Functional and Psychosocial Effects

of Health Qigong in Patients with COPD:

A Randomized Controlled Trial
Bobby H.P. Ng, PhD,
1
Hector W.H. Tsang, PhD,
1
Alice Y.M. Jones,
1
C.T. So, MSc,
2
and Thomas Y.W. Mok, MBBS
3
Abstract
Context: The initial gain from a Pulmonary Rehabilitation Program (PRP) among patients with chronic ob-
structive pulmonary disease (COPD) begins to fade away 6 months after the completion of a rehabilitation
program. One possible reason may be due to the poor compliance of the patients to the existing forms of home
exercise program (e.g., walking, weight training activities, etc.).
Objectives: This study tested the efcacy of health qigong (HQG), a traditional Chinese exercise, as an adjunct
home exercise program in optimizing the gains obtained from PRP until 6 months after discharge.
Design: This was a randomized controlled trial (RCT) on a mindbody exercise intervention.
Participants: Eighty (80) patients with COPD receiving conventional PRP pulmonary rehabilitation program
were randomized to the HQG intervention group (n 40) and control group (n 40).
Outcome measures: Assessments were undertaken by blinded assessors at baseline, discharge from training, and
follow-up (FU) at 3 and 6 months. Primary outcomes involved functional capacity scales and secondary out-
comes involved quality-of-life scales.
Results: Intention-to-treat analysis identied trends of improvement in all outcome measures in the HQG group,
whereas lesser improvement and trends of deteriorations were identied in the control group. Ancillary analysis
using a per-protocol method, however, identied signicantly better improvements in functional capacity
measures among the HQG at the 6-month FU.
Conclusions: This RCT provided some evidence to support the positive effect of HQG as an adjunct home
exercise for rehabilitation among people with COPD and to support further related research.
Introduction
P
ulmonary rehabilitation program (PRP) has been
shown to be effective in controlling symptoms and im-
proving quality of life (QOL) among patients with chronic
obstructive pulmonary diseases (COPD).
1
However, it re-
mains uncertain how long the treatment effects would per-
sist.
2
Both overseas reports and local experience of the authors
suggest that the initial gain fromPRP would begin to decrease
6 months after the completion of the rehabilitation program,
especially among older and frailer adults.
3,4
One (1) possible
reason may be due to the poor compliance of the patients to
the existing forms of home exercise program (e.g., walking,
weight-training activities, etc.). Such limitation of the con-
ventional intervention has inspired this research team to ex-
plore whether qigong, a traditional Chinese mindbody
exercise, can serve as an adjunct home exercise program, based
on its several characteristics that seem to favor better compli-
ance. First, it is easy to learn. Second, it can be practiced within
a conned environment not affected by weather. Third, it has
higher perceived therapeutic value from a cultural perspec-
tive.
5
The authors prior studies demonstrated that compliance
with the daily practice of health qigong (HQG) was signicantly
better than conventional remedial activities among frail elderly
clients with multiple chronic disabilities.
6,7
Qigong has long been used to promote a healthy life and to
treat various chronic diseases as described in the earliest
Traditional Chinese Medicine (TCM) text.
8
This kind of ex-
ercise is practiced based on the integration of three aspects,
namely, postural adjustment, breathing regulation, and
1
Centre for East-Meets-West, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong
Kong.
2
Occupational Therapy Department, Kowloon Hospital, Kowloon, Hong Kong.
3
Respiratory Medical Department, Kowloon Hospital, Kowloon, Hong Kong.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 17, Number 3, 2011, pp. 243251
Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2010.0215
243
calming the mind.
9,10
It can be regarded as a form of
mindbody exercise according to the IDEA Mindbody
Fitness Committee,
11
and its application in health and reha-
bilitation is receiving more attention.
12
The current ofcial
name for this kind of self-practice mindbody exercise in
mainland China is Health Qigong (HQG).
13
According to TCM, the pathology of COPD reects not
only the invasion of an external pathogen, but also a func-
tional disorder of the lung, spleen, and kidney.
14
HQG is an
exercise that TCM practitioners would prescribe to patients
with COPD for strengthening the function of different in-
ternal organs during the remission stage. The effect of HQG
training among patients with COPD has been explored by
two prior studies. The rst study showed that the extent of
paradoxical thoraco-abdominal motion both at rest and
during resistance was abated, and the threshold of dyspnea
was raised after 16 weeks of qigong training.
