Tai Chi as an Alternative and Complementary Therapy for Patients With Asthma and Chronic Obstructive Pulmonary Disease

Abstract

Chronic obstructive pulmonary disease and asthma are the third ranking cause of death worldwide. A systematic review was conducted to determine the efficacy of tai chi as a therapy to relieve symptoms of chronic obstructive pulmonary disease and/or asthma. Inclusion criteria were (a) published in the English language, (b) between the period January 2008 and July 2012, (c) included tai chi or any form of modified tai chi as a therapy in an intervention, (d) used any quantitative study design, and (e) measured chronic obstructive pulmonary disease and/or asthma as an outcome. A total of 5 interventions from 6 studies met these criteria. Tai chi as an effective therapy for asthma and chronic obstructive pulmonary disease is still difficult to determine, although the result listed here are promising. Limitations include small sample sizes, high attrition rates, and short intervention durations.

Introduction

A study from 2008 indicates that chronic obstructive pulmonary disease and asthma, together, are the third leading cause of death in the United States. Symptoms associated with chronic obstructive pulmonary disease (chronic bronchitis and emphysema) include increasing difficulty filling and emptying the lungs, wheezing, coughing, and breathlessness. ¹ The prevalence of chronic obstructive pulmonary disease varies regarding method of diagnosis, populations tested, and age-group analyzed, but it has been estimated at 37% in the United States. The burden associated with chronic obstructive pulmonary disease includes loss of work, hospitalization, decline in quality of life, and death. ²

Asthma is similar to chronic obstructive pulmonary disease in that it is a chronic respiratory disease, but airway obstruction is temporarily reversible with treatment. More than half of all asthma-related deaths occur among adults 65 years and older ³ and it is estimated that more than 20 million people in the United States suffer from asthma. ⁴ Moreover, the health care burden associated with asthma, in the United States, was estimated at $20.7 billion in 2010. ⁵

Pulmonary rehabilitation programs, which include exercise training, are considered the most effective form of chronic respiratory disease management, but only 1% of people with moderate to severe chronic obstructive pulmonary disease have access to these programs. Furthermore, there is an overlap of asthma and chronic obstructive pulmonary disease mortality in older adults, resulting in difficulties when treating these diseases separately. ³ This has led some health practitioners to explore alternative therapies that can treat both conditions. Because tai chi is easy to learn, requires no exercise equipment, and can improve pulmonary capacity, it may be an effective alternative to the more expensive management programs currently popular. ⁶

Tai chi is a traditional healing therapy that originated in China, but has since gained popularity in the United States. Many studies have analyzed the efficacy of tai chi for depression, low back pain, osteoarthritis, and heart disease, but limited data are available for respiratory conditions, including chronic obstructive pulmonary disease and asthma. ⁷ Considering tai chi incorporates slow movements focusing on strength and balance it could be a possible alternative to improve the quality of life of elderly adults suffering from chronic obstructive pulmonary disease and asthma. ⁶ Additionally, studies have shown that both asthma and chronic obstructive pulmonary disease sufferers are turning to complementary and alternative medicine approaches to mitigate symptoms. ⁴ Because of this trend, there is a need for researchers to analyze the effectiveness of such treatments.

Research questions addressed in this study include the following: Is tai chi efficacious as an alternative therapy for chronic obstructive pulmonary disease and/or asthma and is there sufficient data available to draw conclusions regarding the efficacy of tai chi as a therapy/alleviator of symptoms associated with chronic obstructive pulmonary disease and asthma?

Methods

A systematic review of the literature of tai chi as an alternative or complementary therapy for chronic obstructive pulmonary disease and/or asthma was the method used in this study. To be included in this review the study must have (a) been published in the English language, (b) been reported between the period January 2008 and July 2012 (past 5 years), (c) included tai chi or any form of modified tai chi as a therapy in an intervention, (d) used any quantitative study design, and (e) measured chronic obstructive pulmonary disease and/or asthma as an outcome. Exclusion criteria included studies that did not (a) implement a quantitative design, (b) sample subjects diagnosed with chronic obstructive pulmonary disease and/or asthma, and (c) index in any of the following databases—CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline, or Alt Health Watch.

Because very few studies were identified using tai chi as an alternative therapy for chronic obstructive pulmonary disease and/or asthma, a study that used Health Qigong, a complementary alternative system of medicine approach similar to tai chi was included here. ⁸ Additionally, studies that implemented variations of tai chi, including tai chi qigong, ⁹ and tai chi chuan, ¹⁰ were also included. One study was published in 2 different journals, both have been included here. ^9,11

Three phases of review were used to find studies meeting the previously defined criteria (Figure 1). Medline, Alt Health Watch, and CINAHL database searches were enlisted to complete phase I. Boolean terms used to identify studies meeting the criteria included tai chi AND COPD OR chronic obstructive pulmonary disease OR tai chi AND asthma.

