Sleep Medicine 33 (2017) 70e75

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Sleep Medicine
journal homepage: www.elsevier.com/locate/sleep

Original Article

Effect of Tai Ji Quan training on self-reported sleep quality in elderly

Chinese women with knee osteoarthritis: a randomized controlled
trail
Jiaojiao Lü, Lingyan Huang, Xie Wu, Weijie Fu, Yu Liu*
Key Laboratory of Exercise and Health Sciences of Ministry of Education, Shanghai University of Sport, Shanghai, 200438, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The purpose of this study was to explore the effects of a 24-week Tai Ji Quan training program
Received 17 January 2016 on sleep quality, quality of life, and physical performance among elderly Chinese women with knee
Received in revised form osteoarthritis (OA).
18 March 2016
Methods: A 24-week randomized, controlled trial of 46 elderly women with knee OA. Participants were
Accepted 14 December 2016
Available online 6 February 2017
randomly assigned to either a Tai Ji Quan group (n ¼ 23) or a control group (n ¼ 23). Participants in the
Tai Ji Quan group completed training sessions three times per week, while those in the control group had
bi-weekly educational classes. The primary outcome was total score of the Pittsburgh Sleep Quality of
Keywords:
Tai Chi
Index (PSQI). Secondary outcomes were: seven subscales of the PSQI; sleep latency; total sleep time;
Rheumatic diseases sleep efficiency; physical component summary (PCS) and mental component summary (MCS) of the 36-
Sleep quality item Short Form Health Survey (SF-36); Berg Balance Scale (BBS); and Timed Up and Go (TUG).
Quality of life Results: Compared with the control group, participants in the Tai Ji Quan group had significantly
Aging improved primary outcome (global PSQI score, p ¼ 0.006) and secondary outcomes, including three PSQI
sub-scores (sleep latency, p ¼ 0.031; sleep duration, p ¼ 0.043; daytime dysfunction, p ¼ 0.007), total
sleep time (p ¼ 0.033), and SF-36 PCS (p ¼ 0.006). The Tai Ji Quan group also had significant improve-
ments compared with baseline in three PSQI sub-scores (sleep latency, p ¼ 0.031; habitual sleep effi-
ciency, p ¼ 0.049; sleep disturbance, p ¼ 0.016), sleep latency (p ¼ 0.003), BBS (p ¼ 0.001), and TUG
(p ¼ 0.006).
Conclusion: Tai Ji Quan training is an effective treatment approach to improve sleep quality and quality of
life in elderly Chinese women with knee OA.
Trial registration: Chinese Clinical Trial Registry (June 16, 2013): ChiCTR-TRC-13003264.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction
Knee osteoarthritis (OA) is the most common joint disorder and
a leading cause of chronic pain, functional limitation and physical
disability; it affects women more frequently than men [1]. The
prevalence of symptomatic knee OA is higher in China than in
Western countries [2], especially in women (40% higher in Beijing
than in Framingham, USA) [3]. Sleep complaints are more common
in people with OA because of chronic pain and poor physical
function [4,5]. Sleep disturbances occur in more than two-thirds of
OA patients, leading to augmentation of pain severity, and poor
* Corresponding author. Fax: þ86 21 51253242.
E-mail address: yuliu@sus.edu.cn (Y. Liu).
quality of life and mental health [6]. Therefore, sleep quality is an
important outcome relevant to the treatment efficacy of OA [7].
Non-pharmacological interventions, such as exercise, play an
important role in the treatment of knee OA [1], and can have
beneficial effects on pain, physical function, sleep quality, and
quality of life [8e10]. Tai Ji Quan is a traditional Chinese exercise
that has the potential to improve muscular strength, joint stability
and flexibility, and reduce pain, depression and physical disability
[11,12]. It has been shown that Tai Ji Quan is effective in improving
the sleep quality among different populations, including college
students [13], middle-aged adults [14], older adults [15e17], and
cancer survivors [18]. Subjects participating in Tai Ji Quan have
improved self-reported sleep quality, increased sleep duration, and
reduced sleep-onset latency and sleep disturbances [15,17]. More-
over, there is evidence that this kind of range of motion and low-

