Qigong and Tai Chi Detailed Scientific Review

Overview

Background

Qigong (or Chi-Gung) is based upon a set of health promoting practices that developed during pre-historic times in ceremonial and other tribal dances1. The dance includes special forms of breathing, meditation and postures. Taijiquan (ty chee chuan) is a subset that developed as a "soft form" of martial arts about 300 years ago. Both work with energy and are distinctive for their slowly moving meditative exercises or posture changes that flow from one form to another. Many of these postures have been paralleled after the movements of animals and are often described as "swimming in the air"^1-4.

The word Qigong may be analyzed as qi, meaning vitality, life energy or life force and gong, meaning diligent practice, cultivation or refinement. Therefore, Qigong roughly translates as "cultivate and refine your life force through diligent practice", a definition that became popular in the 20th century⁴.

According to the Chinese government, over 5,000 styles of Qigong exist, each with its own history and training methods. The Tientsin Chinese Medicine Academy has suggested applying different styles of Qigong diet, deep breathing and exercises for different medical conditions². Qigong for general health maintenance may be practiced for as little as 20 minutes a day; for mild diseases, three to four hours; and for serious diseases, eight to 12 hours. A typical daily Qigong session consists of five components: meditation, cleansing chi, strengthening chi, circulating chi and dispersing chi⁴. Others describe three primary approaches: purging to remove excess or toxic Qi, toning for strengthening deficient internal organs and regulating in order to balance the body’s energy system⁵.

Water has been used to illustrate the nature of Qigong. Blood and energy move through channels in the body like water flowing through rivers, deep diaphragmatic breathing rises and falls with the rhythmic regularity of waves on the ocean and the human mind rests in meditation like the surface of a lake on a windless day¹. Original Qi is inherited from ones parents and the universe, but this internal Qi (Nei Qi) may be mobilized and cultivated. When it becomes abundant and strong, it is believed that it can be spread to others. It is believed that this "spreading Qi" (Bu Qi), later known as external Qi (Wai Qi), may then be projected to areas of blockage in another person. Although cultivation of ones own Qi may be of equal or even greater value as that received from another, the effects of external Qi on living cells or animals are often studied in an attempt to remove psychological effects^4,6,7.

Tai Chi, has been roughly translated as "the supreme ultimate fist", and is practiced as a foundation for martial arts. According to one legend, Tai Chi was created by a Taoist (or Daoist) monk who watched a battle between a crane and a snake. He was impressed by the snake’s ability to subtly and swiftly avoid the bird’s thrusts not by meeting force with force, but by causing his opponent’s own momentum to work against him⁴

Several studies have reported positive effects of Tai Chi or Qigong for enhancing balance and preventing falls in the elderly^8-10. One review of therapies for the treatment of balance and other musculoskeletal disorders in the elderly concluded, "Qigong appears to confer benefits to sufferers of many chronic diseases common in the elderly. . .but, good controlled research does not exist."¹¹

A randomized controlled study of Qigong with a real versus a "sham" master evaluated effects upon intractable pain (reflex sympathetic dystrophy). The study reported significant transient (within session) relief of pain, long-term reduction in anxiety and fewer symptoms of depression over time in the group who practiced Qigong. However, there were no significant differences in long-lasting pain relief, medical symptoms, range of motion, surface skin temperature or domestic functioning¹².

On any morning in parks throughout China, thousands of people may be seen practicing Qigong and Tai Chi, either individually or in large groups. One may even see patients in hospital pajamas doing special forms designed for patients with cancer and other health problems. Although Tai Chi and Qigong originated in China, people are engaging in these ancient practices in the parks of many cities throughout the world.

Proposed mechanism of action

In order to describe possible mechanisms of action, one must understand the oriental concepts of internal organ channels (meridians) and fields of Qi (dantians in the Chinese system or chakras in the Indian Yoga systems). Meridians may also be thought of as paths of energy that flow near the surface of the body, and dantians or chakras may be thought of as deeper separate but interconnected organizing centers¹³. Qigong and Tai Chi are ways of balancing and enhancing these natural energy resources so that healing may be encouraged through improved immune and other functions.

Side effects and possible risks

Although one can learn much about Qigong and Tai Chi from books and videos, some aspects of Qigong or Tai Chi can be harmful if practiced incorrectly. Accordingly, it is wise to seek at least occasional help from an experienced master who can guide one safely through the more advanced and complicated routines.

Some have described Qigong as a "Chinese healing system based on trance" and as such it may be a risk for persons who are not mentally stable. Reports of mental disorders said to be induced by Qigong have been limited to the Chinese literature; however, so may be a culturally dependent risk factor¹⁴.

