Body-Mind-Spirit Therapy/Qigong

STUDY PURPOSE: To assess the strength of evidence addressing qigong therapy in supportive cancer care and describe the definition of effective qigong therapy in supportive cancer care

TYPE OF STUDY: Systematic review

• FINAL NUMBER STUDIES INCLUDED = 11
• TOTAL PATIENTS INCLUDED IN REVIEW = 831 patients
• SAMPLE RANGE ACROSS STUDIES: 32–162 patients
• KEY SAMPLE CHARACTERISTICS: Wide variety of geographic regions; heterogeneous populations, of which 50% had breast cancer; wide variations in time of interventions from early treatment to recovery; patients receiving multiple treatment modalities

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Elder care

For the purpose of the reviewer’s comments, results were limited to the primary symptom of fatigue and two common concurrent symptoms, depression and fatigue. Five of the 11 studies included fatigue as an outcome measure. Measures improved significantly in groups using some form of qigong or tai chi intervention in four studies and showed no difference in the fifth study. Mixed benefits on depression were reported. No significant differences in sleep were reported. Constructs of qigong therapy were identified as slow, gentle, repetitious, flowing, weight-bearing movements, breath regulation, mindfulness, meditation, energy cultivation, and relaxation.

The authors reported growing research evidence that the practice of qigong has benefits for managing fatigue and improving quality of life in individuals with cancer. However, outcomes on mediation of inflammation/immune support, depression, anxiety, stress, mood, sleep, systolic blood pressure, and survival rate were reported as mixed, and, as only 4 or the 11 studies included samples from the U.S. (N = 389 of 831 participants included in the review [47%]), the validity of the conclusion is questionable for a broader to application to general supportive care across all populations with cancer.

• Limited search
• Limited number of studies included
• Mostly low quality/high risk of bias studies
• High heterogeneity
• Low sample sizes
• The technique requires expert skills to train participants
• Limited access to qigong expertise in U.S.
• Variations in constructs for qigong and limited descriptions of techniques of qigong intervention reported in studies

Logically consistent operational and conceptual definitions of qigong are needed for future research. Additional evidence is needed prior to recommending qigong to be integrated into cancer care. Access to trained qigong practitioners is needed for application to research across broad populations of patients with cancer.

STUDY PURPOSE: The purpose of this systematic review of the literature was to evaluate the effectiveness of Qigong on symptom management in patients with cancer. Qigong is a complementary therapy with the goal of relaxation involving simple, repeated body posture or movements, breathing exercises, and meditation performed in synchrony.

TYPE OF STUDY: Systematic review

DATABASES USED: PubMed/MEDLINE, CINAHL, Cochrane Library, and PEDRO

YEARS INCLUDED: From 1995 through 12/2015

INCLUSION CRITERIA: RCTs, quasi-experimental with comparison group, and feasibility trials; adults ≥ 18 years of age; cancer diagnosis; receiving care in any healthcare setting; using Qigong during or after cancer treatment versus placebo, usual care, or other intervention to manage symptoms, including patient-reported physical-psychological symptoms reported as continuous or dichotomous and quality of life. 

EXCLUSION CRITERIA: Trials including patients receiving hospice care or were at the end-of-life

TOTAL REFERENCES RETRIEVED: N = 266

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane Collaboration’s Tool for Assessing Risk of Bias (Cochrane Collaboration, 2011) and strength of the evidence were evaluated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence (Oxford Centre for Evidence-Based Medicine, 2009).

FINAL NUMBER STUDIES INCLUDED: N = 22

TOTAL PATIENTS INCLUDED IN REVIEW: 1,751

SAMPLE RANGE ACROSS STUDIES: 20-211

KEY SAMPLE CHARACTERISTICS: Studies were conducted in Hong Kong, China, Taiwan, Malaysia, South Korea, United States, Israel, and Australia. Various cancer diagnoses were included (i.e., breast, prostate, gynecologic, nasopharyngeal, hepatocellular, colon, non-Hodgkin lymphoma, lung cancer, and gastrointestinal cancers) from early in the treatment period through the recovery phase. Median intervention duration was 6 weeks (ranged from 3 to 24 weeks).

