A comprehensive review of health benefits of qigong and tai chi ...
A Comprehensive Review of Health Benefits of Qigong and Tai Chi Roger Jahnke, OMD1, Linda Larkey, PhD2, Carol Rogers3, Jennifer Etnier, PhD4, and Fang Lin5 Roger Jahnke: roger@healthaction.net Linda Larkey: larkeylite@msn.com Carol Rogers: carol.rogers@asu.edu Jennifer Etnier: JLEtnier@uncg.edu Fang Lin: fanglin60@hotmail.com 1 The Institute of Integral Qigong and Tai Chi, 243 Pebble Beach Santa Barbara CA, 93117 2 Arizona State University College of Nursing and Healthcare Innovation, 500 N. 3rd Street, Phoenix, AZ 85004 3 Arizona State University College of Nursing and Healthcare Innovation, 500 N. 3rd Street, Phoenix, AZ 85004. Phone: (602) 677-0711, Fax (602) 496-0775 4 University of North Carolina, Greensboro, Department of Exercise and Sport Science, P.O. Box 26170, Greensboro, NC 27140 5 13448 E Bloomfield Drive, Scottsdale AZ 85259 Abstract Objective���Research examining psychological and physiological benefits of Qigong and Tai Chi is growing rapidly. The many practices described as Qigong or Tai Chi have similar theoretical roots, proposed mechanisms of action and expected benefits. Research trials and reviews, however, treat them as separate targets of examination. This review examines the evidence for achieving outcomes from randomized controlled trials (RCTs) of both. Data Sources���The key words tai chi, taiji, and qigong were entered into electronic search engines for the Cumulative Index for Allied Health and Nursing (CINAHL), Psychological Literature (PsychInfo), PubMed, Cochrane database, and Google Scholar. Study Inclusion Criteria���RCTs reporting on the results of Qigong or Tai Chi interventions and published in peer reviewed journals published from 1993���2007 Data Extraction���Country, type and duration of activity, number/type of subjects, control conditions, 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 9 outcome category groupings that emerged were: bone density (n=4), cardiopulmonary effects (n=19), physical function (n=16), falls and related risk factors (n=23), Quality of Life (n=17), self-efficacy (n=8), patient reported outcomes (n=13), psychological symptoms (n=27), and immune function (n=6). Conclusions���Research has demonstrated consistent, significant results for a number of health benefits in RCTs, evidencing progress toward recognizing the similarity and equivalence of Qigong and Tai Chi. Keywords tai chi taiji meditation qigong mind body practice meditative movement moderate exercise breathing NIH Public Access Author Manuscript Am J Health Promot. Author manuscript available in PMC 2011 July 1. Published in final edited form as: Am J Health Promot. 2010 24(6): e1���e25. doi:10.4278/ajhp.081013-LIT-248. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript

A substantial body of published research has examined the health benefits of Tai Chi (also called Taiji) a traditional Chinese wellness practice. In addition, a strong body of research is also emerging for Qigong, an even more ancient traditional Chinese wellness practice that has similar characteristics to Tai Chi. Qigong and Tai Chi have been proposed, along with Yoga and Pranayama from India, to constitute a unique category or type of exercise referred to currently as meditative movement.1 These two forms of meditative movement, Qigong and Tai Chi, are close relatives having shared theoretical roots, common operational components, and similar links to the wellness and health promoting aspects of traditional Chinese medicine. They are nearly identical in practical application in the health enhancement context and share much overlap in what traditional Chinese medicine describes as the ���three regulations���: body focus (posture and movement), breath focus, and mind focus (meditative components).1, 2 Due to the similarity of Qigong and Tai Chi, this review of the state of the science for these forms of meditative movement will investigate the benefits of both forms together. In presenting evidence for a variety of health benefits, many of which are attributable to both practices, we will point to the magnitude of the combined literature and suggest under what circumstances Qigong and Tai Chi may be considered as potentially equivalent interventions, with recommendations for standards and further research to clarify this potential. Objectives Previously published reviews have reported on specific outcomes of either Tai Chi or Qigong, mostly addressing only one of these practices, and rarely taking into account the similarity of the two forms and their similar outcomes. These reviews have covered a wide variety of outcomes, with many focused on specific diseases or symptoms including: hypertension 3 cardiovascular disease 4, 5 cancer 6���8 arthritic disease 9 stroke rehabilitation 10 aerobic capacity 11 falls and balance 12, 13 bone mineral density 14 and shingles-related immunity,15 with varying degrees of support noted for outcomes in response to Qigong or Tai Chi. Other reviews have addressed a broad spectrum of outcomes to demonstrate how Qigong16���19 or Tai Chi20���26 have demonstrated improvements for participants with a variety of chronic health problems or with vulnerable older adults. While many of these reviews have utilized selection criteria which restrict their focus to rigorous empirical studies, others have used less stringent criteria. The purpose of this review is to evaluate the current evidence for a broad range of health benefits for both Qigong and Tai Chi using only randomized controlled trials (RCTs), and to evaluate the potential of treating these two forms of meditative movement as equivalent forms. A complete description of Qigong and Tai Chi is presented and the equivalence of their theoretical roots and their common elements of practice are established. Then, the body of evidence for outcomes in response to Qigong and Tai Chi is reviewed to examine the range of health benefits. Finally, to more critically evaluate similarities across studies of the two practices we discuss the potential of treating them as equivalent interventions in research and the interpretation of results across studies. Research Question 1: What health benefits are evidenced from RCTs of Qigong and Tai Chi? Research Question 2: In examining the Qigong and Tai Chi practices incorporated in research, and the evidence for health benefits commensurate with each, what claims can be Jahnke et al. Page 2 Am J Health Promot. Author manuscript available in PMC 2011 July 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript

made for equivalence of these two forms of practice/exercise that have typically been considered to be separate and different? Overview of Qigong and Tai Chi Qigong is, definitively, more ancient in origin than Tai Chi and it is the over-arching, more original discipline incorporating widely diverse practices designed to cultivate functional integrity and the enhancement of the life essence that the Chinese call Qi. Both Qigong and Tai Chi sessions incorporate a wide range of physical movements, including slow, meditative, flowing, dance-like motions. In addition, they both can include sitting or standing meditation postures as well as either gentle or vigorous body shaking. Most importantly, both incorporate the purposeful regulation of both breath and mind coordinated with the regulation of the body. Qigong and Tai Chi are both based on theoretical principles that are inherent to traditional Chinese medicine (TCM).1 In the ancient teachings of health- oriented Qigong and Tai Chi, the instructions for attaining the state of enhanced Qi capacity and function point to the purposeful coordination of body, breath and mind (paraphrased here): ���Mind the body and the breath, and then clear the mind to distill the Heavenly elixir within.��� This combination of self-awareness with self-correction of the posture and movement of the body, the flow of breath, and stilling of the mind, are thought to comprise a state which activates the natural self-regulatory (self-healing) capacity, stimulating the balanced release of endogenous neurohormones and a wide array of natural health recovery mechanisms which are evoked by the intentful integration of body and mind. Despite variations among the myriad forms, we assert that health oriented Tai Chi and Qigong emphasize the same principles and practice elements. Given these similar foundations and the fashion in which Tai Chi has typically been modified for implementation in clinical research, we suggest that the research literature for these two forms of meditative movement should be considered as one body of evidence. Qigong Qigong translates from Chinese to mean, roughly, to cultivate or enhance the inherent functional (energetic) essence of the human being. It is considered to be the contemporary offspring of some of the most ancient (before recorded history) healing and medical practices of Asia. Earliest forms of Qigong make up one of the historic roots of contemporary Traditional Chinese Medicine (TCM) theory and practice.2 Many branches of Qigong have a health and medical focus and have been refined for well over 5000 years. Qigong purportedly allows individuals to cultivate the natural force or energy (���Qi���) in TCM that is associated with physiological and psychological functionality. Qi is the conceptual foundation of TCM in acupuncture, herbal medicine and Chinese physical therapy. It is considered to be a ubiquitous resource of nature that sustains human well-being and assists in healing disease as well as (according to TCM theory) having fundamental influence on all life and even the orderly function of celestial mechanics and the laws of physics. Qigong exercises consist of a series of orchestrated practices including body posture/movement, breath practice, and meditation, all designed to enhance Qi function (that is, drawing upon natural forces to optimize and balance energy within) through the attainment of deeply focused and relaxed states. From the perspective of Western thought and science, Qigong practices activate naturally occurring physiological and psychological mechanisms of self-repair and health recovery. Also considered part of the overall domain of Qigong is ���external Qigong��� wherein a trained medical Qigong therapist diagnoses patients according to the principles of TCM and uses ���emitted Qi��� to foster healing. Both internal Qigong (personal practice) and external Qigong (clinician emitted Qi) are seen as affecting the balance and flow of energy and enhancing Jahnke et al. Page 3 Am J Health Promot. Author manuscript available in PMC 2011 July 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript

functionality in the body and the mind. For the purposes of our review, we are focused only on the individual, internal Qigong practice of exercises performed with the intent of cultivating enhanced function, inner Qi that is ample and unrestrained. This is the aspect of Qigong that parallels what is typically investigated in Tai Chi research. There are thousands of forms of Qigong practice that have developed in different regions of China during various historic periods and that have been created by many specific teachers and schools. Some of these forms were designed for general health enhancement purposes and some for specific TCM diagnostic categories. Some were originally developed as rituals for spiritual practice, and others to empower greater skill in the martial arts. An overview of the research literature pertaining to internal Qigong yields more than a dozen forms that have been studied as they relate to health outcomes (e.g., Guo-lin, ChunDoSunBup, Vitality or Bu Zheng Qigong, Eight Brocade, Medical Qigong).2, 27���29 The internal Qigong practices generally tested in health research (and that are addressed in this review), incorporate a range of simple movements (repeated and often flowing in nature), or postures (standing or sitting) and include a focused state of relaxed awareness and a variety of breathing techniques that accompany the movements or postures. A key underlying philosophy of the practice is that any form of Qigong has an effect on the cultivation of balance and harmony of