Effect of health Qigong on rehabilitation of stroke patients: A systematic review and meta-analysis

Fengguang Guan; Qiulu Ji

doi:10.4103/jin.jin_67_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 5 | Issue : 1 | Page : 15-20

Effect of health Qigong on rehabilitation of stroke patients: A systematic review and meta-analysis

Fengguang Guan¹, Qiulu Ji²
¹ Department of Nursing, The Second People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
² Department of Nursing, Affiliated Sanming First Hospital, Fujian Medical University, Sanming, China

Date of Submission	18-Jul-2022
Date of Decision	27-Nov-2022
Date of Acceptance	16-Jan-2023
Date of Web Publication	23-Mar-2023

Correspondence Address:
Dr. Fengguang Guan
Department of Nursing, The Second People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, No. 282, Wusi Road, Fuzhou 350001
China

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jin.jin_67_22

Abstract

Objective: The objective of this study is to evaluate the effects of health Qigong on the rehabilitation of hemiplegic patients after stroke.
Methods: The randomized controlled trials on health Qigong intervention in rehabilitation after stroke were searched in eight databases: PubMed, Cochrane Library, Embase, Web of Science, CBM, CNKI, Wanfang Database, and VIP Database from the inception to February 2022, and the data were analyzed using RevMan 5.3 software.
Results: A total of 17 studies involving 1146 hemiplegic patients after stroke were included. Meta-analysis results showed that the motor function and activities of daily living in the intervention group were better than those in the control group at different intervention times (intervention time <3 months and 3 months–24 weeks) (P < 0.01). When the intervention time was <3 months, the improvement of balance function in the intervention group was better than that in the control group (P < 0.01). However, when the intervention time was 3 months–24 weeks, there was no significant difference in the balance function between the intervention group and the control group (P = 0.10).
Conclusion: Health Qigong has a positive effect on the improvement of motor function and activities of daily living in hemiplegic patients after stroke, but the improvement of balance function is not sure. Due to the low overall quality of the included literature and the heterogeneity of some research results, more rigorous randomized controlled trials are needed to verify its efficacy.

Keywords: Health Qigong, meta-analysis, motor function, rehabilitation, stroke, systematic review, traditional Chinese medicine

How to cite this article:
Guan F, Ji Q. Effect of health Qigong on rehabilitation of stroke patients: A systematic review and meta-analysis. J Integr Nurs 2023;5:15-20

How to cite this URL:
Guan F, Ji Q. Effect of health Qigong on rehabilitation of stroke patients: A systematic review and meta-analysis. J Integr Nurs [serial online] 2023 [cited 2023 May 27];5:15-20. Available from: https://www.journalin.org/text.asp?2023/5/1/15/372418

Introduction

Stroke is a sudden disorder of cerebrovascular circulation. It is reported that the prevalence of stroke in adults aged 20 and over in China is 1114.8/100000 and the mortality is 114.8/100000.^[1] Poststroke usually causes different degrees of dysfunction, such as sensory and motor dysfunction, speech or communication dysfunction, and cognitive dysfunction, among which the rehabilitation of motor function is the focus of stroke rehabilitation.^[2] Health Qigong, as an important traditional sports event group promoted by China, is very popular and has distinct Chinese characteristics, including nine kinds of skills: Baduanjin (eight-sectioned exercise), Yijinjing (muscle–bone-strengthening exercise), Wuqinxi (five-animal exercises), Liuzijue (six-word Qigong), twelve-sectioned exercise, Dawu, twelve movements of health maintenance Qigong for guiding Qi movement, Mawangdui Guiding Technique, and Tai-Chi health-cultivation cane.^[3] Due to the safety, simplicity, and wide application of Qigong, it has been applied to rehabilitation after stroke in many clinical studies, with good results achieved. However, there is no evidence of integrating the effect of various health Qigong on the rehabilitation of stroke patients. Therefore, this study intends to evaluate the effect of traditional health Qigong on rehabilitation after stroke through meta-analysis.

Materials and Methods

Design

This is a systematic review and meta-analysis of evaluating the effects of health Qigong on the rehabilitation of hemiplegic patients after stroke. The reporting was in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Version 2020).

Search strategy

Two independent reviewers conducted comprehensive searches of relevant electronic databases. Eight electronic databases were searched including PubMed, Cochrane Library, Embase, Web of Science, CBM, CNKI, Wanfang Database, and VIP Database. The search period was from the establishment of databases to February 2022. The search languages are limited to Chinese and English. The search terms were stroke, cerebrovascular accident, CVA, cerebral stroke, brain vascular accident, apoplexy, Qigong, traditional exercise, Baduanjin/eight-sectioned exercise, Yijinjing/muscle–bone-strengthening exercise), Wuqinxi/five-animal exercises, Liuzijue/six-word Qigong, twelve-sectioned exercise, Dawu, twelve movements of health maintenance Qigong for guiding Qi movement, Mawangdui guiding technique, and Tai-Chi health-cultivation cane. In the case of any disagreement between the two reviewers, a third collaborator participated in the decision-making process.