15
In the second
study, lung function and the breadth of the diaphragm
movements improved signicantly as compared to external
diaphragm pacer therapy after 3 weeks of HQG training.
16
However, data pertinent to the long-term effect of regular
HQG practice on such other aspects as functional capacity
and QOL are scarce. The current study investigated the effect
of a more extended period of practice of Baduanjin, one form
of standardized HQG, on optimizing and maintaining the
physical and psychosocial benets obtained by patients with
COPD receiving a pulmonary rehabilitation program. It was
hypothesized that Baduanjin as an adjunct home exercise
program would maintain the functional capacity and QOL
better than the conventional management at the 6-month
follow-up (FU) assessment.
Methods
Design of the experiment
This was a randomized controlled trial with single blinded
outcome assessors. The outcomes assessments were adminis-
tered by blinded assessors who were ignorant of the treatment
arm in which each subject was assigned. The assessments
were conducted at four time points, including at admission to
the study prior to randomization, the time of discharged from
the pulmonary rehabilitation program, 3-month FU, and 6-
month FU. Institutional ethical approvals were sought from
The Hong Kong Polytechnic University and the participating
clinical setting before the study began. In addition, individual
written and informed consents were sought from all partici-
pants before data collection commenced.
Participants and setting
The study was undertaken in a respiratory care hospital
that has provided ambulatory rehabilitation program for
patients with COPD since the early 1990s in Hong Kong.
Subjects fullling the following criteria were recruited: (1)
with diagnosis of COPD conrmed by both medical history
and air-ow limitation (i.e., the ratio of forced expiratory
volume in the rst second (FEV
1
) to forced vital capacity was
less than 70%), as reected by spirometric readings mea-
sured after postbronchodilator therapy and according to the
American Thoracic Society standard
17
; (2) medically stable as
interpreted by no hospital admissions for chest problems in
the past month, (3) had already stopped smoking at least for
6 months, (4) no other disabling diseases (e.g., strokes, par-
kinsonism, etc.), (5) participating in our 12-session outpatient
pulmonary rehabilitation program, and (6) no prior history
of practicing qigong.
Sample size and power calculation
The 6-minute walk test (6MW), which is commonly ac-
cepted as the most sensitive outcome measure in pulmonary
rehabilitation,
18
was employed for sample size estimation. A
change of 54 m in 6MW was identied as the minimal sig-
nicant difference between group means (minDIFF). The
standard deviation (SD) of the measure was reported as 57 m
according to our past experience. Setting the a at 0.05 (two-
tailed) and the power at 80%, the minimum sample size for
each arm was 19 according to the following formula:
[1.96 0.84]
2
* 2 * SD
2
/minDIFF
2
. To compensate for the
estimated 30% attrition of subjects, the sample size was ad-
justed to be 27 subjects for each arm. Based on this estima-
tion, 80 patients were eventually recruited.
Randomization and allocation concealment
A prior randomization list was drawn based on computer-
generated random numbers before the study commenced. It
was then sealed in a database le with security password. In
order to achieve a balanced number of treatment and control
subjects at every single point of time, a randomization
strategy according to permuted blocks was adopted.
19
According to the permutated blocks strategy, the possible
combination sequences for every block of 4 subjects were as
follows: (1) TTCC, (2) TCTC, (3) TCCT, (4) CCTT, (5) CTCT,
and (6) CTTC, where T indicated Treatment and C indicated
Control. Based on the random number drawn for the rst of
every four allocations, the particular sequence of T and C out
of the six possible combinations was selected for these 4
subjects. In case the random number for the rst subject was
beyond the range from 1 to 6, the random number for the
second subject was adopted. On the ninth training session of
the pulmonary rehabilitation training program for each po-
tential subject, the occupational therapist who was blind to the
list opened the le and assigned the subject to either the
treatment or the control group accordingly. A home exercise
program was usually introduced to our patients with COPD
on the ninth session of our conventional PRP.
Intervention protocols
For the treatment group, each patient received four 45-
minute training sessions on HQG led by a trained therapist
on the ninth, tenth, eleventh, and twelfth sessions of the PRP,
together with a home learning package in form of audiovi-
sual materials. The specic form of HQG chosen in this study
was Baduanjin.