Figure 1.

Flowchart depicting the 3-phase data extraction process.

Using the above terms, 30 articles were returned as follows: from Medline—chronic obstructive pulmonary disease n = 4, asthma n = 3; from Alt Health Watch—chronic obstructive pulmonary disease n = 2, asthma n = 7; and from CINAHL—chronic obstructive pulmonary disease n = 4, asthma n = 10. Phase II included preliminary distillation of the articles by eliminating duplicates (n = 2) and review/discussion articles (n = 22). Phase III consisted of a manuscript review of the remaining articles (n = 6). Of these articles, 2 were on the same intervention. As a result, 5 articles from 6 studies were used to review tai chi as an effective treatment for chronic obstructive pulmonary disease and asthma.

Results

The 3-phase data extraction process resulted in 4 articles satisfying the eligibility criteria. Table 1 summarizes the studies, including the year of publication, authors, study design and sample size, age of participants, intervention modality, outcomes modified, and the salient findings. The studies are arranged by year of publication in the ascending order.

Table 1.

Summary of Tai Chi Interventions for Chronic Obstructive Pulmonary Disease and Asthma.

Year	Authors	Design and Sample	Age	Outcomes Modified	Salient Findings	Confounding Factors
2008	Chang et al 10	Randomized control design; n = 30 asthmatic children randomized to tai chi chuan and control groups	9 years 11.6 months ± 1 year 9.3 months	Pulmonary function test, including forced vital capacity, forced expiratory volume, peak expiratory flow, symptom score	Baseline versus after 12 weeks for those in the tai chi group showed significant improvements in forced vital capacity, forced expiratory volume, peak expiratory flow, and symptoms score (P < .001). Tai chi group showed a significant improvement in forced vital capacity (P = .019) after exercise versus control group, at rest tai chi chuan group showed significant improvement in forced vital capacity and forced expiratory volume (P = .024 and P = .049, respectively) versus control group.	None listed.
2010, 2011	Chan et al 9,11	Single-blind randomized control design; n = 158 patients with chronic obstructive pulmonary disease randomized to exercise (n = 50), tai chi qigong (n = 60), and control (n = 48) groups	55-88 years	6-minure walk test, Borg scale (fatigue measure), oxygen saturation level, forced expiratory volume, and forced vital capacity, hospital visits, and chronic obstructive pulmonary exacerbations	St. George’s Respiratory Questionnaire results shows that the tai chi group had greater improvements in symptoms (P = .010) and activity (P = .035) domains versus the control and exercise groups. No significant differences in impact domain was detected (P = .265). No significant differences in Borg scale regarding dyspnea (P = .542), fatigue (P = .517), and oxygen saturation level (P = .096). No differences were found in the hospital admission rate (P = .148)	Heart disease, hypertension, and diabetes mellitus were listed as coexisting diseases. For the tai chi qigong group 13% reported heart disease, 40% hypertension, and 10% diabetes mellitus. For the exercise group. 15%, 52%, and 9% reported heart disease, hypertension, and diabetes mellitus, respectively. For the control group 9%, reported heart disease 42% hypertension, and 10% diabetes mellitus. These were not found to be statistically significant.
2010	Ng et al 8	Single blind randomized control design; n = 80 elderly adults diagnosed with chronic obstructive pulmonary disease randomized to health qigong and control (conventional exercise) groups	70+ years	Primary outcomes: 6-minute walk test, maximum metabolic equivalent, and Monitored Functional Task Evaluation (daily living scale for chronic obstructive pulmonary disease patients). Secondary outcomes: General Health and Mental Health subscales of the 36-Item Short Form Health Survey (SF-36) and the Chinese Chronic Respiratory Questionnaire	Results from the Monitored Functional Task Evaluation instrument showed significant improvements of experimental subjects versus control group at 6-month follow-up (P < .02). The 6-minute walk test showed significant improvements of the experimental group versus the control group at 6-month follow-up (P < .00). Quality of life subscales showed positive changes for the experimental group and negative trends in quality of living for the control group, but none reached statistically significant levels.	Patients with recent hospital admissions due to chest pain or those that reported other debilitating disease (stroke, Parkinson’s, etc) were not included in the study.
2010	Yeh et al 12	Randomized control design (pilot study); n = 10 patients with moderate to severe chronic obstructive pulmonary disease randomized to tai chi + usual care or usual care alone groups	66 ± 6 years (must be >45 years)	Peak oxygen intake, cycle endurance, Chronic Respiratory Disease Questionnaire, dyspnea, spirometry effects, total lung capacity, ratio of inspiratory capacity to total lung capacity functional residual capacity	Chronic Respiratory Disease Questionnaire showed significant improvement among tai chi subjects versus control group (P = .03) at the end of the 12 weeks. Six-minute walk test showed no significant differences between the 2 groups. No significant differences observed for scores from the depression scale, the shortness of breath score, and the chronic obstructive pulmonary disease self-efficacy scale scores for tai chi versus control group.	Patients who had a chronic obstructive pulmonary disease exacerbation causing them to need steroids, antibiotics, emergency room visits, or hospitalization over the past month were excluded. Additionally, patients with severe peripheral vascular disease were also excluded.
2011	Leung et al 6	Randomized control design; n = 38 (part A) subjects suffering from chronic obstructive pulmonary disease randomized to tai chi or control (usual care) groups; part B, n = 15 subjects from tai chi underwent additional testing	Not available	Endurance shuttle walk test, functional exercise capacity, physical performance and balance, self-efficacy, anxiety, depression, quality of life	Compared with the control group, the experimental group significantly increased endurance shuttle walk time (mean difference, 95% confidence interval) (384 seconds, 186-510); reduced medial–lateral body sway in semitandem stand (−12.4 millimeters, −21 to −3); and increased total score on the Chronic Respiratory Disease Questionnaire (11 points, 4-18). The exercise intensity of experimental group was 53% (18%) of oxygen volume reserve.	Patients with an acute chronic obstructive pulmonary disease exacerbation within the past 4 weeks or those with comorbidities such as internal malignancy or heart disease were excluded.

