“No Pain,More Gain”: Subjective Responses to a T’ai Chi and Qigong Program For Back Pain

Abstract

Background

Low back pain is the leading cause of disability worldwide. Multidisciplinary approaches to chronic pain can support resilience in recovery of functioning. The ancient arts of t’ai chi and qigong have been touted for centuries as multimodal approaches to health and healing. An RCT of an on-line t’ai chi and qigong program for individuals with chronic low back pain found clinically significant improvements in pain, physical function, and quality of life. The program consisted of the integrated practice of t’ai chi movement and the stillness of qigong practice. Meditations in the program focused on developing positive mental attitudes to support resilience in managing the emotional challenges of pain and disease.

Objective

The purpose of the current qualitative study aimed to better understand participants’ experiences during the online Heal and Strengthen the Spine with T’ai Chi and Qigong (HSSTQ) program.

Methods

Written feedback was received from 96 program participants, and semi-structured interviews were completed with 20 participants. Interviews were transcribed and coded based upon the written feedback and interview questions. A thematic narrative was developed from the coded segments of texts and reviewed by participants in a member check.

Results

Three interlocking themes characterized the experiences of participants in the program: (1) participants learned skills to relieve back pain including moderation in movement; (2) the holistic nature of the program enabled a range of benefits for participants beyond pain reduction; and (3) personal healing experience, the enthusiasm of the instructor, the program itself, and available staff resources motivated individuals to participate.

Conclusion

The conclusion from this study and the initial RCT is that a virtually delivered integrated tai chi, qigong, and meditation program may be a viable treatment option for adults with low back pain.

Introduction

Low back pain is the leading cause of years lived with disability, and over half a billion individuals worldwide are affected. ¹ Best practices in pain management include the use of multidisciplinary approaches to support resilience in physical and mental/emotional recovery.^2,3 A recent review located through ProQuest concluded that t’ai chi might reduce pain and functional disorders in individuals suffering from back pain. ⁴

T’ai chi (also spelled tai chi or taijiquan) and qigong are traditional Chinese mind-body practices that integrate slow, deliberate movements, breath regulation, and focused attention to promote physical and mental well-being. While t’ai chi originated as a martial art and emphasizes continuous movement sequences, qigong consists of both dynamic and meditative practices designed to cultivate and balance the body’s internal energy, or qi. Both practices are considered multimodal interventions that can improve posture, balance, strength, relaxation, and psychological resilience—factors relevant to chronic pain management, including low back pain.^5-8

A randomized controlled trial (RCT) of a 3-month on-line t’ai chi and qigong training program called Heal and Strengthen the Spine with T’ai Chi and Qigong (HSSTQ) was conducted for individuals with chronic low back pain. ⁹ The HSSTQ program was created by combining traditional t’ai chi and qigong training methods, science-based insights, and wisdom from classical Chinese healing and martial arts. Having recovered from severe chronic back pain following a bike accident, Y. Yang systematized the t’ai chi, qigong, and meditations that he used in his own recovery to help others relieve and manage their back pain.

The underlying physical mechanisms of t’ai chi’s effectiveness continue to be studied, but little attention has been given to the important “mind” aspects of traditional training.^10,11 The HSSTQ program made the mind part of the mind-body practice of t’ai chi and qigong a clear focus through sitting meditation practice, one of the 3 stillness modalities used in the program: sitting, standing, and lying down meditation. These practices have a long history of traditional t’ai chi training but are relatively rarely practiced or even spoken about in the West today.

In sitting meditation, participants were guided in changing their mental and emotional set through the contemplation of healing perspectives drawn from Chinese philosophy and traditional medical practice. These meditation themes, like “the body can heal itself” and “no pain, more gain,” served to calm the mind and internalize methods for relieving pain and avoiding setbacks and reinjuries.

T’ai chi and qigong movement practice can relieve pain through cultivating relaxation, proper posture and body mechanics, flexibility, core strength, and by boosting energy flow in movements. Standing meditation focused on proper alignment, relaxation, lengthening the spine, and improving strength. The lying down practice focused on deeper relaxation and improving sleep. Combining traditional movement exercises with stillness in standing, sitting, and lying down meditation resulted in a complete holistic curriculum.