6,7,20
It consists of eight distinct movement
routines, with each movement routine being repeated six
times. The whole protocol usually takes 1215 minutes to
complete at the usual pace. To address the special needs of
patients with COPD, an expert panel review was conducted
to assess its potential clinical effectiveness. A eld test was
also conducted to study the safety in its application to COPD
patients prior to the RCT. Five (5) adaptations were ulti-
mately recommended by the experts (Box 1).
21
In order to
maximize the potential benets of the training, the minimal
dosage of the training protocol that the experts advised was
244 NG ET AL.
to keep practice at least 1 time per day and for at least 4 times
a week until the 6-month FU. To keep a record of their own
practice, each patient was issued a daily log.
For the control group, each patient received the same
number and duration of additional training sessions re-
inforcing the breathing (including pursed-lip and coordi-
nated breathing) and walking exercises of the conventional
program to make it comparable to the treatment group in
terms of additional staff attention given to the participants.
In addition, another set of audiovisual training material on
the corresponding aspects was issued to each control subject.
They were also advised to keep daily walking for not less
than 30 minutes until the 6-month FU.
Outcome measures
Outcome measures were selected based on a number of
criteria that included specicity for pulmonary rehabilita-
tion, practicality, responsiveness to change,
22
and availability
of Chinese translation and local validation data.
Primary outcomes. The 6MW has well-documented test
retest reliability (intraclass correlation being 0.97), and is
found to be linearly related to maximum metabolic equiva-
lents (METs) (r 0.687, p <0.001).
23
A related assessment
procedure was conducted according to the American Thoracic
Society guideline.
24
The Monitored Functional Task Evalua-
tion (MFTE) is an activity of daily living scale specic for
patients with COPD. It has very good testretest reliability
(intraclass correlation being 0.92), and is linearly related to
COPD disability scale (r 0.583, p <0.01) and 6-minute
walk (r 0.322, p <0.01).
25
Secondary outcomes. These are QOL scales, including
the General Health and the Mental Health subscales of the
Medical Outcomes 36-Item Short Form Health Survey (SF-
36), and the Chinese Chronic Respiratory Questionnaire
(CCRQ). The SF-36 is a generic QOL scale with high internal-
consistency reliability (Cronbachs a >0.70 for both General
Health and Mental Health Subscales). The Mental Health
subscale correlated highly with the associated hospital anx-
iety and depression scores (Spearman rank correlation coef-
cient 0.62, p <0.05).
26,27
The CCRQ, in contrast, is a
disease-specic QOL scale with strong testretest reliability
(Spearmans r correlation ranged from 0.79 to 0.94 for dif-
ferent subscores) and is linearly related to the 6-minute walk
(r 0.26, p <0.01) and MFTE (r 0.36, p <0.01).
28
Lung
function data and the BODE index (BodyMass Index, Air-
ow Obstruction, Dyspnea, and Exercise Capacity Index),
which were routinely assessed by the team at baseline,
would be adopted for use in possible subgroup analysis.
Data analysis
The analysis was rst conducted with the intention-to-
treat (ITT) analysis, which included all randomized subjects
classied according to their randomization and irrespective
of their completion of treatment and FU assessments. Miss-
ing values at discharge, 3-month FU, and 6-month FU were
imputed using last observation carried forward method.
Then ancillary analysis was conducted adopting the per-
protocol method, which included only subjects who had
completed all FU assessments and well complied with the
treatment protocol (i.e., at least 4 times of HQG practice in a
week). Students t test and Fisher exact test were used to
compare baseline characteristics of the two groups. To test
for group differences in mean change from baseline within
subject at the 6-month FU, t test was used. To test for dif-
ferences in group and time interaction, repeated-measures
analysis of variance (ANOVA), followed by post-hoc t test
Box 1. The Health Qigong Protocol Baduanjin and the recommended adaptations for patients with chronic
obstructive pulmonary disease (COPD)
Adaptations for patients with COPD
1) Focuses the Mind on perceived exertion, perceived dyspnea or perceived pain (not over 4.5 on visual analog scale)
in order to control the pace of practice,
2) Natural breathing; use movements to guide breathing pattern and incorporate pursed-lip breathing if necessary,
3) Movements should be performed at a range within the ones comfort zone, but a little sense of stretching is required,
4) Allows pauses for rest, whenever necessary, and,
5) Allows choices of routines that the patients feel competent to practice at the start and gradually upgrade to the full
set according to individual progress.