Inclusion and exclusion criteria

Inclusion criteria were as follows: (1) studies designed with randomized controlled trials; (2) the subjects met the diagnostic criteria of stroke; (3) the control group was blank control or other nontraditional Qigong therapy, while the intervention group was treated with Qigong therapy on the basis of the control group; and (4) studies must include any of the following outcome indexes: Motor function assessed by the Fugl-Meyer Assessment (FMA), activities of daily living assessed by the Modified Barthel Index (MBI) or Barthel Index (BI), or balance function assessed by the Berg Balance Scale (BBS). The exclusion criteria were as follows: (1) animal experiments; (2) studies with unclear research type; and (3) repeated publication, incomplete original data, no full text, or incorrect statistical methods.

Literature screening and data extraction

After the duplicate literatures were removed by NoteExpress, all articles were read by two independent reviewers. We extracted data on the first author, published year, number of participants, intervention methods of the experimental group and control group, the outcome index, etc. The above steps were completed independently by the two researchers and checked with each other. In the event of differences, they were decided after a panel discussion.

Literature quality evaluation

In this study, Jadad scale was used to evaluate the quality of the included literature.^[4] The total score of the scale is five points, 1–2 points indicate low-quality studies and 3–5 points indicate high-quality studies. The quality is evaluated from three aspects: randomization, blind method, and follow-up.

Statistical analysis

The data were entered into RevMan5 (version 5.3) software package. Continuous variable data were calculated by mean difference (MD) or standardized mean difference (SMD), and 95% confidence interval (CI) was used for interval estimation. When P > 0.1, I² ≤ 50%, the studies were considered to be homogeneous, the fixed effect model was used to combine the effect value, otherwise the random effect model was used.

Results

Inclusion of documents

Strictly according to the literature retrieval strategy, 873 articles were obtained after preliminary retrieval. After preliminary screening and reading the full text, 17 articles were finally included, including 15 Chinese articles and 2 English articles. The literature screening process and results are shown in [Figure 1].

Figure 1: Document retrieval flow chart

Click here to view

Basic information and quality evaluation of the included literature

A total of 17 articles were included, involving 1146 subjects, including 583 cases in the experimental group and 563 cases in the control group. In the experimental group, there were 12 studies on Baduanjin,^{[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16]} 3 studies on Yijinjing,^{[17],[18],[19]} and 2 studies on Wuqinxi.^[20],[21] Literature quality evaluation showed that there were 3 articles with Jadad score of ≥3 and 14 articles with Jadad score of <3. The basic characteristics and quality evaluation of the included studies are shown in [Table 1].

Table 1: Research characteristics and quality evaluation score

Click here to view

Meta-analysis results

In the nine studies,^{[7],[10],[12],[13],[14],[17],[18],[19],[20]} the FMA scale was used to assess patients' motor function at different intervention times. There was statistical heterogeneity among the studies, so the random effects model was used. The results showed that the improvement of limb motor function in the intervention group was better than that in the control group, and the differences were statistically significant when the intervention time was <3 months (SMD = 1.03, 95% CI [0.35, 1.70], Z = 2.96 [P = 0.003]) and when the intervention time was ≥3 months (SMD = 0.86, 95% CI [0.54, 1.18], Z = 5.24 [P < 0.00001]) [Figure 2].

Figure 2: Meta-analysis of patients' motor function in 2 groups after intervention

Click here to view

In the seven studies,^{[5],[6],[8],[10],[12],[19],[21]} BI/MBI scale was used to assess patients' activities of daily living at different intervention times. There was statistical heterogeneity among the studies, so the random effects model was used. The results showed that intervention time <3 months and intervention time ≥3 months, the improvement of activities of daily living in the intervention group was better than that in the control group, and the differences were statistically significant when the intervention time was <3 months (SMD = 2.14, 95% CI [0.88, 3.41], Z = 3.32 [P = 0.0009]) and the intervention time was ≥3 months (SMD = 9.79, 95% CI [4.45, 15.13], Z = 3.59 [P = 0.0003]) [Figure 3].