Table 2 provides in-depth details of the tai chi intervention, as many of the studies modified this ancient Chinese technique for asthma or chronic obstructive pulmonary disease sufferers. Table 2 summarizes the style of tai chi used, details of the specific exercises performed, intervention dosage, and specifies the type of instructor used.

Table 2.

Details of Tai Chi Interventions.

Year	Authors	Style of Tai chi	Details of Exercises	Taught by	Intervention Dosage
2008	Chang et al 10	Tai chi chuan	Chen-32 style (the most ancient)	Unspecified	12 weeks of 40-minute tai chi chuan sessions 3 times weekly.
2010, 2011	Chan et al 9,11	Tai chi qigong	13-form tai chi modified from the 18-form tajii qigong developed by Master Lin Hou Sheng, including controlled breathing, upper limb movements to improve lung expansion, and mental concentration	Qualified tai chi instructor (2 experts were consulted regarding the modified tai chi)	60 minutes of tai chi qigong twice weekly for 3 months with a master; 60 minutes of at-home tai chi exercise was encouraged with DVD and pictures.
2010	Ng et al 8	Health qigong	Mind–body therapy, specifically Baduanjin method, including 8 distinct movement routines that repeat 6 times (5 modifications were recommended by experts for patients with chronic obstructive pulmonary disease)	Trained therapist	Four 45-minute training sessions on health qigong by a trained therapist over a 12-week pulmonary rehabilitation workshop together with a home learning kit, including audiovisual materials. Those in the experimental group practiced at least once per day (12-15 minutes) at least 4 times weekly for 6 months.
2010	Yeh et al 12	Tai chi customized for patients with respiratory diseases	Traditional warm-up exercises, including weight shifting, arm swinging, gentle stretches of the neck, shoulders, spine, arms, legs, visualization techniques, and traditional breathing methods (dan tien breathing and whole body breathing). Then tai chi movements were adapted from Master Cheng Man-Ch’ing’s Yang style short-form performed repetitively	Two certified and experienced instructors	1-hour class twice weekly of tai chi taught by an instructor for 12 weeks, encouraged practice of 3 times a week at home with instructional video.
2011	Leung et al 6	Short-form Sun-style tai chi	21 forms taking 4 minutes to complete, repeated 5 to 6 times (30 minutes). Each session consisted of 10 minutes warm-up and 10 minutes cool down	Supervised training, unspecified instructor	50 minutes twice weekly supervised tai chi training and home-based training the 5 remaining days with DVD and booklet for 12 weeks.