Figures in Box 1 Chinese Health Qigong Association. Reproduced with permission.
HEALTH QIGONG 245
analysis at each FU time point, were employed. Results were
reported as signicant at a 0.05, except in post-hoc analysis
where the a values were adjusted accordingly.
Results
Attrition and compliance
A total of 83 subjects were approached. Eighty (80) of them
aligned with the inclusion criteria and agreed to participate
and continued with the random allocation (Fig. 1). Forty (40)
subjects were allocated to each treatment arm with no sig-
nicance differences between the two groups at baseline
(Table 1). The total numbers of dropout and loss to FU did
not differ signicantly between the two groups (i.e., 30% for
the HQG group and 27.5% for the control group). Both the
HQG group and the control group subjects performed daily
walking exercise for not less than 30 minutes during the 6
months of FU. For the HQG group, only 23 cases followed
through the HQG practice of not less than 1 time a day and 4
times a week by themselves up to the 6-month FU, according
to the prescribed protocol. The remaining 5 withdrew from
practice shortly after discharge from the PRP program. The
reasons were that they forgot how to perform the various
routines and how to use the audiovisual training material.
Table 1. Comparison of Baseline Characteristics of All Randomized Patients
Health qigong
(n40)
Conventional control
(n40) p
Age 71.75 (1.05) 73.12 (1.33) 0.42
a
% of Male 92.5% 85.0% 0.29
b
% of Oxygen Therapy 37.5% 40.0% 0.82
b
BODE Index 4.68 (0.32) 4.95 (0.35) 0.57
a
BodyMass Index 18.89 (0.60) 19.97 (0.61) 0.21
a
FEV
1
(% of predicted) 37.13 (2.22) 36.75 (2.11) 0.90
a
Functional Capacity
6-Minute Walk (m) 310.78 (10.71) 310.15 (14.99) 0.97
a
MFTE 17.23 (0.45) 17.53 (0.53) 0.67
a
Quality of Life
SF-36: General Health subscale 42.58 (3.38) 49.48 (3.69) 0.17
a
Mental Health subscale 68.40 (3.55) 72.60 (4.31) 0.45
a
CRQ: Dyspnea subscale 4.76 (0.19) 5.03 (0.17) 0.28
a
Fatigue subscale 4.66 (0.18) 4.69 (0.20) 0.93
a
Emotion subscale 5.05 (0.20) 5.31 (0.20) 0.37
a
Mastery subscale 5.01 (0.19) 5.27 (0.19) 0.34
a
Numbers in parentheses designate standard error.
a
Independent sample t test.
b
Fishers Exact test.
BODE, BodyMass Index, Airow Obstruction, Dyspnea, and Exercise Capacity; FEV
1
, forced expiratory volume in the rst second; MFTE,
monitored functional task evaluation; SF-36, 36-Item Short Form Health Survey; CRQ, chronic respiratory questionnaire.
FIG. 1. CONSORT ow diagram.
E
n
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Assessed for
eligibility (n= 83)
Randomized
(n=80)
Analyzed,per-protocol (n=23) Analyzed,per-protocol (n=29)
Lost to follow-up (n=6)
Discontinued intervention (n=5)
Complaint poor health, n=2/ Diff. with AV, n=3
Hosp. adm., n=1/ Died, n=3/ Unidentified, n=2
Allocated to Health Qigong
(n=40)
Received allocated intervention
(n=34)
Did not receive allocated
intervention (n=6)
Hosp. adm., n=1/ Did, n=2/ Unidentified, n=3
Lost to follow-up (n=8)
Discontinued intervention (n=0)
Hosp. adm., n=1/ Died, n=2/ Unidentified, n=5
Allocated to Conventional
Training (n=40)
Received allocated intervention
(n=37)
Did not receive allocated
intervention (n=3)
Unidentified, n=3
Excluded (n=3)
Refuse to participate (n= 2)
Practise tai chi (n=1)
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246 NG ET AL.
Intention-to-treat (ITT) analysis
In the ITT analysis, functional capacity measures and
QOL measures did not differ signicantly between treatment
groups in both t test on mean changes from baseline within
subject to the 6-month FU and repeated-measure ANOVA.