Figure 3: Meta-analysis of patients' activities of daily living in 2 groups after intervention

Click here to view

In the nine studies,^{[7],[9],[10],[11],[14],[15],[16],[18],[21]} BBS scale was used to assess patients' balance function at different intervention times. There was statistical heterogeneity among the studies, so the random effects model was used. When the intervention time was <3 months, the improvement of balance function in the intervention group was better than that in the control group, and the differences were statistically significant (MD = 11.93, 95% CI [6.58, 17.28], Z = 4.37 [P < 0.0001]). When the intervention time was ≥3 months, there was no significant difference in the balance function between the intervention group and the control group (MD = 4.90, 95% CI [−0.92, 10.73], Z = 1.65 [P = 0.10]) [Figure 4].

Figure 4: Meta-analysis of patients' balance function in 2 groups after intervention

Click here to view

Sensitivity analysis

Because some results of this study showed heterogeneity, sensitivity analysis was performed to find the source of heterogeneity. The sensitivity analysis of each included research data was carried out by the item-by-item elimination method, showing that there was no significant difference in the I² of each research result.

Discussion

Effect of health Qigong on motor function of stroke patients

Motor dysfunction is the most common sequela after stroke. The recovery effect of limb motor function in patients after stroke is of great significance to their quality of life. Therefore, the recovery of hemiplegic limb function after stroke has been the focus of research. In this study, there were a total of nine articles of using the FMA scale to evaluate the motor function of patients, including 5 articles on Baduanjin, 3 articles on Yijinjing, and 1 article on Wuqinxi. Meta-analysis results showed that the improvement of limb motor function in the intervention group was better than that in the control group when the intervention time was less than 3 months (P < 0.01), and 3 months–24 weeks (P < 0.01). Health Qigong is based on ancient people's cognition and grasp of human life. Therefore, in the arrangement of functional movements and the skills of action in practice, it not only follows the laws of sports physiology, but also uses the theories of Yin and Yang, five elements, meridians, and blood circulation of traditional Chinese medicine.^[22] The movement of hip flexion and knee flexion during Baduanjin exercise can significantly increase the activation of lower limb muscles.^[23] The knee flexion, bow step, and horse step in Yijinjing method meet the requirements of lower limb movement in modern rehabilitation treatment technology, and can effectively activate lower limb muscles.^[24] Wuqinxi can improve the activity of human joints and waist limbs by imitating the activity characteristics of various animals.

Effect of Health Qigong on activities of daily living of stroke patients

This study included 7 articles using the BI scale or MBI scale, including 5 articles on Baduanjin, 1 article on Yijinjing, and 1 article on Wuqinxi. The ultimate goal of rehabilitation after stroke is to enable patients to achieve the maximum degree of self-care, but in the actual rehabilitation process, the ability of daily living activities is often improved slowly due to the emphasis on the recovery of limb motor function. The results of meta-analysis in this study showed that the activities of daily living in the intervention group were better than those in the control group when the intervention time was <3 months (P < 0.01), and 3 months–24 weeks (P < 0.01). However, subgroup analysis showed that there was great heterogeneity, with I² of 93% and 99%, respectively. Therefore, the effectiveness of Qigong on activities of daily living in stroke patients cannot be determined.

Effect of health Qigong on balance function of stroke patients

In this study, there were a total of 9 articles using the BBS scale to evaluate the motor function of patients, including 7 articles on Baduanjin, 1 article on Yijinjing, and 1 article on Wuqinxi. The results of meta-analysis in this study showed that the balance function of the intervention group was better than that of the control group when the intervention time was less than 3 months (P < 0.01), However, when the intervention time was ≥3 months, there was no statistically significant difference in the balance function between the two groups (P = 0.10). The reason may be related to the strong plasticity of brain nerves in the early stage after stroke. Early functional exercise realizes the reconstruction of the cerebral cortex map, to learn and acquire new skills, or to repair and compensate functional damage by continuously establishing new neural connections and neural networks.^[2] However, due to the large heterogeneity of the results of this study, more high-quality randomized controlled trials are needed to prove the effect of long-term (3 months–24 weeks) health Qigong on the balance function of patients after stroke.

The quality score of 11 articles included in this study was 2, especially the blind method and the hidden description of allocation were not clear, suggesting that there were different degrees of selection bias, implementation bias, and measurement bias in the included studies. The time and frequency of intervention in each study and the difference of trainers may be one of the main reasons for heterogeneity.

