunction as measured on the WesternOntario and McMaster UniversitiesOsteoarthritis Index (an osteoarthritis-specific assessment for function, stiff-ness, and pain), were variously foundto be significantly improved in fivestudies comparing Tai Chi to minimalactivity (usual or stretching activity,psychosocial support, or education)comparison groups56,64–66 and onestudy of Tai Chi compared to anexercise therapy control interven-tion.64 One of these studies combinedfunctional walking with Tai Chi toachieve significant improvements withprefrail elders compared to usualcare.30

In contrast, in seven studies includ-ing participants with osteoarthritis ormultiple comorbidities, some of thephysical function measures were notsignificantly different for Tai Chi orQigong in comparison to inactive

controls. This was the case for gaitspeed,47 timed up and go, 50-ft walkand stair climb31 and 50-ft walk andchair stand.67,68 In one study of 30patients with osteoarthritis practicingTai Chi twice per week67 and anotherwith 36 participants with fibromyalgiathat utilized hand grip and chair standto test a 20-minutes-per-week Qigongintervention,69 neither achieved signif-icant improvements compared to usualcare. In one exception to this trend,one measure of functional perfor-mance, time to complete chair rise, wassignificantly improved in transitionallyfrail elders in the Tai Chi groupcompared to a wellness educationcontrol group.47

Studies using self-report measuresconsistently show positive results forTai Chi. Self-reported improvement inphysical function for sedentary olderadults was demonstrated for Tai Chicompared to wait-list controls68,70 and astretching exercise control.33

Results in this category of outcomesare inconsistent, with a preponderanceof studies recruiting sedentary orchronically ill or frail elder partici-pants. Even so, a handful of thesestudies successfully demonstrated po-tential for Qigong and Tai Chi to buildperformance, even with health-com-promised individuals. Further studiesare needed to examine the factors thatare important to more critically evalu-ate these interventions (such as powerconsiderations or dose and frequencyof the interventions), or learn if thereare particular states of ill health thatare less likely to respond to this form ofexercise.

Falls and BalanceAnother large grouping of studies

focused primarily on falls prevention,balance, and physical function testsrelated to falls and balance (such asone-leg stance). Although there maybe some crossover of implied benefitsto the more general physical functionmeasures reported above, this separatecategory was established to report onthe studies of interventions primarilytargeting falls and related measures.Fear of falling is reported with thepsychological outcomes and falls self-efficacy is reported in the self-efficacyoutcomes rather than in this categoryof falls and balance.

Outcomes related to falls such asbalance, fall rates, and improvedstrength and flexibility were reportedin 24 articles (Qigong, n 5 2; Tai Chi,n 5 20; and two studies that includedboth practices). Scores directly assess-ing balance (such as one-leg stance) orother closely related measures wereconsistently, significantly improved in16 Tai Chi studies that included onlyparticipants who were sedentary ordeemed at risk for falls at base-line.33,43,49,53,59,65,71–81

Qigong has been less studied inrelationship to balance-related out-comes; however, results suggest thatthere was a trend to maintain balanceusing Qigong in a population ofpatients with muscular dystrophy.58 Intwo studies that used both Qigong andTai Chi, several measures of balancewere significantly improved with sed-entary women82 and with elderlyhealthy adults (mean age 80.4 years)compared to wait list controls.83

Another set of studies shows theeffect of Tai Chi on balance to besimilar to that of conventional exerciseor physical therapy control interven-tions aimed at improving physicalfunction related to balance53,72,84 orvestibular rehabilitation.85,86 On theother hand, in a study of strokesurvivors comparing Tai Chi to balanceexercises, significant improvements inbalance were achieved in the exercisecontrol group, but not for Tai Chi.87

Although knee extension was signifi-cantly improved, balance was not im-proved significantly in a Tai Chiintervention with sedentary womencompared to a flexibility training con-trol group.74

Mechanisms of gait performance,which are important to understandinghow Tai Chi affects balance, were alsostudied. Reported improvements werefound in four studies.80,85,86,88 Strengthand flexibility are also important to fallprevention. Four studies found signif-icant improvements in these factorswhen Tai Chi was compared to anactive control (brisk walking)33,53,59,73,81

or inactive controls.59,73,81

Eight studies directly monitored fallrates. Studies that incorporate educa-tional or less active control interven-tions (e.g., stretching) variously dem-onstrated significant falls reduction forTai Chi30,75,78,79 or nonsignificant re-



ductions compared to control.43,49 In astudy comparing Tai Chi to an activephysical therapy intervention designedto improve balance, results were simi-lar (nonsignificant differences) be-tween the two groups.84 The results aredifficult to interpret because someparticipants may fall more becausetheir level of activity has increased andsome interventions are not monitoredlong enough to detect changes in fallrates.73