While RCTs are essential for establishing efficacy, they often do not capture the nuanced, personal experiences that influence how participants engage with and benefit from an intervention. Qualitative studies provide critical insight into the how and why behind quantitative outcomes, particularly in complex, multimodal interventions like t’ai chi and qigong. Understanding participants’ perspectives can reveal factors influencing adherence, identify components perceived as most helpful, and illuminate psychosocial mechanisms (e.g., shifts in beliefs about pain, emotional coping strategies, motivation for sustained practice) that are not readily measured in standard outcome assessments. This deeper understanding can guide program refinement, enhance clinical relevance, and inform the implementation of mind-body interventions in broader health care settings. ¹²

Purpose

The purpose of this qualitative study was to explore how participants experienced and responded to a virtually delivered t’ai chi and qigong program designed for individuals with chronic low back pain. This study sought to gain deeper insight into the subjective experiences that may underlie or complement the observed quantitative outcomes.

Research Question

What were the experiences of active participants in the Heal and Strengthen the Spine with T’ai Chi and Qigong (HSSTQ) program, and how did they perceive its impact on their physical, emotional, and mental well-being in the context of chronic low back pain?

Methodology

Participants

Participants were eligible to participate if they were at least 18 years old, had experienced low back pain for at least 6 weeks prior to study enrollment, understood written and spoken English, were not pregnant, had not previously taken t'ai chi classes, and had not undergone spinal surgery within the last 6 months. Participants found out about the program through the medical community associated with the wider New York City metropolitan area through a variety of methods: (1) email lists of physicians for people with low back pain; (2) referrals from physicians of primary care, geriatrics, and osteopathic medicine; and (3) an employee wellness program newsletter. Diagnoses associated with their chronic back pain included spinal stenosis, spondylolisthesis, uterine fibroids, osteoporosis, compressed discs, and Parkinson’s disease. Participants previously had tried a range of methods to reduce their pain, including other forms of exercise, physical therapy, pain medications, injections, and surgeries.

Participants in the research project were invited to give feedback throughout the program through online surveys, online community meetings, and individual phone interviews with the instructor. Based on a final request for written feedback, questions for a semi-structured interview were designed to gain a fuller understanding of participants’ experiences during the program. IRB approval was secured for the interviews. Invitations were sent to 47 participants who had been active in the intervention attending at least 80% of the classes either live while the classes were offered on-line or through review of the class videos throughout the week. Most of these were in the control group because their memories of the program would be more current than those of the treatment group. Twenty-four participants scheduled an interview and provided written consent to participate in the interviews. Of these, 20 completed the 30 to 45-min interviews via the Zoom platform. Four participants had unexpected life circumstances that prevented their completing the interviews. Participants created pseudo names for use in the data analysis and write-up.

The interviewers completed a training session to pilot the interview questions and provide consistency across interviews. Interviews were recorded and conducted by 4 different interviewers (2 females and 2 males) who had no previous relationships with the interviewees; 1 interviewer attended the online program as an observer (SS), 1 interviewer had other previous t’ai chi and qigong training (KC), and 2 had no previous t’ai chi or qigong training (JA & SA). Each interviewer had doctoral level training in education (SS), public health (JA & SA), or counseling (KC). Participants were encouraged to ask questions at the beginning of the interviews to confirm their understanding of the research process and to build rapport with the interviewer.