Although some studies have shown that Qigong and Tai Chi can help to improve balance and prevent falls by elderly persons¹¹, persons with serious balance issues (unable to stand on one leg for at least three seconds) could be at risk of falling. Such people can lessen their risks by being individually supervised by a physical therapist or other knowledgeable health professional, and/or using a wall or chair or just staying seated until their balance improves.

Qigong and Tai Chi require a commitment of time that may compete with other activities.

In general these are mild exercises that are safe for most people¹¹.

Research findings applicable to cancer

A review of research findings specifically concerning patients with cancer may be found in the Summary of Research.

Summary of Research

Searches of the Medline, CINAHL and Alt HealthWatch databases from May of 2002 through December of 2004, identified 19 articles in English that mentioned either "Qigong" or "Chi Gung" or "Tai Chi" or "Taiji" or "Tai Ji" and also included cancer related terms. Twelve of these articles were directly applicable to patients with cancer and were retrieved as complete articles. An additional search for immune related articles identified three articles with relevance to cancer patients.

Previous search of the Medline database for Tai Chi had identified 90 articles between January 1, 1966, and April 3, 2002, but none of these were applicable to cancer. Another previous search of the Medline database for Qigong had identified 87 articles about Qigong between January 1, 1966, and April 3, 2002, of which five were applicable to cancer.

We characterized these 20 articles as the following types of information.

*The author of one of these human studies had a theory that solar energy at sunrise and sunset was the same as Qigong energy and could be stored on cards¹⁵. This broad definition of Qigong will not be included within the scope of this review.

**Studies of the effects of external Qi, or bioenergy, emitted from Qigong practitioners.

We characterized the seven studies of actual Qigong or Tai Chi practice among patients with cancer as the following study designs:

One of the three non-blinded randomized controlled trials (RCTs) evaluated the effects of Tai Chi on quality of life and self-esteem in 21 breast cancer survivors. Overall, the Tai Chi group exhibited significant improvements in quality of life and self-esteem compared with the psychosocial support therapy group, which had declines in both. However, Tai Chi was not compared with other forms of physical movement and differences in the levels of training and experience of the group instructors could have affected these findings¹⁶. Another RCT evaluated the effects of Tai Chi compared with walking on cancer related fatigue and body mass in 11 women with breast cancer. No significant differences were found which may have been due to the lack of power of this small study to detect such differences¹⁷.

One case report described lowering of PSA levels and other effects in a man who had a rising PSA, but not actual cancer¹⁸. Another case reported was a man with metastatic colon cancer who had been treated with surgery and chemotherapy and wanted to stop the chemotherapy. He was persuaded to continue after the addition of Qigong, recovered and had no evidence of cancer on CT scan as of three years following his diagnosis².

Immune effects in healthy persons were evaluated in one RCT, a non-randomized controlled trial and a clinical series. The RCT compared Qi-therapy to placebo Qi-therapy in 31 adult males and found significant time and group by time effects for natural killer cell activity, neutrophil function, mood and anxiety. Significant time effects were found for cortisol levels and significant group by time effects were found for melatonin¹⁹. In the non-randomized controlled trial, 75 male volunteers were divided into five groups based on their duration of Qigong training. A significant decrease in the CD8⁺ T lymphocyte count and increase in CD4⁺/CD8⁺ T lymphocyte ratio was found in groups with five to 12, 13-24 and 25 or more months of Qigong training, compared to the control group with no training²⁰. The non-controlled clinical series evaluated the effect of one hour of Qi-training on nine men. Ten minutes following Qi training, significant effects were observed in superoxide generation, reaction velocity and neutrophil adhesion capacity. A significant increase in white blood cells, monocytes and lymphocytes was also observed²¹.

Positive effects of Qigong or Tai Chi exercises upon immune functions, fatigue, self-esteem, health and quality of life (in people without cancer) have also been reported in a few randomized controlled trials^22-27. Some of the trials were blinded to the participants, but none were blinded to the evaluators.

Review of qigong studies published in China

Studies of Qigong and cancer published in China during the last 20 years have been reviewed by Chen and Yeung²⁸. They searched the Qigong database of the Qigong Institute²⁹ and "accessible publications" in Chinese during the past 20 years²⁸. Their criteria included

1. Studies with systematic data collection and not simply case reports or testimonials
2. Specific cancer or carcinoma cells with quantifiable results
3. Clinical research with an identifiable baseline tumor description or cancer identification

They classified the 54 studies identified into the following types of information.

The following table is based upon Chen and Yeung’s descriptions of these human studies.