This category of outcomes has alarge body of research supporting theefficacy of Tai Chi on improvingfactors related to falls, and growingevidence that falls may be reduced.Longer-term studies to examine fallrates, and parallel studies that utilizeQigong as the intervention, may fur-ther clarify the potential of theseforms of exercise to affect falls andbalance.

Quality of LifeQOL outcomes were reported in 17

articles (Qigong, n 5 4; Tai Chi, n 513). QOL is a broad-ranging conceptderived in a complex process frommeasures of a person’s perceivedphysical health, psychological state,personal beliefs, social relationships,and relationship to relevant features ofthe person’s environment.89 In 13studies of a wide range of participants(including healthy adults, patients withcancer, poststroke patients, patientswith arthritis, etc.) at least one of thecomponents of QOL was reported tobe significantly improved by Tai Chicompared to inactive34,66,67,71,90–93 oractive controls,87 and by Qigong com-pared to inactive94,95 or active controlgroups.72 Qigong also showed im-provements in QOL compared to anexercise intervention, but not signifi-cantly so.72

Conversely, two studies reported nochange in QOL, both with severelyhealth-compromised individuals. Onewas of short duration (6 weeks),conducted with patients with traumaticbrain injury.96 Some improvement incoping was shown with muscular dys-trophy patients in response to a Qi-gong intervention58; however, thisfinding was not significant, and directQOL measures remained unchanged.One study reported no change in QOLwhen Tai Chi was compared to balance

training and an education controlamong healthy older adults.97

With a few exceptions, the prepon-derance of studies indicate that Qi-gong and Tai Chi hold great potentialfor improving QOL in both healthyand chronically ill patients.

Self-EfficacySelf-efficacy is the confidence a

person feels in performing one orseveral behaviors and the perceivedability to overcome the barriers associ-ated with the performance of thosebehaviors.98 Although this is not ahealth outcome itself, it is often asso-ciated directly with health behaviorsand benefits (e.g., falls self-efficacyassociated with reduced falls) or withpsychological health. Significant im-provements in this outcome werereported in eight studies (Qigong, n 52; Tai Chi, n 5 6). Self-efficacy wasgenerally assessed in the RCTs as asecondary outcome and reflected the‘‘problem’’ area under investigation,such as falls self-efficacy (i.e., feelingconfident that one will not fall) orefficacy to manage a disease (arthritis,fibromyalgia) or symptom (pain). Self-efficacy for falls was significantly in-creased as a result of participation inTai Chi in three studies with adults atrisk for falls compared to wait-list orusual-care, sedentary controlgroups.68,73,99,123 In studies with clinicalpopulations, persons with arthritis ex-perienced improvements in arthritisself-efficacy67 and fibromyalgia patientsexperienced improvements in theability to manage pain100 after partici-pating in Tai Chi as compared toinactive control groups that providedsocial interaction (telephone calls andrelaxation therapy, respectively). Last-ly, the perceived ability to handle stressor novel experiences95,101 and exerciseself-efficacy97,101 were enhanced rela-tive to inactive control groups as afunction of participation in Qigong orTai Chi.

Patient-Reported OutcomesPROs include reports of symptoms

related to disease as perceived by thepatient. The definition of PROs as ‘‘ameasurement of any aspect of a pa-tient’s health status that comes directlyfrom the patient, without the inter-pretation of the patient’s responses bya physician or anyone else,’’102 has

developed over the past decade as animportant indicator of treatment out-comes that matter to the patient,including an array of symptoms such aspain, fatigue, and nausea. AlthoughPRO lists often include factors such asanxiety and depression, these are notincluded here, but rather in a separatesection to address a range of psycho-logical effects.