PHASE OF CARE: Multiple phases of care     

APPLICATIONS: Elder care

Of the 22 studies that met inclusion criteria, there were 14 RCTs and 8 controlled clinical trials. A high risk of bias was reported in 16 studies (73%) specifically in lack of blinding, allocation concealment, and incomplete outcome data. The efficacy of Qigong was examined for symptom management among patients with various cancers. Effects were described according to primary outcome measures, including physical (e.g., fatigue, sleep disturbances, pain, dyspnea) and psychological (e.g., depression, anxiety) symptoms, and quality of life. For example, 10 studies included a fatigue outcome whereas 3 studies included a sleep disturbance measure. In addition, 19 studies evaluated ≥ 2 outcomes. Results indicated that participants in Qigong groups were significantly improved postintervention compared with the control groups or there were positive trends from pre- to postintervention scores. Protocols used to deliver the interventions varied and included seven types or forms of Qigong. Interestingly, all seven styles of Qigong were effective for ≥ one outcome variable. Secondary outcomes found that Qigong was safe and feasible without unwanted side effects. The majority of outcomes were self-reported, but there were a few significant objective clinical outcomes: muscular strength, range of motion, six-minute walk test, and body mass index.

Results of this systematic review suggest that some of the symptoms were significantly improved in the Qigong group postintervention compared to controls. These somewhat promising results are tempered by some major limitations. There was a high risk of bias related to allocation concealment, lack of blinding, and incomplete outcome data. Limitations pertain to the potential incompleteness of the evidence reviewed. Conclusions regarding superiority of one form of Qigong over another were beyond the scope of this review.

Limited number of studies included

Mostly low quality or high risk of bias studies

High heterogeneity

Low sample sizes

Qigong for improving symptoms in patients with cancer are encouraging in some but not all reported studies in this review. For example, only one out of three studies that evaluated sleep quality reported significant improvement with Qigong. More research is needed before Qigong can be recommended for relief of cancer-related symptoms.

PURPOSE: The goal of this study was to systematically review and synthesize the evidence for Tai Chi and Qigong interventions for supportive cancer care, specifically focusing on five clinical outcomes (fatigue, sleep difficulty, mood, pain, and quality of life), to identify the strengths and gaps in the evidence for theses interventions, and suggest directions for future research.

TYPE OF STUDY: Meta analysis and systematic review

• DATABASES USED: PubMed, CINAHL, Web of Science, and Embase
• YEARS INCLUDED: From inception until January 30, 2017
• INCLUSION CRITERIA: RCTs, prospective non-randomized controlled and prospective non-controlled studies, in English, with cancer as primary disease and Tai Chi and Qigong as the primary interventions. 
• EXCLUSION CRITERIA: Review articles, other intervention, not cancer, outcome unrelated, other language, observational study.

• TOTAL REFERENCES RETRIEVED: 478
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane Collaboration Risk of Bias Tool updated 2009; individual domains endorsed with low or high risk of bias; low risk of bias with at least 50% of criteria designates as low risk; high risk of bias when more than 50% of criteria endorsed with high bias or unclear.

• FINAL NUMBER OF STUDIES INCLUDED: 22 for qualitative analysis and 15 for quantitative analysis
• TOTAL PATIENTS INCLUDED IN REVIEW: 1,571
• SAMPLE RANGE ACROSS STUDIES: 12-197
• KEY SAMPLE CHARACTERISTICS: 10 studies included women with breast cancer only, 2 included men with prostate cancer only, 5 studies included mixed solid cancers, and single studies exclusively included patients with lung cancer, non-Hodgkin lymphoma, nasopharyngeal cancer, and gastric cancer.