Data Analysis

Data analysis proceeded with a phenomenological theoretical orientation and widely accepted general principles of qualitative research.^12,13 To enhance the trustworthiness of the analysis, we followed Lincoln and Guba’s (1985) criteria. ¹⁴ Credibility was supported through member checking and peer review of codes and themes. Thick description was used to support transferability. An audit trail of coding memos and data displays was maintained for dependability, and confirmability was strengthened by involving multiple team members in the development of interview questions and data analysis. ¹⁴

Interview questions were developed during team meetings (see Appendix for interview questions). Initial codes were developed from participants’ written responses to the final request for feedback as well as the interview questions. There were 96 responses to the final request for feedback on the program. Interviews were transcribed prior to open coding. Statements from the interviews were reviewed across questions using the initial coding scheme with a constant comparative method. ¹⁵ “Sparkling quotes” were identified that were vivid, emotionally salient participant statements that illuminated key themes.^16,17 We engaged in a search for data that did not fit our emerging themes as part of enhancing the credibility of our findings. ¹² One researcher (KC) organized text from the interviews in a data display by the following categories: (a) reasons for participating in the study, (b) previous methods tried to manage pain, (c) benefits to participating, (d) intervention practices engaged in and challenges to practice, and (e) other comments. ¹⁸ The data display was shared with the team members, and one (YY) offered detailed feedback, suggested possible themes, and shared his thoughts with the research team.

Our experience of coding development and thematic analysis was informed by Guest et al.’s 2006 experience in that basic elements for meta themes emerged within the first 6 interviews and data saturation occurred after 12 interviews. ¹⁹ After we completed 15 interviews, 1 researcher (KC) developed a draft narrative that could describe participants’ experiences. Three team members (YY, SS, SD) responded with suggestions and comments on this draft narrative offering additional possible quotes. The coding system and narrative were then tested for dependability and data saturation in 5 additional interviews. No new themes were developed from these final 5 interviews. The initial narrative was revised with quotes from the 5 additional interviews. A member check was conducted by sending a draft narrative to the 20 interviewees, asking if their experience was represented in the narrative, and requesting suggested changes. All who responded (n = 19) reported that the narrative reflected their experiences in the program.

Results

Of the 20 participants, 15 were females and 5 were males. Ages of participants ranged from 44 to 82 with a mean of 66.5 years of age. All participants identified as White and reported a range of occupations including elementary school staff, business project management, artist, pastry chef, marketing, finance, healthcare, and massage therapist. Nine of the interviewees reported being retired. These demographics roughly align with the demographics of the larger RCT where 20% of research participants were male, the mean age was 57.9 years (SD 15.6 years), 71% were White, and 30% were retired. All met the RCT study criteria for having had back pain for at least 6 weeks, however, one of the interviewees commented that she had had chronic back pain for over 50 years. Participants tried a range of methods to reduce their pain and improve their health including other forms of exercise, physical therapy, pain medications, injections, and surgery. Pseudo names were created for each participant to maintain their confidentiality and still refer to them as individuals.

As is common in qualitative research, themes in this study were not mutually exclusive but interconnected, reflecting the complex and overlapping nature of participants’ experiences.^20,21 Three interlocking themes characterize the experiences of participants in the program: (1) participants learned skills to relieve back pain including moderation in movement; (2) the holistic nature of the program enabled a range of benefits for participants beyond pain reduction; and (3) personal healing experience from back pain, the enthusiasm of the instructor, the program itself, and available staff resources motivated individuals to participate.

Theme One: Participants Learned Skills to Relieve Back Pain including Moderation in Movement

The approach in the program, as indicated by the title, “no pain, more gain,” emphasized modifying movements as needed and understanding pain as a signal from the body to stop or rest and relax. This approach allowed participants with a range of physical abilities to participate in the program. These abilities ranged from very little ability to move initially all the way up to the ability to engage in all the exercises from the beginning of the program. For example, 1 participant was bedridden because of a knee surgery the week prior to beginning the program. Other participants were using a walker to get around or were unable to put weight on 1 leg. Those who were able to engage in all the exercises at the beginning of the program mentioned having to have patience with the pace of the instruction acknowledging that there was a range of abilities in the community. For example, 1 participant wrote:

I was unsure whether I would benefit from the program considering my multiple health issues. I felt Tai Chi would be too slow paced. However, since the program was introduced and highly recommended to me by my doctor, I decided I would give it a try. I am delighted and grateful for the teachings. My body is benefiting from the results; I feel better, and I look forward to the classes. Each session there is a new and beneficial technique that helps me to relieve my pain.