*Note that case reports did not quality for inclusion in this review.

Chen and Yeung identified three randomized controlled trials (RCTs), but none of these trials were blinded. Also, they were only presented at Qigong conferences rather than being published in journals, so details of variables and methods of analysis are not available. The largest of these trials (n=186) consisted of post-surgical patients with "cardiac adenocarcinoma". A significantly greater proportion survived for five years in the group who practiced Qigong and took prescribed herbs (36%) compared with herbs alone (26.1%), chemotherapy alone (25.1%) or no further treatment (20.8%)(P<.01)²⁸.

Rate of "unscheduled DNA synthesis" (i.e., DNA repair) of peripheral blood lymphocytes was the subject of a second and smaller randomized trial (n=65). Patients who practiced Qigong for three months were compared with those who only received chemotherapy and both groups were compared with a third control group without cancer. Although both groups with cancer had lower DNA repair rates than those without cancer, the Qigong group with cancer had a significantly greater improvement in their DNA repair rate than those who only had chemotherapy (P<0.01)²⁸.

The third randomized trial evaluated three groups of patients with stage I or II disease who had previously received chemotherapy or radiotherapy. One group subsequently practiced Qigong, another group received additional chemotherapy and the third group both practiced Qigong and received additional chemotherapy. After 60 days, the group who just practiced Qigong had significant rises in their white blood cells (WBCs), red blood cells (RBCs) and serum hemoglobin (P<.01) while the group who only received chemotherapy had significant reductions in these levels (P<.01). The chemotherapy plus Qigong group had significant elevations in platelets, RBCs and serum hemoglobin (P<.01), but not in WBC levels²⁸.

Many of the non-randomized controlled studies were published in journals cited in the review. These studies reported Qigong benefits for immune function, sleep, appetite, weight gain, strength, reduced diarrhea, normalized blood counts, less side effects of chemotherapy or radiotherapy and improved health. The largest study (1648 patients) did not have any control groups. The hospital in which it was conducted combined Qigong with other forms of conventional cancer therapy and reported better five-year survival rates than other hospitals²⁸.

Chen and Yeung also reviewed effects of external Qigong on cancer cells and animals in whom tumors or cancerous cells had been implanted. In most of the 15 cellular studies, inhibition of tumor growth and killing of malignant cells by external Qigong was reported. Similar effects were reported from among the 18 studies in animals, but one study reported the opposite - increased tumor growth in eight of 25 separate experiments²⁸.

Conclusions of Chen and Yeung: Chen and Yeung noted that many Qigong healers in these studies could not effectively repeat what they had done in a prior study; thus raising concern about the reliability and validity of these results. In spite of these difficulties and problems with replication, they concluded that Qigong therapy might actually stop and prevent cancer growth, and help patients to recover from many different diseases²⁸.

(Note that previous summaries on this Web site of reviews and articles identified on the Qigong Database^11,30 are no longer included in this Web site summary as they have been replaced by Chen and Yeung’s more comprehensive and recent review.)

Further Conclusions concerning the benefits of Qigong for cancer patients await the development of randomized controlled trials that are blinded at least to the evaluator(s). Principles and unique issues encountered in the design of a current NIH sponsored clinical trial of external Qi on patients awaiting heart transplantation are discussed in an article by Ai and colleagues at the University of Michigan³¹.

Seven published studies of Tai Chi and Qigong in English are described in more detail in the Annotated Bibliography.

Annotated Bibliography

Human Studies in English

Randomized Controlled Trials (2)

¹⁶Mustian KM, Katula JA, Gill DL, Roscoe JA, Lang D, Murphy K. Tai Chi Chuan, health-related quality of life and self-esteem: a randomized trial with breast cancer survivors. Support Care Cancer 2004, Dec 12(12):871-876.

Purpose: Evaluation of Tai Chi effects upon quality of life and self-esteem
Type of Study: Randomized controlled trial
Methods: (Breast cancer) Breast cancer survivors were recruited through mass mailings, flyers and physician referrals for participation in the study. Thirty-one (out of an unknown number) met eligibility requirements and were enrolled in the study and 21 (68%) completed the study. Subjects were randomized into a Tai Chi Chuan group (TCC) or a psychosocial support therapy group (PST). Each group met three times a week for 60 minutes for 12 weeks. A graduate student under the direct supervision of a Master’s trained counselor led the PST sessions. An experienced TCC instructor conducted TCC sessions. Subjects in both groups were instructed not to begin any other physical activity programs or change their normal daily physical activity during the duration of the study. Self-report questionnaires were administered at baseline, six weeks and 12 weeks measuring health related quality of life (HRQL) and self-esteem. All participants were also instructed to keep a daily log to monitor attendance and compliance to the sessions.
Results: Participants in the two groups were found to be significantly different in terms of baseline self-esteem, but not in any other characteristics. The attendance/compliance rates for the TCC participants and PST participants were 72% and 67% respectively. Across the 12-week study period, the TCC group showed significant improvements in Health Related Quality of Life (P=0.03) and self esteem (P=0.01) compared to the PST group. The authors noted that prior research has shown that physical activity has a positive influence on self-esteem, which may be a possible explanation for the improvements in the TCC group over the PST group.
Comment: It should be noted that the PST sessions were led by a graduate exercise psychology student, whereas the TCC sessions were led by an experienced TCC instructor certified in health and fitness instruction. This difference in experience level may also have affected the findings.