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care

TCQ interventions varied in content, dosage, duration, and intensity. Of the 22 studies, Tai Chi was applied in 7 studies, Qigong in 10 studies, and Tai Chi and Qigong were explicitly combined in 4 studies. All results based on a random effects model due to statistical heterogeneity. Ten studies pooled for analysis revealed an overall effect size that indicated a beneficial effect of TCQ on fatigue in patients with cancer (Hedges g = − 0.53, 95% CI [−0.97, −0.28], p < 0.001). Six studies pooled for analysis revealed an overall effect size with a beneficial effect of TCQ on sleep difficulty in patients with cancer (Hedges g = − 0.49, 95% CI [−0.89, −0.09], p = 0.018). The overall effect size based on seven studies favored TCQ on depression in patients with cancer (Hedges g = −0.27, 95% CI [−0.44, −0.11], p = 0.001). Four pooled studies suggested that a statistically non-significant trend was in favor of TCQ on cancer-related pain (Hedges g = −0.38, 95% CI [−0.89, 0.12], p = 0.136). Quality of life was assessed with eleven studies and favored TCQ in patients with cancer (Hedges g = 0.33, 95% CI [0.1, 0.56], p = 0.004). Findings from non-RCTs paralleled meta-analysis results. Funnel plots suggest some degree of publication bias.

Findings support that TCQ may be effective in reducing multiple symptoms commonly experienced by cancer survivors. Statistically significant and clinically meaningful medium effect sizes in favor of TCQ were observed for symptoms of fatigue and sleep difficulty. Smaller but statistically significant effect sizes were also observed for QOL and depression, and a non-significant trend in favor of TCQ was observed for pain.

• High heterogeneity
• Low sample sizes

Tai chi and Qigong are mind-body interventions that show promise for reducing cancer-related symptoms, including fatigue, sleep problems, and depression as well as improving quality of life. Evidence from this review comes from a qualitative synthesis as well as a meta-analysis. The review included studies that included patients with different types of cancer.

To evaluate whether patients with breast cancer undergoing radiotherapy (RT) who practiced qigong would report better quality of life, less fatigue, and less sleep disturbance than did patients in a control group.

Patients were randomly assigned to a group that received a qigong intervention or to a wait-list control group. Patients were assigned to cohorts to prevent group contamination during the study. Each week, the qigong group participated in five classes lasting 40 minutes each during RT. These patients received printed materials and a DVD of the qigong program. Patients were encouraged to practice qigong techniques on their own. The intervention included relaxation breathing, meditation, walking in a circle while breathing in sync with arm movement, and self-massage. The control group received standard care. Assessments were performed at baseline, in the middle of the RT schedule, during the last week of RT, and at one and three months after treatment.

• The sample was comprised of 95 participants (100% female).
• Mean age was 45 years (range 25–62).
• All participants had breast cancer.
• Most participants had stage II or stage III disease.
• All participants had undergone mastectomy or lumpectomy.
• Of the participants in both groups, 78% were receiving 25 RT fractions.
• Most participants were married, and 52.5% had some college or higher education.

• Single site
• Multiple settings
• China and the United States

Participants were undergoing the active antitumor treatment phase of care.

The study was a randomized, controlled trial.

• Brief Fatigue Inventory (BFI)
• Center for Epidemiologic Studies Depression (CESD) Scale 
• Pittsburgh Sleep Quality Index (PSQI)
• Functional Assessment of Cancer Therapy-General (FACT-G)
• Salivary cortisol samples taken for two consecutive days at waking, 45 minutes after waking, 45 minutes later, eight hours later, and at bedtime

• Time had a significant effect in reducing depression, with a significantly greater effect in the qigong group (p = 0.05); however, no significant differences were observed between groups at any time point.
• Participants with low measures of depression symptoms at baseline showed no significant differences in fatigue, regardless of group. At the end of the study, of participants who had had high measures of depression symptoms at baseline, those in the qigong group had measures of fatigue that were significantly lower (p < 0.05; 2.93 versus 4.19) than those in the control group.
• No differences were observed between groups in sleep quality, and there was no interaction of depression symptoms with sleep measures.
• One-third of participants attended 100% of the sessions and 78.3% attended more than 50% of the sessions. Attendance ranged from five to 30 sessions.
• Sessions involved one to 10 people at a time.
• No differences were observed between groups in regard to cortisol measures.

Practicing qigong appears to be beneficial in reducing fatigue and depression during RT and appears to be of most benefit to women with high measures of depression symptoms.

• The study had a small sample size, with less than 100 participants.
• The study had risks of bias due to no blinding and no appropriate attentional control condition.
• Adherence varied. No information was provided regarding participants' qigong practice outside the treatment group.
• The study was inconclusive in regard to the effectiveness of qigong itself versus the potential effect of the group activity involved in the qigong intervention.
• Follow-up time was limited.

Qigong, a type of mind-body discipline, appears to have benefit in reducing fatigue and depression over time, particularly among women who have high measures of depression symptoms. Effects were not seen until after RT completion.

The purpose was to examine whether tai chi chih (TCC) is noninferior in effect to cognitive behavioral therapy (CBT-I) in reducing insomnia in breast cancer survivors.

Participants were randomly assigned to two groups: those receiving CBT-I and those receiving TCC. Prior to the intervention, participants were enrolled in a 2-month phase-in period to establish their degree of insomnia. CBT-I and TCC groups were comprised of 7-10 participants and consisted of weekly 120-minute sessions. Interventions were held over two months, with a third month of skill consolidation and adherence (three months total intervention exposure). Remission of insomnia was also measured by an interviewer blinded to intervention exposure who evaluated remission according to DSM-IV-TR criteria. Assessments  of insomnia, a daily sleep diary, polysomnography levels, levels of fatigue, sleepiness, depressive symptoms, body mass index, and physical activity levels were collected at month 2 (baseline data), month 3 (post intervention), and follow-up assessments at months 6 and 15.

• N: 90   
• AGE: Range = 42-83 years, Mean = 59.6
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Breast cancer survivors met the DSM-IV-TR criteria for insomnia had reported sleep difficulties at least 3 times or more per week for at least three months or more; had finished surgical, radiation, or chemotherapy treatment at least 6 months prior; and did not have recurrence of cancer or a new tumor.

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: Los Angeles, CA

PHASE OF CARE: Late effects and survivorship

Two groups were established in a randomized, partially blinded, noninferiority trial. Participants were blinded to the hypothesis and the alternate treatment group.

• Sleep quality was measured using the Pittsburgh Sleep Quality Index and Athens Insomnia Severity Index. 
• Objective sleep continuity was measured using polysomnography and subjectively with sleep diaries. 
• For secondary outcomes, insomnia remission was evaluated using DSM-IV-TR criteria and reviewed utilizing board-certified psychiatrists and psychologists. Fatigue was measured using the Multidimensional Fatigue Symptom Inventory, sleepiness was measured using the Epworth Sleepiness Scale, and depressive symptoms were measured using the Inventory of Depressive Symptoms. Body mass index and physical activity levels (Yale Physical Activity Survey) were also measured. A noninferiority margin of 50% was used.

Responsiveness to CBT-I or TCC treatment was comparable with a responsiveness rate of 43.6% and 46.7%, respectively. The noninferiority margin for this study’s purposes was set at 50%, and noninferiority of TCC was observed at month 3 (p = 0.02), month 6 (p =< 0.01), and month 15 (p = 0.02). Both treatments resulted in comparable insomnia remission rates at month 15 (46.2% and 37.9%, respectively). Differences in change of PSQI or AISI, as well as change in sleep time and wake after sleep onset, and effects on fatigue, sleepiness, or depression from baseline were not significant in comparing treatment groups (p > 0.3, p > 0.4, p > 0.5, respectively). PSG did not demonstrate treatment effects or differences across groups of significance.

CBT-I and TCC demonstrated high patient responsiveness and sustainable insomnia reduction at follow up yet yielded nonsignificant differences between treatment groups, thereby demonstrating noninferiority of TCC to CBT-I. Improvements in sleep quality, fatigue, sleepiness, and depressive symptoms were observed among both groups, but group differences were again not significant.

• Small sample (< 100)
• Findings were not generalizable.
• Intervention was expensive and impractical, and training was needed.
• Subject withdrawals ≥ 10%

Given not only the prevalence, but debilitative effect insomnia has on patients with cancer, alternative treatments to CBT-I, such as TCC, are important for nurses to assess and identify for patients, who may have variances in access to clinical CBT-I treatment.