Thirteen studies are included in thiscategory (Qigong, n 5 3; Tai Chi, n 510). Arthritic pain31,71,103,104 decreasedsignificantly in response to Tai Chicompared to inactive (health educa-tion or usual-care) controls. Self-re-ported neck pain and disability64 im-proved to a similar degree for Qigongand an exercise comparison interven-tion, but the difference betweengroups was not significant. Fibromyal-gia symptoms improved significantly inone study comparing Tai Chi to arelaxation intervention,100 whereas an-other study reported slight improve-ments in symptoms for both Qigongand a usual-care control group with nosignificant difference between thegroups.69 Perceived symptoms of heartfailure,55 disability,30 and sickness im-pact scores32 decreased in response toTai Chi interventions as compared toinactive controls (either usual care oreducational interventions) and sleepquality improved for Tai Chi even ascompared to an exercise interven-tion.105 With Tai Chi, dissociative ex-periences and symptoms improvedclinically, but were not statisticallydifferent from gains achieved by asupport group among male veterans.106

Parkinson’s disease symptoms and dis-ability were not significantly changedfollowing a 7-week session of Qigongcompared to aerobic trainingsessions.57

With the wide range of symptomsand irregular outcomes of these PROsstudies, it is difficult to draw meaning-ful conclusions about this category.Pain consistently responded to Tai Chiin four studies, but other symptomswere not uniformly assessed.

PsychologicalTwenty-seven articles (Qigong, n 5

7; Tai Chi, n 5 19; and one study usingboth Qigong and Tai Chi) reported onpsychological factors such as anxiety,depression, stress, mood, fear of fall-



ing, and self-esteem. Most of thesestudies examined psychological factorsas secondary goals of the study, andconsequently, they often did not in-tentionally recruit participants withappreciable psychological distress.Nevertheless, a number of substantialfindings dominate this category.

Anxiety decreased significantly forparticipants practicing Qigong com-pared to an active exercisegroup.28,46,107 Depression was shown toimprove significantly in studies com-paring Qigong to an inactive control,newspaper reading,95 and for Tai Chicompared to usual-care, psychosocialsupport, or stretching/education con-trols.56,71,108 General measures of mood(e.g., Profile of Mood States) wereimproved significantly for participantspracticing Tai Chi compared to usual-care controls.66,96,101,109

Depression improved, but not sig-nificantly, for both Qigong and exer-cise comparison groups28,94 and for TaiChi compared to an educational in-tervention.110 One study reported im-proved depression, anxiety, and stressamong patients with osteoarthritis forboth Tai Chi and hydrotherapy groupscompared to a wait-list control, butonly significantly so for hydrotherapy.31

Nonsignificant changes in anxietywere reported in a study of Tai Chicompared to a relaxation interven-tion100 and two other studies did notdetect significant differences in de-pression in response to Tai Chi55,100 orQigong58 compared to usual-care orinactive controls. Fear of falling de-creased significantly in most stud-ies49,80,81,99,111 except for one thatshowed no change.82 Reports of self-esteem significantly improved in testsof Tai Chi compared to usual care91,112

and psychosocial support,93 but theincrease in self-esteem compared toexercise and education controls wasnot significant.97

Jin109 specifically created a stressfulsituation and measured the responsein mood, self-reported stress levels, andblood pressure across four interven-tions, including Tai Chi, meditation,brisk walking, and neutral reading.Significant improvements were shownin adrenaline, heart rate, and nor-adrenaline in Tai Chi compared to aneutral reading intervention, and allgroups showed improvements in corti-

sol. In another study examining bloodmarkers related to stress response,norepinephrine, epinephrine, andcortisol blood levels were significantlydecreased in response to Qigong com-pared to a wait-list control group.117

This category of symptoms, particu-larly anxiety and depression, showsfairly consistent responses to both TaiChi and Qigong, especially when thecontrol intervention does not includeactive interventions such as exercise. Inparticular, with a few studies indicatingthat there may be changes in bio-markers associated with anxiety and/ordepression in response to the inter-ventions, this category shows promisefor examining potential mechanismsof action for the change in psycholog-ical state.

Immune Function and InflammationImmune-related responses have also

been reported in response to Qigong(n 5 3) and Tai Chi (n 5 3) studies.Manzaneque et al.113 reported im-provements in a number of immune-related blood markers, including totalnumber of leukocytes, number ofeosinophils, and number and percent-age of monocytes, as well as comple-ment C3 levels, following a 1-monthQigong intervention compared tousual care. Antibody levels in responseto flu vaccinations were significantlyincreased among a Qigong groupcompared to usual care.114 Varicellazoster virus titers and T cells increasedin response to vaccine among Tai Chipractitioners.110 An earlier study con-ducted by Irwin et al.90 reported anincrease in varicella zoster virus–spe-cific cell-mediated immunity amongthose practicing Tai Chi compared towait-list controls.