However, trends of better improvement in functional capacity
among the HQG subjects were noted. The mean changes from
baseline within subject for the 6MW were 27.25 m (standard
error [SE] 52.26) in the HQG group and 10.65 (SE59.43) in
the control group, and those for the MFTE were 1.07
(SE3.08) in the HQG group and 0.50 (SE1.78) in the
control group. Moreover, trends of deterioration in QOL
measures were noted in the control group. Four (4) QOL
subscales showed negative changes in the mean changes from
baseline in the control group, but all QOL subscales showed
positive changes in the HQG group.
Ancillary analysis:
Per-protocol
In the per-protocol analysis, the HQG group showed
signicant improvement in functional capacity measures
and the General Health subscale of the SF-36 in mean of
changes within subject from baseline score. The mean of
changes within subject from baseline for the 6MW, the
MFTE, and the General Health subscale of the SF-36 were
55.22 m (SE10.24), 1.96 (SE0.65), and 9.04 (SE3.52),
respectively, in the HQG group, whereas the mean changes
from baseline for the 6MW, the MFTE, and the General
Health subscale of the SF-36 were 7.28 (SE9.91), 0.21
(SE0.27), and 3.48 (SE4.82), respectively, in the con-
trol group (Table 2 and Fig. 2). In repeated-measures
ANOVA, signicant differences in grouptime interaction
were also noted in the functional capacity outcome vari-
ables. Related post-hoc analysis further reected that the
initial benet from PRP for the control subjects ceased to
improve and/or even started to deteriorate in the period
between 3-month and 6-month FU. However, for the HQG
subjects, outcomes were maintained and/or continued to
improve in the period (Table 3). For the other QOL sub-
scales, trends of better improvement among the HQG
subjects in the 3-month and 6-month FU periods were noted
but did not reached signicant levels.
Progress of those 5 participants who defaulted
HQG training
Subgroup analysis of those 5 participants who defaulted
HQG training was conducted by comparing the mean chan-
ges within subjects from baseline at 6-month FU among the
three groups; HQG: Full compliant (n23), HQG: Non-
compliant (n5), and the Control (n29) using one-way
ANOVA. Post-hoc analysis, using the Bonferroni method, was
then performed to further detect differences between these
groups. Signicant differences were identied for the primary
outcome measures and the SF36-General Health Subscale
among the three groups. Post-hoc analysis found that the 5
participants, who defaulted HQG training, made progress
similar to that of the control group but had signicant differ-
ence when compared with the HQG: Full compliant group.
Discussion
The results provided evidence to support the hypothesis
that HQG, as an adjunct home exercise program, better
maintained the improvement in the functional capacity
gained from a pulmonary rehabilitation program among
patients with COPD until the 6-month FU than the conven-
tional program. The result was more apparent when the
subjects complied with the HQG protocol. This nding is not
surprising, because the word gong in Chinese literally refers
to skills or accomplishment cultivated through committed
and regular practice. Participating only in a few sessions of
HQG training is not adequate to produce any improvement
in health status. Moreover, the effect sizes for functional ca-
pacities (i.e., 0.920.94) appeared larger than those for the
QOL subscales (i.e., all below 0.59). The phenomenon is also
noted in our prior studies, which suggested that it took ac-
cumulation of more improvement in physical function over a
longer time to make the effect generalized to subjective re-
port of better outcomes among the Chinese population.
6,7
Despite the fact that our study had much improvement to
address the methodological shortcomings of prior qigong
studies (e.g., stricter measures to ensure randomization and
allocation concealment, recruiting more subjects, longer FU
period, etc.), there are still limitations that might have con-
founded the validity of our results. First, our male subjects
outnumbered female subjects, which may restrict general-
Table 2. Comparison of Mean Changes Within Subjects from Baseline at 6-Month Follow-Up
Intention-to-treatLOCF Ancillary analysis, per-protocol
Outcomes HQG Control p-Value HQG Control p-Value
6MW 27.25 (52.26) 10.65 (59.43) 0.26 55.22 (10.24) 7.28 (9.91) 0.00
a
MFTE 1.07 (3.08) 0.50 (1.78) 0.31 1.96 (0.65) 0.21 (0.27) 0.02
a
SF36: GH 1.4 (17.66) 4.0 (19.17) 0.39 9.04 (3.52) 3.48 (4.82) 0.04
a
SF-36: MH 0.1 (18.38) 3.1 (17.22) 0.42 3.83 (3.23) 5.52 (4.81) 0.12
CRQ: Dyspnea 0.29 (1.12) 0.25 (1.05) 0.87 0.64 (0.26) 0.26 (0.21) 0.27
CRQ: Fatigue 0.11 (0.82) 0.07 (1.32) 0.48 0.30 (0.19) 0.06 (0.27) 0.30
CRQ: Emotion 0.24 (1.23) 0.07 (0.85) 0.11 0.44 (0.21) 0.03 (0.16) 0.08
CRQ: Mastery 0.48 (1.13) 0.21 (1.07) 0.28 0.64 (0.29) 0.33 (0.20) 0.39
Numbers in parentheses represent the standard error.