http://dx.doi.org/10.1016/j.sleep.2016.12.024
1389-9457/© 2017 Elsevier B.V. All rights reserved.
 J. Lü et al. / Sleep Medicine 33 (2017) 70e75
impact physical activity is associated with improvements in
arthritic symptoms and physical function in patients with OA [19].
However, most of these prior studies have dealt mainly with pain
and physical function, with relatively little attention being paid to
other outcome measures, such as sleep quality and quality of life,
which reflect the real impact of knee OA on patients.
The primary purpose of this study was therefore to determine
the effect of a 24-week Tai Ji Quan training program on self-
reported sleep quality among elderly Chinese women with knee
OA. A secondary purpose was to examine the effects of Tai Ji Quan
on quality of life and physical performance. It was hypothesized
that Tai Ji Quan training would lead to improvement in sleep
quality, quality of life, and physical performance outcome
measures.
2. Methods
2.1. Study design and participants
The study was designed as a randomized, controlled interven-
tion trial with two groups. Participants were randomly assigned
into either a Tai Ji Quan training or health education control group.
The study protocol has been described in detail elsewhere [20] and
was approved by the ethics committee of Shanghai University of
Sport. Written informed consent was obtained from all
participants.
Chinese women, who have a higher risk of both OA and age-
related sleep problems than men [1,21], were recruited from two
community centers in Shanghai between January 2013 and March
2013. Detailed descriptions of inclusion criteria, recruitment and
adherence have already been presented by Zhu et al. [20]. Briefly:
individuals were eligible if they had a clinical diagnosis of knee OA,
an age of 60e70 years, stable medication use, and willingness to
engage in the study and to be assigned to any of the two in-
terventions. Forty-six participants who qualified according to the
eligibility criteria were randomized to the Tai Ji Quan training group
(Tai Ji Quan, n ¼ 23) and the health education control group (con-
trol, n ¼ 23) [20]. Of these, six participants dropped out due to time
conflict and health-related issues (two in the intervention group
and four in the control group).
2.2. Intervention
Individuals in the Tai Ji Quan group participated in a 60-
min session three times a week for 24 weeks. Considering the
symptoms of knee OA and avoiding strenuous activities on joints,
the Tai Ji Quan program was designed to be more suitable for pa-
tients with knee OA, and followed an easy-to-difficult progression,
focusing on reducing sustained unilateral weight bearing, dynamic
rotational weight shifting at the knee joints and excessive knee
flexion. The training program included eight Tai Ji Quan forms
adapted primarily from the 24-form practice routine [22]: (1)
“withdraw and push”; (2) “fan through the back”; (3) “wave hands
like clouds”; (4) “life hand”; (5) “brush knee and twist steps”; (6)
“step back to repulse monkey”; (7) “fair lady works at shuttles” and
(8) “golden pheasant stands with one leg (right and left)”. Each
exercise session included a 5-min warm-up, 50 min of Tai Ji Quan,
and 5-minute cool down, all of which took place in the morning (at
approximately 08:00e09:00). For more details of the Tai Ji Quan
intervention, please refer to Zhu et al. [20]. Mean attendance at Tai
Ji Quan sessions (total of 72) was 87% over 24 weeks (SD 5%; median
[IQR] 88% [83e91%]).
During the 24-week study period, participants in the control
group received 60-min bi-weekly wellness education classes
71
regarding health promotion. Health education participants attended
78% of scheduled sessions (SD 16%; median [IQR] 77% [67e92%]).
2.3. Outcome measures
All outcome measures were assessed at baseline (before inter-
vention) and the end of the study (after intervention), and included
demographic and clinical profiles, anthropometric measures, study
primary outcome measures and secondary outcome measures. All
assessments were completed in a research laboratory at Shanghai
University of Sport, and study assessors who conducted outcome
assessments were blinded to the participants' group allocation.
2.3.1. Primary outcome measures
The Pittsburgh Sleep Quality Index (PSQI, Chinese version [23])
was used as a outcome measure for assessing sleep quality and
disturbances over a one-month time interval, with higher scores
indicating poorer sleep quality [24]. The PSQI is a 19-item self-report
scale with seven components: subjective sleep quality, sleep latency,
sleep duration, habitual sleep efficiency, sleep disturbance, use of
sleeping medications, and daytime dysfunction. The global PSQI
score is the sum of the seven components, ranging from 0 to 21.
The global PSQI score was the primary outcome and the subscale
scores were secondary outcomes in this study. This scale has a high
degree of internal consistency (Cronbach's alpha ¼ 0.83) with good
sensitive (89.6%) and specificity (86.5%) [24].
2.3.2. Secondary outcome measure
Secondary outcome measures included: (1) sleep latency (mi-
nutes), total sleep time (hours) and sleep efficiency (%), and seven
subscales of PSQI (range score: 0e3) [24], (2) physical component
summary (PCS) and mental component summary (MCS) of the 36-
item Short Form Health Survey (SF-36) used as measures of quality
of life, with a range of 0e100 [25], (3) Berg Balance Scale (BBS)
assessing balance, which consisted of 14 items, including simple
mobility tasks (eg, transfers, standing unsupported, sit-to-stand)
and more difficult tasks (eg, tandem standing, turning 360 ,
single-leg stance) [26], (4) Timed Up and Go test (TUG) assessing
mobility in which the participant was asked to stand up from a
chair, walk 3 m, turn around, return to the chair and sit down [27].
2.4. Statistical analysis
All analyses were conducted on an intent-to-treat basis so that
all participants were included and analyzed regardless of adher-
ence or dropout status. The incomplete data resulting from drop-
outs were handled through the method of “last observation carried
forward” [28]. Baseline characteristics of the study participants
were analyzed using analysis of variance for continuous variables
and Chi-squared test or ManneWhitney U test for categorical var-
iables. Differences in each group before and after intervention were
analyzed by paired t-test for normally distributed data and Wil-
coxon signed-rank test for non-parametric data. Mean changes
from baseline were compared between groups using repeated
measure analysis of variance. For the variables that were signifi-
cantly different between groups at baseline, mean changes be-
tween groups were analyzed using analysis of covariance
(ANCOVA) adjusting for baseline levels of the dependent variables.
Relationships between changes in sleep quality, knee pain, quality
of life and physical performance were evaluated using Pearson
correlation analysis. An alpha level of 0.05 was considered as sta-
tistical significance. Data analyses were performed using SPSS
software (version 20.0, IBM Corporation, Armonk, NY, USA).
This randomized, controlled trial was originally powered to
examine effects on gait kinematics [20], which determined the
72 J. Lü et al. / Sleep Medicine 33 (2017) 70e75