Immune function and inflammationare closely related, and are oftenassessed using a variety of blood mark-ers, particularly certain cytokines and C-reactive protein. Interleukin-6, an im-portant marker of inflammation, wasfound to be significantly modulated inresponse to practicing Qigong, com-pared to a no-exercise control group.40

On the other hand, C-reactive proteinand erythrocyte sedimentation ratesremained unchanged among a group ofrheumatoid arthritis patients who par-ticipated in a Tai Chi class compared tostretching and wellness education.71

A number of studies not utilizing anRCT design have examined bloodmarkers prior to and after Tai Chi orQigong interventions, providing someindication of factors that might beimportant to explore in future RCTs(and not reported in the table). Forexample, improvements in thyroid-stimulating hormone, follicle-stimulat-ing hormone, triiodothyronine,115 andlymphocyte production116 have beennoted in response to Tai Chi comparedto matched controls. Pre-post Tai Chiintervention designs have also shownan improvement in immunoglobulinG117 and natural killer cells,118 andsimilar non-RCTs have suggested thatQigong improves immune functionand reduces inflammation profiles asindicated by cytokine and T-lympho-cyte subset proportions.119–121

As with the category of psychologicaloutcomes, these immune- and inflam-mation-related parameters fairly con-sistently respond to Tai Chi andQigong, while also providing potentialfor examining mechanisms of action.

DISCUSSION

In answering research question 1, wehave identified nine categories ofhealth benefits related to Tai Chi andQigong interventions, with varyinglevels of support. Six domains ofhealth-related benefits have dominatedthe research with 16 or more RCTspublished for each of these outcomes:psychological effects (27), falls/bal-ance (23), cardiopulmonary fitness(19), QOL (17), PROs (18), andphysical function (16). These areasrepresent most of the RCTs reviewed,with many of the studies includingmultiple measured outcomes spanningacross several categories (n 5 42).Substantially fewer RCTs have beencompleted in the other three catego-ries, including bone density (4), self-efficacy (8), and studies examiningmarkers of immune function or in-flammation (6).

The preponderance of studiesshowed significant, positive results onthe tested health outcomes, especiallywhen comparisons were made withminimally active or inactive controls (n5 52). For some of the outcomesaddressed in this review, there werestudies that did not demonstrate sig-



nificant improvements for the Tai Chior Qigong intervention as compared tothe control condition. For the mostpart, however, these nonsignificantfindings occurred in studies in whichthe control design was actually atreatment type of control expected toproduce similar benefits, such as aneducational control group interven-tion producing similar outcomes to TaiChi for self-esteem,97 aerobic exerciseshowing similar results to Qigong inreducing depression,28,57 an acupres-sure group successfully maintainingweight loss compared to no interven-tion effect for Qigong,60 or resistancetraining producing similar (nonsignif-icant) effects as Tai Chi for musclestrength, balance, and falls.43,66 It isimportant to note that although theTai Chi and Qigong interventions didnot produce larger benefits than theseactive treatment controls, in most casessubstantial improvements in the out-come were observed for both treat-ment groups.Other studies in which the improve-

ments did not significantly differ be-tween the treatment group and thecontrol group suffered from (1) studydesigns of shorter duration (4–8 weeks,rather than the usual 12 or moreweeks),51,96 although there were someexceptional studies with significantresults after only 8 weeks44,81,101; (2)selection of very health-compromisedparticipants or individuals with condi-tions that do not generally respond toother conventional treatments ormedicines, such as muscular dystro-phy,58 multiple morbidities,47 fibromy-algia,69 or arthritis;71 or (3) the out-come measured was not noted asparticularly problematic nor set as aneligibility criteria for poor startinglevels at baseline (n 5 5).28,94

On the other hand, in the areas ofresearch that address outcomes typi-cally associated with physical exercise,such as cardiopulmonary health orphysical function, results are fairlyconsistent in showing that positive,significantly larger effects are observedfor both Tai Chi and Qigong whencompared to no-exercise controlgroups and similar health outcomesare found when compared to exercisecontrols. Even with the very wide rangeof study design types and strength ofcontrol interventions, and the entry

level of the health status of studyparticipants, there remains a numberof remarkable and persistent findingsof health benefits in response to bothQigong and Tai Chi.

In response to research question 2,we have noted in earlier sections theways in which Qigong and Tai Chi areconsidered equivalent, and now ad-dress how studies identifying similaroutcomes in response to these practic-es may provide additional evidence forequivalence. On the surface, researchthat examines the effects of Qigong onhealth outcomes appears to be of lessermagnitude than the research on whatis typically called Tai Chi. For eachcategory of outcomes described above,we noted how many RCTs had beenconducted for each, Tai Chi andQigong, and for the most part, therewere many fewer reports on Qigongthan for what is named Tai Chi for anygiven outcome examined. Neverthe-less, across the outcomes examined inRCTs, the findings are often similar,with no particular trends indicatingthat one has different effects than theother.

As noted earlier, however, it is notunusual for the intervention used in astudy or trial to be named Tai Chi, butto actually apply a set of activities that ismore a form of Qigong, that is, easy-to-learn movements that are simple andrepeatable rather than the long com-plex sequences of traditional Tai Chimovements that can take a long time tolearn. For example, a large number ofstudies examining Tai Chi effects onbalance use a modified, repetitive formof Tai Chi that is more like Qigong.Thus, although it appears that fewerstudies have been conducted to testwhat is called Qigong, it is also clearthat when a practice called Tai Chi ismodified to focus especially on balanceenhancement, for example, it actuallymay be Tai Chi in name only.

Given the apparent similarity ofpractice forms utilized in research, thediscussion of equivalence of Tai Chiand Qigong extends beyond the earlierobservation that they are similar inpractice and philosophy. Because re-search designs often incorporateblended aspects of both Qigong andTai Chi, it is unreasonable to claim thatthe evidence is lacking for one or theother and it becomes inappropriate

not to claim their equivalence. Wesuggest that the combined currentresearch provides a wider base ofgrowing evidence indicating that thesetwo forms produce a wide range ofhealth-related benefits.

The problem with claiming equiva-lence, then, does not lie within thesmaller number of studies using a formcalled Qigong, but rather in the lack ofdetail reported across the studies re-garding whether or not the interven-tions contain the key elements philo-sophically and operationally thoughtto define meditative movement prac-tices such as Tai Chi and Qigong. Inprevious publications, and in thisreview, we note that the roots of bothof these TCM-based wellness practicesrequire that the key elements ofmeditative movement be implement-ed: focus on regulating the body(movement/posture); focus on regu-lating the breath; and focus on regu-lating the mind (consciousness) toachieve a meditative state. Given theequivalence noted in foundationalprinciples and practice, the differencesamong interventions and resultanteffects on outcomes would perhapsmore purposefully be assessed forintervention fidelity (i.e., adherence tothe criteria of meditative movement).

Beyond the meditative movementfactors that tie the practices andexpected outcomes together, other,more conventional factors would beimportant to assess, each potentiallycontributing to variations in outcomesachieved. For example, dosing (i.e.,frequency, duration, and level of in-tensity, including estimate of aerobiclevel or metabolic equivalents) may beimportant in whether or not benefitsaccrue. Or a focus on particular musclegroups may be critical to understand-ing changes relative to certain goals(e.g., how many of the exerciseschosen for a study protocol developquadriceps strength likely to produceresults for specific physical functiontests?). Beyond the important similari-ties of movement and a focus onbreath and mind to achieve meditativestates, there are other aspects that varygreatly within the wide variety of bothTai Chi and Qigong exercises, includ-ing speed of execution, muscle groupsused, and range of motion, all of whichmay provide differences in the physio-



logically oriented outcomes (similar tothe differences that could be noted inthe wide variety of exercises consideredunder the aerobic umbrella).

While equivalence of Qigong andTai Chi is established for philosophyand practice, there is still work to bedone to test for similarity of effects.With consistent reporting on adher-ence to the above mentioned aspectsof practice, not only could a level ofstandardization be implemented, butalso measures that control for variationof interventions could be used tobetter understand differences andsimilarities in effects.1

LIMITATIONS

For purposes of this review, a studywas selected if it was designed as anRCT and compared the effects ofeither Tai Chi or Qigong to those of acontrol condition on a physical orpsychological health outcome. Howev-er, there was no further grading of thequality of the research design. As aresult of this relatively broad inclusioncriterion, the studies represent a widevariety in methods of controlling forbalanced randomization and intent totreat analyses, in the specific methodsof implementing Tai Chi and Qigong,in the outcomes assessed, in themeasurement tools used to ascertainthe outcomes, and in the populationsbeing studied.