Discussion

A total of 5 studies were found to fit the inclusion criteria. Of these 5 studies, 2 were performed in Hong Kong, China, ^8,9,11 1 in Taiwan, ¹⁰ 1 in Australia, ⁶ and 1 in the United States. ¹² All 5 studies demonstrated statistically significant improvements among the experimental group versus the control group regarding symptoms or pulmonary capacity. Although the majority of the studies did measure pulmonary function in terms of forced vital capacity, forced expiratory volume, and/or 6-minute walk tests, there was no consensus on scales used. The scales used in these studies include the International Study of Asthma and Allergies in Childhood Questionnaire, ¹⁰ St. George’s Respiratory Questionnaire, ^9,11 Monitored Functional Task Evaluation, ⁸ Chronic Respiratory Questionnaire, ¹² Center for Epidemiologic Studies Depression Scale, ¹² the University of California, San Diego Shortness of Breath score, ¹² the chronic obstructive pulmonary disease Self-efficacy Scale, ¹² and the Chronic Respiratory Disease Questionnaire, ⁶ among others.

The most robust study design, randomized control design, was used in all studies examined. This type of design is defined as the most rigorous as it enlists pretests and posttests, randomizes the subject into a control and an experimental group, and minimizes threats to internal and external validity. To minimize researcher bias, three studies instituted single-blind randomization, where the program’s data collectors were not informed of the group the subjects were assigned. ^8,9,11

For 2 of the studies examined, the significant differences in baseline measurements were found. The study listed in 2 journals, measuring tai chi in children suffering from asthma, gender was significantly different among groups, as only one female was randomized to the experimental group (P = .021). As a result, gender was identified as a covariate. ^9,11 Additionally, this study reported that those randomized to the tai chi group experienced exacerbation rates significantly higher than those of the control group in the weeks prior to the intervention. ¹¹ For another study, measuring chronic obstructive pulmonary disease among older adults, those randomized to the tai chi group initially reported statistically significant higher levels of activity, higher scores on the Chronic Respiratory Questionnaire, and worse quality-of-life scores. This study did not report adjustments for these baseline differences, making it difficult to interpret results effectively. Interestingly, this study reported no significant differences at the end of the study between the tai chi group versus the control group regarding shortness of breath, depression, and self-efficacy, although significant improvements among the tai chi group versus control were reported for Chronic Respiratory Questionnaire scores. ¹²

Modality dosage varied among the 5 studies, although all study durations were 3 months. One study that did not encourage at-home training provided 3 times weekly of 40-minute instructional sessions, but reported favorable outcomes for tai chi chuan group versus control; forced vital capacity, forced expiratory volume, peak expiratory flow, and symptom scores (P < .001). ¹⁰ The remaining 5 studies encouraged at-home practice on the days they did not meet, providing DVDs, booklets, and other audiovisual materials for instruction. The intervention dosage for these varied from 60 minutes of tai chi twice weekly with 60 minutes at-home practice every day, ^9,11 to four 45-minute sessions weekly with at least 4 days of at-home practice for 12 to 15 minutes, ⁸ 50-minute twice weekly sessions with at-home practice the 5 remaining days, ⁶ and finally, 1-hour class twice weekly of tai chi encouraging at-home training 3 days a week. ¹² Although the studies provided journals to log at-home practice, it was impossible to assess, definitively, the amount and quality of at-home practice that subjects performed. Additionally, since the outcomes associated with the intervention were most favorable, it cannot be yet determined whether at-home practice is necessary to improve the effects of tai chi on asthma- and chronic obstructive pulmonary disease–related symptoms.

Confounding factors such as comorbidities with heart disease, exacerbated chronic obstructive pulmonary disease events, and musculoskeletal disease that may limit a patient’s ability to perform tai chi were taken in to account in several of the studies. Chan et al ^9,11 listed heart disease, hypertension, and diabetes mellitus as coexisting diseases, but did not find the number of participants, in any of the 3 intervention groups, to be statistically significant. Three of the studies excluded subjects who had an exacerbated chronic obstructive pulmonary disease incident within the past 4 weeks, those with heart disease or other comorbidities. ^6,8,12 Only one study did not address comorbidities and possible confounding factors, making it difficult to determine the efficacy of such an intervention. ¹⁰ Future studies must address such variables to determine the relevance of such an intervention in the clinical setting.