sample size of 46 participants with 20% attrition rate. A meaningful
change of PSQI has not been identified. However, this trial had 80%
power to detect a moderate effect size of 0.40 (range 0.30e0.80) for
patient-reported outcomes [29], which may be appropriate for
PSQI, using a two-tailed alpha of 0.05.
3. Results
3.1. Baseline characteristics of participants
Table 1 shows the baseline characteristics of participants,
including demographic, anthropometric, and clinical features, and
the outcome measures in the Tai Ji Quan and control groups. There
were no significant differences between the two groups (p < 0.05).
3.1.1. Sleep quality
At 24 weeks, there was statistically significant difference be-
tween the Tai Ji Quan and control groups for global PSQI score
(F ¼ 8.43, p ¼ 0.006). Participants in the Tai Ji Quan group also
exhibited a significant pre-to-post-intervention improvement in
global PSQI score (t ¼ 3.87, p ¼ 0.001) with a moderate
improvement (25%), while no significant improvement was
observed in control group. Compared with the control group, par-
ticipants in the Tai Ji Quan group showed significant improvements
in three sub-scores of PSQI (sleep latency, F ¼ 4.99, p ¼ 0.031; sleep
duration, F ¼ 4.37, p ¼ 0.043; daytime dysfunction, F ¼ 8.13,
p ¼ 0.007) and the total sleep time (F ¼ 4.90, p ¼ 0.033). In follow-
up pre-to-post-intervention comparisons at 24 weeks, participants
in the Tai Ji Quan group showed significant improvements in three
sub-scores of PSQI (sleep latency, t ¼ 2.32, p ¼ 0.031; habitual
sleep efficiency, t ¼ 2.09, p ¼ 0.049; sleep disturbance, t ¼ 2.65,
p ¼ 0.016) and sleep latency (t ¼ 3.23, p ¼ 0.003) with 32%
improvement, while there was no significant improvement in the
control group (Table 2 and Fig. 1).
3.1.2. Quality of life and physical performance
There was a significant group difference between the Tai Ji Quan
and control groups for PCS score at 24 weeks (F ¼ 8.42, p ¼ 0.006).
In follow-up pre-to-post-intervention comparisons, participants in
the Tai Ji Quan group demonstrated significant improvement in PCS
(t ¼ 2.36, p ¼ 0.029), while no significant improvement was shown
in the control group (Table 3).
Participants in the Tai Ji Quan group also showed significant pre-
to-post-intervention improvements in BBS (t ¼ 3.69, p ¼ 0.001) and
TUG (t ¼ 3.05, p ¼ 0.006). Compared with those in the control
group, there was no significant difference between the two groups
(Table 3).
3.1.3. Correlations between changes in sleep quality, pain, quality of
life and physical performance
The reduction in PSQI score was significantly associated with
greater reduction in knee pain measured by the Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC) score
(r ¼ 0.336, p ¼ 0.045; see Zhu et al. [20] for a detailed description of
intervention-related changes) and there was also a significant
negative correlation between changes in sleep latency and SF-36
PCS (r ¼ 0.340, p ¼ 0.037), indicating that improvement in sleep
quality may be associated with pain relief and better quality of life.
Improvements in sleep quality were not associated with changes in
physical performance measured by BBS and TUG.