Skills to Change Pain Related Thoughts and Behaviors

The program taught specific adaptive tools and encouraged participants to use these tools to modify the movements and practice to fit their individual condition. The emphasis was on addressing the fear of movement as well as understanding pain as a signal from the body to stop or rest and/or adjust the intensity of the movement. All but one of the participants referred to having learned practices that helped them change their relationship to pain.

For example, Charlotte (a pseudo name) described her change in relationship to pain as one in which she had a high pain tolerance prior to the program “but my inclination to experience pain is reduced. I understand pain as a signal from my body to stop.” Angel commented that she was most helped by the mantra to “go slow.” This helped calm her anxiety and allowed her to engage in the movements even with the limitations she had immediately following surgery.

This “less is more” philosophy included an emphasis on teaching participants methods to relax the body and mind whether in stillness or in movement. Heather described it this way:

You don't realize how much tension you hold in your body. But when you learn to figure out where it is, and you learn how to release it, it makes such a big difference. I think that was the first thing, that you do have some of that control within yourself, and you just didn't know it was there before.

Charlotte described the philosophy of the program as one that allowed the body to “incrementally move forward rather than pushing.” This included tools for identifying the source of pain and ways to eliminate it. The effect of this approach was described in detail by Portia:

One of the problems that you have when you have chronic back pain is that you tense up when you are getting ready to move or during the movement. Relaxation made a huge difference in the level of pain that I was experiencing. Once I started to get a twinge or once my back started to hurt, I would stop. I would hear [the instructor’s] voice telling me “Relax, relax, relax,” and I would attempt to just relax my back. This would happen also during the physical therapy sessions. I would find that I would get pain during the physical therapy sessions. I would tell my therapist, “I have to stop a second.” I would relax. I may even do a movement that I had learned in the class. And it would only take a minute. And then I'd say “Okay, I'm not in pain anymore. Let's proceed.”

This skill of relaxing muscles was echoed by Heather who reflected: “When I do start feeling tension, I have more skills to figure out where it is and relax and release some of that tension. . . Realizing that I could get better made a big difference in my mind.” Larry reported having learned how to relax his muscles to prevent muscle spasms. The decreased pain allowed him to have greater range of motion.

Learning the Importance of Moderation in Movement

Half of the participants specifically mentioned that the program’s emphasis on moderation and the mantra “no pain, more gain” changed the way that they related to their pain. Harry talked about moving from a philosophy of “nothing exceeds like excess” to a philosophy of “less is more.” Marian indicated that as a former athlete, this was her biggest challenge, having to move from overdoing to moderation. Harry also noted that this approach helped him moderate his athletic activities, lessening his chances of re-injuring his back.

Theme Two: The Holistic Nature of the Program Enabled a Range of Benefits For Participants Beyond Pain Reduction

Given the wide range of physical functioning of the interviewees, it may not be surprising that they reported a range of benefits which varied based on their initial physical conditions. All participants stated that they experienced at least one benefit beyond pain reduction. Participants reported improvements in pain and physical function, subjective sleep quality, as well as mental and emotional functioning.

Pain and Physical Function

Seventeen of the 20 indicated that they were having some degree of pain when they started the program. Of these 17, 13 stated that their pain had reduced during the program. Along with the reduction in pain, others felt subjective changes in physical function, including a stronger core, increased strength, improved balance, wider range of motion, improved body awareness and coordination, improved posture, and improved energy.

Encouragement to lengthen and relax the body was noted by several participants as beneficial for improving posture and strengthening the spine. For example, Cindy noted that her husband had been concerned that she was developing a dowager’s hump; through the program, she worked on lengthening her spine as was suggested in the exercises. She said, “Now I stand up straight and I’m standing taller.” Others recalled the instructor’s encouragement: “Imagine you are 2 inches taller.”