To compare a meditative movement practice, Qigong/Tai Chi Easy (QG/TCE), with sham Qigong (SQG), testing the effects of the meditation/breath aspects of QG/TCE on breast cancer survivors’ persistent fatigue and other symptoms

Hour-long sessions held twice weekly taught breast cancer survivors QE/TCE or SQG for 12 weeks measuring the effect on fatigue, depression, and sleep. Participants were asked to practice at home at least 30 minutes per day.

• N = 87  
• AGE RANGE = 40–75 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Stages 0–III; the majority of participants were educated at the level of at least some college and were at higher income levels. 90% were white and non-Latino.

• SITE: Single-site    
• SETTING TYPE: Outpatient    
• LOCATION: Mayo Clinic Cancer Center, Scottsdale, AZ

• PHASE OF CARE: Late effects and survivorship

This was a double-blinded, randomized, controlled trial. Fatigue was the primary outcome and sleep quality and depression were secondary outcomes.

• Fatigue Symptom Inventory (FSI)
• The Pittsburgh Sleep Quality Index (PSQI)
• Beck Depression Inventory (BDI)

Fatigue decreased in the QG/TCE group compared to the SQG group at postintervention and at the three-month follow-up (p = .024). However, fatigue declined significantly in both groups. Depression and sleep quality did not demonstrate improvement in the QG/TCE group compared to the SQG group at the post-intervention and at the three-month follow-up.

QG/TCE showed significant improvement over time compared to SQG for fatigue. Both groups showed improvement for fatigue, depression, and sleep dysfunction

• Small sample (< 100)
• Findings not generalizable
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Blinding of the session instructors is identified as a limitation. The instructors could have unintentionally made a difference in the delivery of the interventions and outcomes. There is a concern that the contrast between the two interventions may have not been enough. The sham intervention is not described fully. There was a greater than 15% drop-out rate with no intent to treat analysis.

Low-intensity exercise may be beneficial in reducing a number of symptoms and improving the well-being of cancer survivors. This study demonstrates that QG/TCE’s focus on meditative movement with a focus on breath appears to have an advantage for improving breast cancer survivors' persistent fatigue. A larger sample and longer intervention time is needed.

To examine the efficacy of qigong or tai chi to alleviate treatment-related fatigue and disturbed sleep in men who were undergoing radiotherapy for prostate cancer

• N = 90   
• MEAN AGE = Qigong group: 62.2 years (SD = 7.4 years), light exercise: 65 years (SD = 5.9 years), wait-list control: 66 years (SD = 8.4 years)
• MALES: 100%  
• CURRENT TREATMENT: Radiation 
• KEY DISEASE CHARACTERISTICS: Prostate
• OTHER KEY SAMPLE CHARACTERISTICS: Thirty-three participants were in stage T2a or less, 19 participants were in T2b–T2c, and 14 were in T3a or greater. The majority of participants were also undergoing androgen deprivation therapy.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: MD Anderson Cancer Center, Texas

PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• Pittsburgh Sleep Quality Index (PSQI)
• Brief Fatigue Inventory (BFI)
• Expanded Prostate Cancer Index Composite (EPIC) 

This study did not show improvements in fatigue scores reported in any group either during treatment or after. Improvements in sleep duration was reported by those in the qigong group when compared to the light exercise group and the wait-list control. Sleep disturbance remained higher than clinical cutoff for all groups. Adherence to attendance at intervention in all classes was 64%. Additional practice at home after radiotherapy ended was not assessed.

Men undergoing radiotherapy for prostate cancer are able and willing to participate in physical activity interventions, such as qigong and/or light exercise. Fatigue and sleep disturbance are common symptoms experienced by men undergoing radiotherapy for prostate cancer and may persist after treatment is complete. However, qigong improved sleep duration for participants during radiotherapy treatment. This study did not detect improvements in fatigue or sleep disturbance that were sustained over the three-month period of the study.

• Small sample (< 100)
• Findings not generalizable
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%

No side effects were reported in either intervention group (qigong or light exercise).