Table 1
Baseline characteristics of the study participants.

Measure Tai Ji Quan (n ¼ 23) Control (n ¼ 23) p

Age, years, Mean (SD) 64.61 (3.40) 64.53 (3.43) 0.758

Body Mass Index, kg/m2, Mean (SD) 25.23 (3.46) 25.05 (3.42) 0.872
Education, years, Mean (SD) 9.86 (1.39) 10.11 (3.35) 0.766
Health statusa (1e5), Mean (SD) 3.48 (0.75) 3.89 (0.81) 0.098
Duration of knee pain, months, Mean (SD) 21.91 (13.62) 22.30 (11.77) 0.937
WOMAC score, Mean (SD)
Knee pain 8.46 (4.90) 9.65 (5.64) 0.457
Knee stiffness 3.57 (2.69) 4.76 (3.00) 0.473
Functional limitation 24.70 (12.95) 25.37 (14.64) 0.267
Radiographic severity of knee, n (%)
K/L Grade 1 7 (30.44) 6 (26.09)
K/L Grade 2 12 (52.17) 14 (60.87)
K/L Grade 3 4 (17.39) 3 (13.04) 0.830c
Comorbidities, n (%)
Neck pain 2 (8.69) 3 (13.04)
Low back pain 4 (17.39) 3 (13.04)
Heart disease 1 (4.34) 0
Hypertension 7 (30.43) 8 (34.78) 0.703c
Sleep quality, Mean (SD)
PSQI (0e21) 6.00 (3.02) 8.47 (4.78) 0.063
Poor sleep quality,b n (%) 9 (39.13) 13 (56.52) 0.376c
Sleep latency, minutes, Median (Range) 30.00 (5, 210) 30.00 (5, 60) 0.510y
Total sleep time, hours 7.00 (1.18) 6.21 (1.46) 0.070
Sleep efficiency (%) 87.27 (14.08) 81.94 (19.56) 0.325
SF-36, Mean (SD)
PCS (0e100) 49.05 (8.25) 44.23 (6.81) 0.056
MCS (0e100) 51.54 (9.93) 50.45 (9.35) 0.727
Physical performance, Mean (SD)
BBS (0e56) 53.05 (3.04) 54.58 (1.74) 0.062
TUG, seconds 8.82 (1.20) 8.62 (1.32) 0.614

SD, Standard Deviation; BMI, Body Mass Index; WOMAC, the Western Ontario and McMaster Universities Osteoarthritis Index; K/L, KellgreneLawrence scale; PSQI, the
Pittsburgh Sleep Quality Index; SF-36, the 36-item Short Form Health Survey; PCS, Physical Component Summary; MCS, Mental Component Summary; BBS, Berg Balance
Scale; TUG, Timed Up and Go test.
c
Chi-squared test.
y
ManneWhitney U test.
a
Measured on a 5-point Likert scale in which 1 indicated poor and 5 indicated excellent.
b
Defined as Global PSQI >5.
 J. Lü et al. / Sleep Medicine 33 (2017) 70e75 73

Table 2
Changes from baseline and differences between groups in sleep quality.