Conclusion

Health Qigong, as a traditional sport in China, is not only safe and economical but also can effectively improve the motor function and activities of daily living in hemiplegic patients after stroke, which is, therefore, worth popularizing and applying in the community. However, due to the quality of the literature, more high-quality randomized controlled trials are needed in the future to verify the rehabilitation effect of Qigong on stroke patients. In future research, unified outcome indicators can be used to explore the comparison of outcome indicators of Qigong on the rehabilitation effect of stroke patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Wang W, Jiang B, Sun H, et al. Prevalence, incidence, and mortality of stroke in China: Results from a nationwide population-based survey of 480 687 adults. Circulation 2017;135:759-71.
2.	Zhang T. Rehabilitation management in acute stroke. Chin J Neurol 2020;53:312-6.
3.	Song Y, Xia X, Guo Z. Strategy of fitness qigong integrating into and promoting the development of health service industry in China. J Shanghai Institute Phys Educ 2020;44:84-94.
4.	Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials 1996;17:1-12.
5.	Zheng G, Zheng Y, Xiong Z, et al. Effect of Baduanjin exercise on cognitive function in patients with post-stroke cognitive impairment: A randomized controlled trial. Clin Rehabil 2020;34:1028-39.
6.	Yuen M, Ouyang HX, Miller T, et al. Baduanjin qigong improves balance, leg strength, and mobility in individuals with chronic stroke: A randomized controlled study. Neurorehabil Neural Repair 2021;35:444-56.
7.	Zhang Y, Li L. Treatment of 31 cases of balance function disorder after cerebral stroke by eight-section brocade and balance training. Shandong J Tradit Chin Med 2016;35:716-8.
8.	Wei Q, Zhang XJ. Analysis of effect of Baduanjin exercise applied in 40 cases of stroke convalescence. Beijing J Tradit Chin Med 2019;38:816-8.
9.	Zhang M, Guo J, Bai YJ, et al. Effect of Baduanjin combined with rehabilitation exercise on balance function of stroke patients. Shizhen Med Mater Med Res 2013;24:2438-9.
10.	Xie BJ, Yang M, Bai YL. Clinical study on the effect of Baduanjin on motor rehabilitation of stroke patients. West China Med J 2019;34:515-9.
11.	Ding Y, Guo CC, Wang N, et al. Effect of Baduanjin's third part combined with conventional balance training on balance function of patients with cerebral stroke. Shandong J Tradit Chin Med 2019;38:673-6, 704.
12.	Zhang LL, Huang CX. Effects of Baduanjin rehabilitation training on limb motor function, daily life and quality of life of elderly stroke patients with hemiplegia. Chin J Gerontol 2021;41:4620-2.
13.	Yang HX, Liu XL. Effects of Taiji Quan and Baduanjin on motor function of lower limbs for stroke patients using surface electromyography. Chin J Rehabil Theory Pract 2019;25:101-6.
14.	Zhou HY, Wu YY, Wu CL. Effects of eight trigrams boxing combined with rehabilitation training in the treatment of elderly patients with convalescent cerebral vascular accident. Geriatr Health care 2021;27:1191-4.
15.	Zhuang KC, Xu Y, Shen ZH, et al. Application of Baduanjin in improving lower limb balance function and gait in elderly stroke rehabilitation patients. J Mod Med Health 2019;35:3352-4.
16.	Bai YJ, Mao HY, Guo J, et al. Research on Baduanjin combined with function training in improving balance functions of stroke patients. China J Chin Med 2011;26:1231-2.
17.	Zhang J, Jia WZ, Li HY, et al. Study on improving motor function of stroke patients with hemiplegia by fitness qigong and Yijinjing exercise. Sports 2010;86:123-4.
18.	Jia WZ. Effects of Yijinjing on Motor Function, Balance Ability and Emotion of Stroke Patients with Hemiplegia (Dissertation). Shijiazhuang, China: Hebei Normal University; 2008.
19.	Sun PP, Qi R, Ma ZZ, et al. Clinical study of the influence of Yijinjing on motor function and life quality of convalescent patients with cerebral infarction. Shanghai J Tradit Chinese Med 2017;51:48-50.
20.	Tang LX, Gong BM, Shi ZW, et al. Effect of qigong practice wuqinxi on the motor function of elderly patients with stroke hemiplegia. China Med Her 2018;15:112-5.
21.	Zhu XK, Xu P, Nie ZH, et al. Effects of Wuqinxi on balance function and activities of daily life of stroke patients with hemiplegia. China Health Care Nutr 2020;30:48.
22.	Wang SS, Zeng JL, Zhang CY. Study of problems in translating TCM terms of health qigong. J Basic Chin Med 2019;25:1426-9.
23.	Lee NK, Kwon JW, Son SM, et al. The effects of closed and open kinetic chain exercises on lower limb muscle activity and balance in stroke survivors. NeuroRehabilitation 2013;33:177-83.
24.	Chen YX, Zhang LL, Li LL, et al. Application of Yijin Jing in rehabilitation of cerebral apoplexy. Shandong J Tradit Chin Med 2021;40:654-7.