One difficulty in examining such abroad scope of studies is that the largenumber of studies required that welogically, but artificially, construct cat-egories within which to discuss eachgroup of outcomes. However, bychoosing to categorize by health out-comes, rather than participant, patient,or disease types, we have provided oneparticular view of the data, and mayhave obscured other aspects. For ex-ample, in a recently published review,the authors analyzed studies that wereconducted with community-dwellingadults over the age of 55.122 Resultsshowed that interventions utilizing TaiChi and Qigong may help older adultsimprove physical function and reduceblood pressure, fall risk, depression,and anxiety. Another view of these datamay emerge if only studies of chroni-cally ill participants are evaluated.Thus, there may be other ways to

examine the RCTs reported in thecurrent review such that specific dis-eases or selected study populationsmay reveal more consistent findings(positive or negative) for certain out-comes that are clearly tied to entrylevel values.

CONCLUSION

Our intent has been to recognize thecommon critical elements of Qigongand Tai Chi, based on their similaritiesin philosophy and principles as well ascommon practice components. Withthis established, we thoroughly explorethe range of findings for similar healthoutcomes and treat the two as equiva-lent aspects of one form of mind-bodypractice.

The preponderance of findings arepositive for a wide range of healthbenefits in response to Tai Chi, and agrowing evidence base for similarbenefits for Qigong. As described,there are foundational similarities be-tween Qigong and Tai Chi interven-tion protocols, as traditional Tai Chi istypically modified and adapted for easeof dissemination to more closely re-semble forms of Qigong. This supportsthe rationale that outcomes can betabulated across both types of studies,further supporting claims of theequivalence of Qigong and Tai Chi.

A compelling body of researchemerges when Tai Chi studies and thegrowing body of Qigong studies arecombined. The strongest, most consis-tent evidence is demonstrated foreffects on bone health, cardiopulmo-nary fitness, some aspects of physicalfunction, QOL, self-efficacy, and fac-tors related to falls prevention, whilefindings are mixed for effects of TaiChi or Qigong on psychological factorsand PROs. Study design factors thatappear to yield mixed findings are (a)the frequent choice of physical activityas a control group intervention, re-sulting in limited power to detectsignificant differences, (b) selection ofparticipants who do not demonstratedeficiencies in baseline levels of theoutcomes to be assessed, and (c) theuse of study participants with severe,chronic, progressive illnesses who maybe slower to respond or may notrespond at all to the practices. Otherstudies, however, suggest that Tai Chi

or Qigong may improve or slow theprogression of such illnesses. This maybe especially likely when the practicesare implemented early as an aspect ofwellness, prevention, or disease man-agement in a proactive, risk reductioncontext. In a recent review addressingTai Chi and Qigong research amongolder adults, it was pointed out that noadverse events were reported acrossstudies.122 The substantial potential forachieving health benefits, the minimalcost incurred by this form of self-care,the potential cost efficiencies of groupdelivered care, and the apparent safetyof implementation across populations,points to the importance of widerimplementation and dissemination.

SO WHAT? Implications for HealthPromotion Practitioners andResearchersWhat is already known on this topic?

The current state of researchsplinters these TCM-based wellnesspractices by identifying them withdifferent names, and treating themas distinct fields of inquiry, reducingthe potential for evaluating healthoutcomes across Qigong and TaiChi research.What does this article add?

This review has identified nu-merous outcomes with varying levelsof evidence for the efficacy forQigong and Tai Chi. The strongerevidence base for bone health,cardiorespiratory fitness, physicalfunction/balance and QOL, andthe potential demonstrated for psy-chological benefits and falls pre-vention, is sufficient to suggest thatTai Chi and Qigong be promoted asa viable, accessible alternative, es-pecially for individuals who mightprefer these activities over moreconventional or vigorous forms ofexercise. In addition to the healthpromotion and dissemination im-plications, the current state of thescience outlines the challenges forresearchers.What are the implications for healthpromotion practice or research?

The wide variations in popula-tions and outcomes studied, thefrequently lacking descriptions ofinterventions or dose, and the con-



Acknowledgments

This research is supported in part by NIH/NCCAM grantU01 AT002706-03 (PI:Larkey) and NIH/NINR grant1F31NR010852-01 and a John A. Hartford BAGNCScholarship, 2008–2010 (PI:Rogers).

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