Four participants who indicated that their initial pain levels did not decrease during the program found other benefits in it. Florence said that it reinforced a sense of gratitude for her ability to move. She commented, “Getting older doesn’t mean I don’t have to be flexible and use my body to get places, to do things.” Jo commented on the sense of hope that she received from participating. Robin indicated that she felt she had more endurance. Portia described increases in strength and improvements in balance. She stated that:

The difference in pain is that while I still have back pain, and I still have some difficulty walking, I realized that the habits I've formed are going to take some time to resolve, but I'm optimistic that they will be resolved. I am much more aware of my body and what muscle groups I'm using and not using than I was before.”

Subjective Sleep Quality

While 7 of the interviewees observed that they didn’t have any problems related to sleep at the beginning of the program, the other 13 indicated sleep difficulties, and 11 of these stated that their sleep improved during the program. Some reported being able to go to sleep more easily, stay asleep longer, or return to sleep quickly if awakened. Arnold stated that since the program’s end he had been diagnosed with prostate cancer and has disrupted sleep as a result. Now, he finds that he can go right back to sleep because of the relaxation training in the program, and he is also using what he learned to relieve anxiety about his cancer treatment.

Harry reported that he has more anxiety than in the past because of cognitive deficits from a stroke. But the program “helps me deal with the emotional and the physical consequences of life like a back injury and the frustration of stroke recovery.” Even so, he said that he can fall asleep more quickly after the lying down qigong and stillness practice.

Two participants stated that they continue to have sleep problems. One indicated that it is a problem because of sleep apnea, and the other said that the problem stems from perimenopausal changes.

Mental and Emotional Functioning

Other participants also mentioned the reduced anxiety and stress they experienced through the program, although their stated reasons varied. For example, Arnold said:

I’m always trying to think positive. When I was immobile, it was frustrating. . . .The mental and emotional benefits from this program come along with it because you're able to do more and more, and you don't have pain, or your pain is to a point where you can manage it. Your mental and your emotional well-being just automatically gets better.

Cindy’s explanation was more about slowing down and relaxing into a less judgmental frame of mind. She described herself as “pretty high strung” and said that the program helped her slow down. She also described her relationship to pain as changing: “I’ve come to think of the pain as just pain. I don’t make it happen. I always thought I did this wrong. Like I screwed up. And that’s why I have pain. And I don’t really do that anymore.” Later, in referring to the practice of using the t’ai chi imagery of moving in water, she said, “I actually feel like I am in water. And I can relax, and in relaxing, get out of my way because of me always thinking that it's my fault. It’s not my fault. It’s just what happened.”

As an explanation of his improved emotional functioning, Harry referenced being more accepting of the limitations he is living with after his stroke. Larry talked about learning to be less perfectionistic, while Becky spoke of a sense of accomplishment and said that participating in the movements took her mind away from other stressors.

Several participants talked about the sense of hope they had attained. Portia said, “The fact that you can see some light at the end of the tunnel is a great stress reliever.” This sentiment was echoed by Heather: “Realizing that I could get better made a big difference in my mind.” Marion described learning tools to prevent pain from coming on and of regaining her sense of hope:

If I have gone too far (I've spent two hours preparing a meal instead of one hour without any breaks), then I lie down, and I do the relaxation. And within five minutes, if anything hurts, it stops. And that has given me the sense of confidence and a sense of hope. I was resigned to living with pain for the rest of my life.... But I don't think that now.

Theme Three: Personal Healing Experience, the Enthusiasm of the Instructor, the Program Itself, and Available Staff Resources Motivated Individuals to Participate

All the participants who were interviewed were motivated to attend classes and practice because they were experiencing at least one benefit as described in theme 2. Seventeen (85%) specifically mentioned the enthusiasm of the instructor and/or the usefulness of the video recordings as motivating their participation.