Qi, positively influencing the human energy complex (Qi channels/pathways) which functions as a holistic, coherent and mutually interactive system. Tai Chi Tai Chi translates to mean, ���Grand Ultimate���, and in the Chinese culture, it represents an expansive philosophical and theoretical notion which describes the natural world (i.e., the universe) in the spontaneous state of dynamic balance between mutually interactive phenomena including the balance of light and dark, movement and stillness, waves and particles. Tai Chi, the exercise, is named after this concept and was originally developed both as a martial art (Tai Chi Chuan or taijiquan) and as a form of meditative movement. The practice of Tai Chi as meditative movement is expected to elicit functional balance internally for healing, stress neutralization, longevity, and personal tranquility. This form of Tai Chi is the focus of this review. For numerous, complex sociological and political reasons,2 Tai Chi has become one of the best known forms of exercise or practice for refining Qi and is purported to enhance physiological and psychological function. The one factor that appears to differentiate Tai Chi from Qigong is that traditional Tai Chi is typically performed as a highly choreographed, lengthy, and complex series of movements, while health enhancement Qigong is typically a simpler, easy to learn, more repetitive practice. However, even the longer forms of Tai Chi incorporate many movements that are similar to Qigong exercises. Usually, the more complex Tai Chi routines include Qigong exercises as a warm-up, and emphasize the same basic principles for practice, that is, the three regulations of body focus, breath focus and mind focus. Therefore Qigong and Tai Chi, in the health promotion and wellness context, are operationally equivalent. Tai Chi as Defined in the Research Literature It is especially important to note that many of the RCTs investigating what is described as Tai Chi (for health enhancement), are actually not the traditional, lengthy, complex practices that match the formal definition of traditional Tai Chi. The Tai Chi used in research of both disease prevention and as a complement to medical intervention is often a ���modified��� Tai Chi (e.g., Tai Chi Easy, Tai Chi Chih, or ���short forms��� that greatly reduce the number of Jahnke et al. Page 4 Am J Health Promot. Author manuscript available in PMC 2011 July 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript

movements to be learned). The modifications generally simplify the practice, making the movements more like most health oriented Qigong exercises that are simple and repetitive, rather than a lengthy choreographed series of Tai Chi movements that take much longer to learn (and, for many participants, reportedly delay the experience of ���settling��� into the relaxation response). A partial list of examples of modified Tai Chi forms from the RCTs in the review are: balance exercises inspired by Tai Chi,30 Tai Chi for arthritis, 5 movements from Sun Tai Chi,31 Tai Chi Six Form,32 Yang Eight Form Easy,3334 and Yang Five Core Movements.34 In 2003, a panel of Qigong and Tai Chi experts was convened by the University of Illinois and the Blueprint for Physical Activity to explore this very point.35 The expert panel agreed that it is appropriate to modify (simplify) Tai Chi to more efficiently disseminate the benefits to populations in need of cost effective, safe and gentle methods of physical activity and stress reduction. These simplified forms of Tai Chi are very similar to the forms of Qigong used in health research. For this reason, it is not only reasonable, but a critical contribution to the emerging research dialogue to review the RCTs that explore the health benefits resulting from both of these practices together, as one comprehensive evidence base for the meditative movement practices originating from China. Methods Data Sources The following data bases were used to conduct literature searches for potentially relevant articles: Cumulative Index for Allied Health and Nursing (CINAHL), Psychological Literature (PsychInfo), PubMed, Google Scholar, and the Cochrane database. The key words included Tai Chi, Taiji, Tai Chi Chuan, and Qigong combined with RCT or with clinical research terms. Additional hand searches (based on word-of-mouth recommendations) completed the search for articles. Study Inclusion Criteria Criteria for inclusion of articles included that they: a) were published in a peer-reviewed English-language journal between 1993 and December, 2007 b) were cited in nursing, medical, or psychological literature c) were designed to test the effects of Tai Chi or Qigong and d) used a RCT research design. The literature search resulted in the identification of 576 articles to be considered for inclusion. The full texts of 158 articles appearing to meet initial criteria (a���d) were retrieved for further evaluation and to verify which ones were, in fact, RCTs, resulting in a final set of 77 articles meeting all of our inclusion criteria Data Abstraction Articles were read and results were entered into a table according to criteria established by the authors for categorization and evaluation of the studies and outcomes. Included in Table One for review and discussion are: country of study type and number of patients randomized duration and type of intervention and control condition measured outcomes and results. As the information was entered into the table it became apparent that some of the authors reported results from the same study in more than one article. Thus, the 77 articles selected actually represented 67 unique studies, with 1 study reporting a range of outcomes across 4 articles, and 5 other studies��� results published in 2 articles each. An additional two articles were not entered into the table36, 37 as the same results were reported in newer articles. Other than these two dropped articles, multiple articles are entered into the Jahnke et al. Page 5 Am J Health Promot. Author manuscript available in PMC 2011 July 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript