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.

To examine the feasibility and efficacy of a Qigong intervention for improving older prostate cancer survivors’ levels of fatigue and distress

Qigong intervention twice weekly sessions for 12 weeks led by Qigong master for one hour with DVD provided for home practice. Qigong incorporated standing and sitting exercise, with increased standing exercise with each session. Exercises included five minutes of meditative breath at the beginning and end of each session, opening of the nine gates, muscle change, cavity presses, collecting energy of heaven and earth, rocking chair, Tai Chi ruler, hands skimming the water, pushing and pulling space, cloud hands, body weight resistance

Stretching intervention led by instructors from the exercise and sport science department twice weekly for one hour for 12 weeks. Avoided movement similar to meditation; used sitting and standing that increased intensity with each session. A DVD also was provided for home practice.

• N = 29    
• MEAN AGE = 72 years
• MALES: 100
• KEY DISEASE CHARACTERISTICS: Prostate cancer, five-year median diagnosis, 48% on ADT
• OTHER KEY SAMPLE CHARACTERISTICS: No significant difference was noted between those who completed and those who withdrew from intervention.

• SITE: Single site  
• SETTING TYPE: Multiple settings  
• LOCATION: Survivorship and wellness center as well as and home practice

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

• Non-blinded RCT, active control

• FACIT–Fatigue
• Brief Symptom Inventory
• Borg scale
• Self-report
• Class attendance and retention

Baseline fatigue between groups was not statistically different. Change in fatigue from baseline was statistically improved in the Qigong group compared to the stretch group (p = .02). Home practice reports were not significantly different. Sixty-nine percent in the Qigong arm had a minimally important difference of 3 or more points compared to 38% in stretching. BSI score between groups was significantly different for somatization (p = .048), anxiety (p = .003), and global severity index (p = .002).

Fatigue and distress were improved in the Qigong group compared to stretching. High attrition was noted in both groups.

• Small sample (< 30)
• Risk of bias (no blinding)
• Findings not generalizable
• Subject withdrawals ≥ 10%

Qigong as an intervention is a low-risk option for treating fatigue in patients with prostate cancer. Larger RCTs are needed.

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.

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).

To evaluate a method of Chan-Chuang qigong to manage fatigue and sleep disturbance in individuals undergoing chemotherapy for non-Hodgkin lymphoma

Participants randomly assigned to the intervention group received qigong guidance booklets that introduced qigong and provided illustrations of qigong procedures and precautions, as well as daily monitoring guidelines. Study participants were individually trained by qigong practitioners who followed a set study protocol. Initial training of study participants was completed during their two-day hospital stay for first cycle of treatment. The study nurse observed the participant’s qigong practice until his or her form/movement was satisfactory. After discharging patients, the study nurse called them weekly to confirm they were practicing qigong at home. The study recommended two to three (but no more than five) sessions a day of qigoing practice equally spaced in time. This study followed participants for three weeks (21 days).

• N = 102   
• AGE = 59.8 years (16.5)
• MALES: 56%, FEMALES: 44%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: non-Hodgkin lymphoma

• SITE: Single site   
• SETTING TYPE: Multiple settings; inpatient initially, then outpatient
• LOCATION: Northern Taiwan

PHASE OF CARE: Active antitumor treatment

This was a randomized, controlled trial with a two-group design (intervention and control). No blinding was used in this study.

• Fatigue intensity (two questions on an 11-point scale)
• Verran and Snyder-Halpern Sleep Scale

Participants assigned to the intervention (qigong) group reported significantly lower levels of fatigue and improved sleep quality compared with the control group (p < 0.001). Participants reported a near 100% adherence to intervention and completed on average two sessions for a mean time of 47 minutes total.  No adverse effects were reported from this intervention.

• Risk of bias (no blinding)
• Key sample group differences that could influence results

No side effects were reported by the intervention group. The results suggested that qigong may mitigate fatigue and sleep disturbance. However, the high adherence rate may be related to culture belief.