Variable Mean difference from baseline (95% CI); pa Group difference after intervention

Tai Ji Quan Control F pb

Global PSQI (0e21) 1.48 (2.27, 0.68); 0.001 0.47 (2.95, 2.01); 0.693 8.432 0.006
PSQI subscales (0e3)
Subjective sleep quality 0.10 (0.22, 0.41); 0.540 0.21 (0.65, 0.23); 0.331 3.901 0.056
Sleep latency 0.33 (0.63, 0.03); 0.031 0.16 (0.79, 0.47); 0.604 4.989 0.031
Sleep duration 0.14 (0.44, 0.16); 0.329 0.11 (0.35, 0.56); 0.630 4.367 0.043
Habitual sleep efficiency 0.33 (0.67, 0.00); 0.049 0.42 (0.21, 1.05); 0.176 2.128 0.153
Sleep disturbance 0.33 (0.60, 0.07); 0.016 0.21 (0.65, 0.23); 0.331 0.012 0.914
Sleep medicine use 0.05 (0.15, 0.05); 0.329 0.00 (0.43, 0.43); 1.000 1.673 0.204
Daytime dysfunction 0.38 (0.80, 0.04); 0.072 0.42 (1.03, 0.19); 0.163 8.131 0.007z
Sleep latency (minutes) 8.57 (e13.92, 3.23); 0.003y 7.11 (24.30, 10.09); 0.450y 3.747 0.060
Total sleep time (hours) 0.19 (0.20, 0.58); 0.321 0.03 (0.39, 0.44); 0.895 4.897 0.033
Sleep efficiency (%) 5.55 (0.01, 11.11); 0.050 3.13 (8.95, 2.70); 0.274 4.044 0.051

The bold values indicate a statistically significant difference.

PSQI, the Pittsburgh Sleep Quality Index; CI, Confidence Interval.
y
Wilcoxon signed-rank test.
z
Analysis of covariance (ANCOVA) adjusting for baseline level of the variable.
a
Difference between before and after intervention by paired t-test.
b
Between-group difference (Tai Ji Quan and control) and time (before and after intervention) by repeated measure analysis of variance.

Fig. 1. Percent change in global Pittsburgh Sleep Quality Index and other outcomes of sleep quality.

Table 3
Changes from baseline and between-group differences in quality of life and physical performance.

Variable Mean difference from baseline (95% CI); pa Group difference after intervention

Tai Ji Quan Control F pb

SF-36 PCS (0e100) 3.94 (0.45, 7.42); 0.029 2.73 (2.09, 7.54); 0.247 8.415 0.006
SF-36 MCS (0e100) 4.01 (0.17, 8.18); 0.059 0.91 (4.39, 6.21); 0.721 1.851 0.182
BBS (0e56) 1.90 (0.83, 2.98); 0.001 0.00 (1.02, 1.02); 1.000 1.357 0.251
TUG (seconds) 0.73 (1.23, 0.23); 0.006 0.27 (0.77, 0.23); 0.994 0.008 0.931

The bold values indicate a statistically significant difference.