The helpfulness of having the classes recorded and being able to access the recordings between classes to stay motivated to practice was mentioned by 12 (60%) of the participants. As one put it, it’s one thing to follow along with a recording and another thing to remember the movements on one’s own. Access to the recordings after the program ended made a big difference in whether some participants were able to continue practicing or not. Although the recordings were available after the program on a subscription basis, not all participants signed up for the subscription. Charlene indicated that she couldn’t afford to pay for the subscription and would have liked a DVD to continue to practice. Several participants indicated that they easily learned movements and were able to continue practicing even without access to the recordings. One reported that she had made copious notes listing all the movements so that she could continue to practice even without access to the videos.

The instructor’s pedagogical tact and enthusiasm was described by 11(55%) of the participants as important to their experience of the program. The instructor shared his experience of recovering from chronic back pain following a bicycle accident. He shared his frustration with his diagnoses of disc herniation, spinal stenosis, and hip arthritis, and many of the participants had similar diagnoses. This sense of connection and empathy with the participants’ pain strengthened the relationship between them and helped engender a sense of hope for recovery. The instructor also had a unique background with extensive training in traditional t’ai chi as well as Western research such that he could complement traditional wisdom with scientific data. Also, Charlotte described the instructor’s use of “Grandmother wisdom,” concepts and perspectives condensed from Chinese philosophy, as making the “serious and beneficial advice easy to hear” without becoming defensive. On the other hand, Larry referenced the challenge of learning new movements:

My biggest challenges were my own ego, wanting to be executing [the movements] properly, and having to let that go. [The instructor] does address that. He says, “Just do it. Just keep going. You'll get better. You'll get better,” which is insightful. You know, it's hard to let go of the anxiety of trying to be perfect.

This encouraging and positive attitude by the instructor was repeatedly mentioned by participants as motivational. Five (25%) specifically mentioned the helpfulness of being encouraged to smile while doing the movements. One participant mentioned that smiling “changes my attitude and mindset. I still hear his voice encouraging me to smile.” Along these same lines, Robin said, “I always felt better after the class; something about the spirit of [the instructor] constantly reassuring, whatever you’re doing is okay.” Likewise, Lillie talked about lessened anxiety due to the positive expectations that the instructor provided.

Discussion

In summary, the remotely delivered program provided comprehensive and effective tools to relieve pain, cultivate a tranquil and positive mind, and regain physical function in daily life for individuals with a range of limitations. It imparted tools and support for reducing and managing pain as well as increasing physical, emotional, and mental functioning. The purpose of the current study was to investigate the subjective experiences of active study participants as they learned new tools and assembled a new knowledge base for advancing their own healing, a key goal in the HSSTQ program.

Participants in the HSSTQ program reported changes in their pain-related thoughts and behaviors through their experiences and the skills gained in the program. This finding is supported by Ashar and colleagues’ work who found that chronic back pain patients could experience substantial and lasting relief from a psychological treatment focused on changing their beliefs about the threat value and causes of chronic pain. ²² Participants were offered ways to reframe their thoughts about pain and their experience of it, and they came to understand that the body can heal itself. Pain relief led to increased confidence, and their ability to reduce pain left participants less anxious, more hopeful, and motivated to continue to engage in the practice.

The improvements in pain, function, emotional well-being, and self-regulation following the t’ai chi and qigong program suggest potential reductions in healthcare utilization and medication use, indicating that this program may be a cost-saving or cost-effective intervention for chronic back pain. Prior cost-effectiveness evaluations of meditative movement interventions—such as a Tai Ji Quan-based fall prevention programs—have demonstrated favorable cost per fall prevented and cost per quality-adjusted life year gained, suggesting high economic potential.^23,24 Future studies should evaluate the economic impact of implementing this mind–body program at scale, particularly given the strong participant satisfaction observed here. Given the established clinical improvements evidenced in the primary RCT, ⁹ these qualitative insights support the rationale for a formal cost-effectiveness analysis of the virtual HSSTQ intervention. A cost-effectiveness analysis could help determine the value of incorporating this intervention into standard back pain care.

Participants engaged in stillness meditation practices which enhanced their body awareness and helped them identify and relieve tension. Teaching slow, gentle movements encouraged participants to understand their pain better, providing a context in which to learn to adjust movement to reduce or prevent pain. That is, they learned ways to keep moving with minimal setbacks by changing intensity, movement pattern, and/or foot positioning and posture.