a
Signicant nding noted.
LOCF, last observation carried forward; HQG, health qigong; 6MW, 6-minute walk test; MFTE, monitored functional task evaluation; SF36:
GH, 36-Item Short Form Health Survey: General Health; SF-36: MH, 36-Item Short Form Health Survey: Mental Health subscale; CRQ,
chronic respiratory questionnaire.
HEALTH QIGONG 247
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248 NG ET AL.
ization of the results to female patients. However, this is
characteristic of this patient group in the Hong Kong Chinese
population, as males seemed to be more affected or known to
the public health care system than females.
29
Second, the
attrition rates for the two groups were high: 27.5% and 30%.
This might be due to the fact that our subjects were older and
frailer. All were in fact above years 70 of age with FEV
1
values below 40% of the corresponding predicted values.
They might suffer other insidious chronic medical diseases or
repeated acute COPD exacerbations, which affected their
participation. Acute COPD exacerbations, which have an
impact on long-term outcomes and the progress of the dis-
ease,
30
should have been reported to facilitate result inter-
pretation. However, as prior consent from patients was not
sought and thus approval from related authority, related
information through the electronic records of the hospital
data system for the dropped out and loss FU cases could
not be validated due to the personal data privacy policy.
Fortunately, the attrition rates of the two groups appeared
comparable, which suggested that the plausible underlying
conditions did not contribute a bias favoring either group. In
future research, we recommend inclusion of younger sub-
jects, preferably with an age range from 60 to 70 years, to
minimize the attribution rate. Meanwhile, a system to check
possible reasons for attrition should be made available.
Third, the rate of withdrawal from the HQG training protocol
was also high (17.9%). Although the learning of HQG is easy,
our current mode of HQG training, with only four individual
training sessions and a set of self-training materials, might not
be adequate for some patients who were slow in acquiring new
motor skills. Closer monitoring of their progress in learning and
perceived self-efcacy might help identify particular subjects
who may need a longer coaching time. Finally, caution must be
taken regarding the generalization of results to a non-Chinese
population. One of the characteristics of our participants is that
they had a positive view towards HQG even though they have
not had the chance to receive it in the past. This may be due to
their values regarding some practices based on TCM. This posi-
tive attitude toward the intervention might have contributed to
their participation and hence to the outcome. As a result, the
results may not be readily applicable to those with a Western
cultural background. These people may not have a positive atti-
tude toward HQG, which is not relevant to their own culture.
However, with increasing awareness of and interest in this mo-
dality among the Western population,
31
hopefully similar results
will be obtained among non-Chinese patients in the near future.
The basic physiologic mechanism that underpinned the
improvement remains unclear. What is certain is that the im-
provement cannot be explained by overload, which is re-
garded as the conventional exercise training principle. The
overload principle reects the concept of intensity, and im-
plies that in order for the muscle to improve in structure and/
or function, it must be taxed beyond a critical level. The met-
abolic requirement for performing movements of HQG and
tai chi belongs to a low-intensity physical activity. The METs
is estimated to range from 1.5 to 2.6,
32
and the mean of the
induced maximum heart rates ranges from 43% to 49% of
predicted maximum heart rates.
33
On the other hand, high-
intensity exercise may produce adverse effects, such as
muscle wasting
34
and disturbed breathing pattern, which then
may reduce exercise capacity
35
among patients with COPD.