Weaknesses associated with the studies reviewed include intervention duration, quality of instruction, attrition rates, and generalizability. One study noted that an intervention duration of 3 months may not allow enough time for the benefits of tai chi to be fully realized, noting that a study, using tai chi, showed psychosocial health improvements of elderly subjects suffering from chronic obstructive pulmonary disease became substantial after a period of 6 months. ¹¹ Additionally, 2 of the 5 studies were performed in China, where tai chi and similar mind–body therapies have been practiced for centuries and overall acceptance for the practice is high. ⁸ It is important to note that tai chi is gaining popularity in the Western world, making the likelihood of its acceptance, and therefore, generalizability, more favorable. ⁸

Another potential weakness is that no study offered any type of quality assessment tool of the instructors. Terms such as “qualified instructor” ¹¹ and “trained therapist” ⁸ were used, but no credentials were listed. One study did not mention the use of expert instructors, making it difficult to determine the quality and/or presence of such instruction. ¹⁰ Instructional classes can also be costly and inconvenient for participants as they must travel to receive the intervention, adding to the problem of attrition. Considering the types of tai chi varied among the studies, along with varying instructors, could make it difficult to determine the comparability of the studies. It can be said, though, that mind–body therapies, which reinforce meditative states, focus on breathing, and use light movements are similar through all studies.

Finally, attrition rates and sample size issues can affect the efficacy of any study. The study performed by Ng et al ⁸ reported 27.5% and 30% attrition rates for female and male subjects, respectively. Although attrition was quite high, the study was well above the sample size calculation (α = .05) of n = 38 with 80 participants total, making the dropout rate within the acceptable range. ⁸ Hospitalization, increased dyspnea (loss of breath), and death were listed as possible reasons for the 23.3% attrition rate found among another study. ^9,11 Unfortunately, a sample size calculation was not performed for this study and dropout rate acceptability was not indicated. ^9,11 To overcome high attrition rates, it is suggested that the range of ages for interventions for patients suffering from chronic obstructive pulmonary disease and/or asthma be extended to those in their 60s as this population tends to be less frail than the elderly groups seen here. ⁸

Sample size calculations were not mentioned in 2 of the studies. ^10,12 Interestingly, both these studies enlisted few participants divided evenly among the experimental and control groups. For the study by Yeh et al, ¹² only 10 subjects suffering from chronic obstructive pulmonary disease were randomized, as this was identified as a pilot study. The intervention implementing a tai chi program for asthmatic children used a sample size of 30 subjects. ¹⁰ Although the sample sizes were small for both studies, the result was a 0% attrition rate.

Although there were weakness indicated above, it is important to reemphasize that all studies used randomized control design. Additionally, some researchers have suggested that the social support found in a tai chi program versus none in a control could be a driving factor of improvements, not necessarily the tai chi practice itself. A third group of exercise was added to the study of Chan et al ^9,11 ; results indicated that the improvements in forced vital capacity (P = .02), forced expiratory volume (P < .001), and the 6-minute walk test (P < .001) were significant for the tai chi group compared with both the control and exercise groups. Although this study did not measure social support, it does suggest that more studies need to be performed to understand the role of social support in tai chi practice for patients with chronic obstructive pulmonary disease and asthma.

As mentioned previously, researchers have indicated that 6 months may be needed to assess the efficacy of tai chi. Although no studies used a 6-month intervention, one study did perform a 6-month follow-up of 80 elderly adults suffering from chronic obstructive pulmonary disease. Results showed significant improvements of Health Qigong subjects versus control subjects at the 6-month follow-up; the 6-minute walk test (P < 0.00), the Monitored Functional Task Evaluation (an activity of daily living for chronic obstructive pulmonary disease patients, P = .02); and 36-Item Short Form Health Survey: General Health (a generic quality of life scale; P = .04). It should be noted that only 23 subjects reported practicing Health Qigong at least once a week by themselves up to the 6-month follow-up. ⁸ The study does indicate that the mind–body therapy intervention was efficacious, even when subjects’ adherence was not carefully monitored, suggesting that this type of therapy may be an effective alternative to usual care.

Conclusion

It is estimated that 80 million people worldwide suffer from chronic obstructive pulmonary disease each year, ¹¹ unfortunately, data regarding effective treatments other than pulmonary rehabilitation, are lacking. Only 6 studies could be found that met the inclusion criteria for this review, illustrating the need for more studies of chronic obstructive pulmonary disease and asthma sufferers using tai chi and other mind–body therapies to alleviate symptoms. Although the studies presented here were randomized control design, many did not address the vital role of social support as a confounding factor or sample size and dropout rate acceptability. The findings are promising as each study reported improvements among tai chi subjects with regard to pulmonary capacity, quality of life, and/or exercise capacity, but questions regarding the sustainability of tai chi practice, the long-term benefits of such a therapy, and the cost/inconvenience to participants, make it difficult to determine the viability of this therapy.