Other qualitative studies of t’ai chi practice found similar participant experiences of pain relief through a combination of physical, psychological, and attentional mechanisms. Practitioners describe increased body awareness, improved posture, and greater flexibility as contributing to reduced musculoskeletal strain and discomfort. ²⁵ At the same time, the meditative quality of t’ai chi—emphasizing relaxed attention, slow breath, and fluid movement—facilitates mental calm and a redirection of attention away from pain. ²⁶ These experiential accounts support emerging theoretical models suggesting that t’ai chi reduces pain not only through biomechanical means, but also via central modulation of stress, emotion, and interoception. Similar benefits are reported in qualitative studies of qigong. ²⁷ The online delivery and the combination of t’ai chi and qigong are relatively unique in the published literature, and as such, this study is a contribution to the scientific literature.

Changes reported by participants in the HSSTQ program can be explained through reference to the Theoretical Domains Framework with the 3 large domains of capability, opportunity, and motivation.^28,29 The step-by-step instructions and pacing of the program encouraged a sense of capability in participants. Further, the flexibility of the program allowed individuals with a range of abilities to participate. By way of opportunity, the online environment allowed for participation that would not have been possible face-to-face including the ability to review recorded lessons at the participants’ convenience. Participants further became motivated to participate as they began experiencing the benefits of the program.

Many of the participants appeared to expect to gain improvements in their physical function through pain, and this may influence intervention adherence and recruitment. Setting up the expectation in t’ai chi trials early on that gaining through pain is not necessary may increase participant adherence in future trials/programs.

The specific tools offered in the program were based on traditional Chinese approaches that systematically relax the body, calm the mind, and boost energy. One of the guiding principles of traditional Chinese wisdom is that one should act with moderation and avoid excess. ³⁰ There is some evidence that this approach is important in the relation between the intensity of physical activity and chronic low back pain. ³¹ Yet, one of the more difficult beliefs for participants to change was in accepting their need for moderation. Initially, many wished to push through their difficulties with movements and work to excess. This highlighted the importance of repeating the mantra, “no pain, more gain.” Future research on clinical interventions may need to emphasize this need for moderation in movement as a way of improving patient outcomes.

Limitations

There are several limitations of this qualitative project. Participants who were not actively engaged in the program were not interviewed, introducing potential bias and limitations to generalizability. In addition, there are numerous styles of t’ai chi and qigong and various teaching approaches, so the results of this study may not be fully generalizable to other approaches, especially those that focus exclusively on movement. Another limitation was that the interviews relied on the memories of participants who finished the program 2-3 months prior to the interview; thus, there may be memory bias in their responses. At the same time, their responses match well with the quantitative results. ⁹ While this qualitative study provides insights into participants’ experiences in a t’ai chi and qigong program specifically addressing back pain, other possible narratives for explaining the feedback and interview results could be developed given the inevitable biases present in the research team’s frame of reference as would be the case for any qualitative data analysis. ¹²

Conclusion

The ancient arts of t’ai chi and qigong have been touted for centuries as multimodal approaches to health and healing. Recently, researchers have begun to examine t’ai chi and qigong in relation to various health issues, from problems with balance and falls to pain mitigation.^4,32 Our particular focus is on the holistic mitigation of chronic back pain, a problem affecting millions around the globe. ⁹ To study the effects of this approach, Yang Y. designed a program for back pain relief and re-injury prevention emphasizing flexible modification of movement and exercise, stillness/meditative practices, and explicitly facilitating mind-body connections through guided emotional recalibrations. These serve to bring hope, patience, resilience, and positive energy into rehabilitative work. Implemented over 3 months in a randomized control trial and through online instruction, the results in pain, daily physical functioning, sleep, and quality of life were positive and significant. ¹²

This qualitative study described positive health benefits as well as changes in pain-related thoughts and behaviors experienced by participants in a 3-month online t’ai chi and qigong program that integrated practices of movement and stillness.