SF-36, the 36-item Short Form Health Survey; PCS, Physical Component Summary; MCS, Mental Component Summary; BBS, Berg Balance Scale; TUG, the Timed Up and Go
test; CI, Confidence Interval.
a
Difference between before and after intervention by paired t-test.
b
Between-group difference (Tai Ji Quan and control) and time (before and after intervention) by repeated measure analysis of variance.
74 J. Lü et al. / Sleep Medicine 33 (2017) 70e75
4. Discussion
The primary purpose of this study was to clarify the effects of Tai
Ji Quan on self-reported sleep quality in elderly Chinese women
with knee OA. The major findings were that elderly women with
knee OA benefited from 24-week Tai Ji Quan training, while no
improvement was observed in the health education control group.
Compared with the control group, participants in the Tai Ji Quan
group also showed a concomitant improvement in quality of life
measures. The findings of this randomized controlled trial suggest
that 24-week Tai Ji Quan training is an effective treatment for elderly
women with knee OA that improves sleep quality and quality of life.
In the present study, global PSQI score showed a significant
decrease by, on average, 1.42 points in elderly women with knee OA
participating in Tai Ji Quan, representing a moderate degree of
improvement (25%). Significant group differences were also
observed in total sleep time and three subscale scores of PSQI (sleep
latency, sleep duration, and daytime dysfunction). Although no
between-group difference was observed, there were significant
within-group changes (improvements) in sleep latency, sleep effi-
ciency and other two subscale scores of PSQI (habitual sleep effi-
ciency and sleep disturbance). These results are generally
congruent with the findings of other studies, although the samples
used in the earlier studies were not limited to persons with knee
OA. Two studies by Li et al. [15] and Irwin et al. [17], which
examined the effects of Tai Chi on elderly adults, found significant
improvements among participants engaging in Tai Chi training.
Nguyen et al. [16] examined the effect of Tai Chi on sleep quality in
healthy elder Vietnamese. These studies found significantly
reduced PSQI global score (decreased by 1.8e2.06 points) and the
subscale scores, such as subjective sleep quality, sleep duration,
sleep efficiency and sleep disturbance [15-17]. Moreover, Larkey
et al. [30] demonstrated that Tai Chi training also had positive ef-
fects on sleep quality and fatigue among cancer survivors.
Although the sleep benefits from Tai Ji Quan have been well
demonstrated [15e17,30], it is believed that this current study is the
first to evaluate improvements in sleep quality from a Tai Ji Quan
intervention specifically in knee OA patients. The increased joint
pain and disability associated with knee OA could have direct
impact on other aspects of subjects' lives, including sleep quality,
quality of life, emotional status, stress and anxiety [31,32].
Compared with subjects with other chronic diseases or healthy
controls, subjects with OA experience more frequent and more
significant sleep problems [4,6,33]. Poor sleep quality is not only a
consequence of chronic pain in OA, it is also likely to play an inte-
gral role in augmenting clinical OA pain [34]. Therefore, aggressive
management of sleep quality could be an important approach to
ensuring effectiveness of the treatment and maintaining a higher
level of quality of life in individuals with OA [7].
In addition to demonstrating improvement in sleep quality
measures, participants in the Tai Ji Quan group also showed sig-
nificant improvements in quality of life (SF-36 PCS) and physical
performance (BBS and TUG). Although statistically significant
changes were observed in these measures after the 24-week
intervention, the magnitude of the changes was modest (4e8%)
and much lower than previously reported in other studies [35,36].
This lower degree of improvement may be due to differences in
style, duration and intensity of the Tai Ji Quan intervention and the
characteristics of the participants.
There are several factors that may explain the positive effects of
Tai Ji Quan training on sleep quality in elderly Chinese women,
although the mechanism by which Tai Ji Quan induces such
improvement of sleep quality is not fully understood. First, the ef-
ficacy of Tai Ji Quan on relieving pain symptoms among patients
with OA has been well demonstrated [19], and this may be a major
contributing factor behind the positive effect of Tai Ji Quan on sleep
quality in patients with knee OA [37]. The present study is in
keeping with these findings, since, as reported elsewhere, pain
intensity was reduced by 39% in the Tai Ji Quan group [20], and a
significant correlation between reductions in pain and PSQI total
score (r ¼ 0.336) was observed in the present study. Second, sig-
nificant improvements in quality of life and physical performance
from Tai Ji Quan training were found in the present study, and these
factors have previously been associated with sleep quality in OA
patients [4,37]. There was also a significant negative relationship
between changes in sleep latency and SF-36 PCS (r ¼ 0.340).
Finally, the practice of Tai Ji Quan is a mind-body exercise
comprising physical movements, but also with a psychological
focus and emphasis on relaxation, mindfulness of movement and
breathing that may influence depression, stress, anxiety, emotion,
and self-esteem, all of which may be considered as potential me-
diators of improved sleep quality.
Major strengths of this study included the randomized clinical
trial design, the comprehensive evaluation of sleep quality, and the
use of a Tai Ji Quan protocol designed specifically for knee OA.
However, there were some potential limitations of the study. First,
the results of the intervention effects might have been limited by
the relatively small sample size and the fact that only female sub-
jects were included. This may have restricted the generalizability of
the results concerning Tai Ji Quan benefits. Second, outcomes of
sleep quality and quality of life in this study were measured by
subjective questionnaires (PSQI and SF-36) and it was impossible to
blind the participants to treatment. Therefore, the subjective
measures might have introduced a bias, leading to potential over-
estimation of the intervention effects. Third, due to the absence of
follow-up beyond the 24-week intervention period, it was unclear
whether Tai Ji Quan training has lasting health effects on in-
dividuals with knee OA.
In conclusion, this study suggests that Tai Ji Quan training is an
effective and safe treatment for knee OA that improves sleep quality
and quality of life. Given the promising results, future studies are
needed to demonstrate the generalizability of Tai Ji Quan benefits in
clinical populations with knee OA, and using a longer follow-up
time to examine the sustainability of these effects.
Acknowledgement
This study was supported by the National Natural Science
Foundation of China (81572213) and the Science and Technology
Commission of Shanghai (14DZ1103500).
Conflict of interest
The authors declare that there is no potential conflict of interest
with this manuscript.
The ICMJE Uniform Disclosure Form for Potential Conflicts of
Interest associated with this article can be viewed by clicking on the
following link: http://dx.doi.org/10.1016/j.sleep.2016.12.024.
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