Therefore, the authors believe that there should be a different
physiologic mechanism to explain how HQG improved the
functional capacity of the subjects in this study. Physiologic
research efforts on effects of low-intensity muscle activities on
anti-inammation, respiratory sinus arrhythmia, and
meditation-induced specic brain wave patterns provide
hints for future exploration. Repetitive low-intensity muscle
contractions facilitate the modulation of systemic inamma-
tion by upregulating interstitial interleukin-6.
36
Slow breath-
ing, through the Respiratory sinus arrhythmia mechanism,
produces a downregulating effect on the vagal tone
37
and
promotes efciency in gaseous exchange.
38,39
Muscles con-
tractions in harmony with slow breathing facilitate venous
return to the heart fromthe periphery through the respiratory
muscle pump mechanism.
40,41
Meditation involves internal-
ized focus of attention. It produces specic brain-wave pat-
terns (e.g., higher slow a coherence, increases in left-sided
anterior activation, etc.), which are associated with positive
mood and improvement in immune function.
4244
Moreover,
the review of HQG practice among clinical populations sug-
gests that the psychophysiologic outcomes are systemic in
nature, which include enhancing circulation, improving ven-
tilation, and strengthening immune responses.
45
These are in
Table 3. Summary of Repeated-Measures Analysis of Variance
Intention-to-treatLOCF Per-protocol analysis
Outcomes Group Baseline 6-M FU p-Value Baseline 6-M FU p-Value
6MW HQG 310.78 (13.03) 338.53 (13.42) 0.26 316.57 (15.43) 371.78 (14.73) 0.00
a
Control 310.15 (13.03) 320.80 (13.42) 318.66 (14.04) 325.93 (13.29)
MFTE HQG 17.23 (0.49) 18.30 (0.40) 0.39 17.33 (0.57) 19.29 (0.36) 0.01
a
Control 17.53 (0.49) 18.03 (0.40) 18.25 (0.51) 18.45 (0.32)
SF36: GH HQG 42.58 (3.54) 44.00 (3.65) 0.26 44.96 (5.02) 54.00 (5.17) 0.10
Control 49.48 (3.54) 45.48 (3.65) 50.72 (4.47) 47.24 (4.99)
SF-36: MH HQG 68.40 (3.95) 68.50 (4.00) 0.57 70.26 (4.15) 74.09 (5.00) 0.17
Control 72.60 (3.95) 69.50 (4.00) 79.59 (3.69) 74.07 (4.89)
Numbers in parentheses represent the standard error.
a
Signicant nding noted.
LOCF, last observation carried forward; 6-M FU, 6-month follow-up; 6MW, 6-minute walk test; HQG, health qigong; MFTE, monitored
functional task evaluation; SF36: GH, 36-Item Short Form Health Survey: General Health; SF-36: MH, 36-Item Short Form Health Survey:
Mental Health subscale.
HEALTH QIGONG 249
line with the current concepts of the development of comple-
mentary and alternative medicine.
46
On the other hand, the
effect of systemic inammation on the pathophysiology and
morbidity of COPDhas attracted increasing concerns.
47,48
The
effect of HQG on COPD is proposed to be directly related to
the modulation of systemic inammation andstrengthening of
immune responses and/or mediated through the enhance-
ment of circulatory function. Following this proposed mech-
anism, biomarkers documenting the inammation such as C-
reactive protein, interleukin-6, and tumor necrosis factor-a,
should be included in future studies.
Conclusions
To conclude, the exercise instruction, which should be
conducted in order to produce better outcomes over a longer
period, can be further improved, and this study provides
evidence to support the clinical application and further re-
search of HQG as a form of traditional Chinese mindbody
exercise for the rehabilitation of patients with COPD.
Acknowledgments
The authors are grateful to the patients for their partici-
pation in the trial. We also thank the nursing staff and the
physiotherapists of Kowloon Hospital for providing clinical
data of the participants. With the exception of gures in Box
1, all gures were produced by the authors. This work was
supported by the Area of Excellence Grant (A102), Depart-
ment of Rehabilitation Sciences of The Hong Kong Poly-
technic University.
Disclosure Statement
No competing nancial interests exist.
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Address correspondence to:
Hector W.H. Tsang, PhD
Centre for East-Meets-West
Department of Rehabilitation Sciences
The Hong Kong Polytechnic University
Hung Hom, Kowloon
Hong Kong
E-mail: rshtsang@inet.polyu.edu.hk
HEALTH QIGONG 251
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