¹⁷Galantino ML, Capito L, Kane RJ, Ottey N, Switzer S, Packel L. The effects of Tai Chi and walking on fatigue and body mass index in women living with breast cancer: a pilot study. Rehabilitation Oncology. 2003 21(1):17-22.

Purpose: Evaluation of Tai Chi upon fatigue and body mass index
Type of Study: Randomized controlled trial
Methods: (Breast cancer) Eleven women (out of an unknown number) between the ages of 40 to 59 with a diagnosis of stage II to IV breast cancer, and experiencing cancer related fatigue (CRF) were enrolled in the study. Subjects were randomly assigned to the Tai Chi or walking group. At an informational meeting, women in the Tai Chi group received instructions on the Yang family form of Tai Chi and were provided with a Tai Chi video. Women in the walking group received instructions of proper warm-up and footwear and were given a booklet and video on a walking exercise program. All subjects were asked to follow their respective exercise program a minimum of three times per week for six weeks at their home. Three group meetings were held during the six weeks and all participants received weekly phone calls regarding the program. Measurements of body mass index, six-minute walk test, fatigue and functional ability were taken at baseline and six weeks. Subjects were also asked to keep a diary to monitor their exercise program and record their heart rate.
Results: Trends in fatigue reduction and improved quality of life were found for both groups. No significant differences were found which may have been due to the small number of subjects.

Case Reports (2)

¹⁸Chen KW, Turner FD. A case study of simultaneous recovery from multiple physical symptoms with medical Qigong therapy. J Altern Complement Med 2004 Feb 10(1): 159-62.

Purpose: Evaluation of effects of Qigong upon chronic conditions
Type of Study: Case report
Methods: A 58-year-old male with prior experience in complementary and alternative medicine was suffering from various chronic conditions and had experienced a marked increase in his PSA level (although not confirmed cancer). He attended a two-day workshop on Qigong by the World Institute for Self-Healing, had individual sessions with a Qigong healer and attended a 20-day intensive Qigong anticancer seminar over an unknown period of time.
Results: His PSA level dropped from 11 to 4, along with marked improvements in his blood pressure, pulse rate, allergies, asthma and other conditions at the conclusion of the intensive Qigong anticancer seminar. Upon discontinuation of regular Qigong exercise, his PSA level increased to 12. After several months of resuming continuous Qigong practice, his PSA once again dropped to 4.
Comment: Although fluctuations in PSA levels are common, an increase of 0.75 per year is considered significant according to the American Cancer Society³².

²Loh S-H. Qigong therapy in the treatment of metastatic colon cancer. Alternative Therapies in Health & Medicine 1999 Jul;5(4):111-2.

Purpose: Toleration of chemotherapy
Type of Study: Case report
Methods: (Colon cancer) A 60-year-old man was diagnosed with colon cancer metastatic to his regional lymph nodes with a mass in his liver. He received a surgical hemicolectomy with resected margins free of tumor and then began receiving 5-fluorouracil (5-FU) and leucovorin calcium. After 28 treatments, he wanted to stop the chemotherapy, but was persuaded to continue when external Qi was given to him at each chemotherapy session and he was taught to practice Qigong at home for four hours a day.
Results: A little over a year after his diagnosis, a follow-up CT scan of his chest, abdomen and pelvis was negative. Previously described masses in the liver and para-aortic retrocrural lymph nodes had disappeared and all but one blood test (transaminase) was normal. As of three years after diagnosis he was alive and in good health and still practicing Qigong for four hours a day.

Studies in Normal Populations

¹⁹Lee M, Huh H, Hong S, Jang H, Ryu H, Lee H, et al. Psychoneuroimmunological effects of Qi-therapy: preliminary study on the changes of level of anxiety, mood, cortisol and melatonin and cellular function of neutrophil and natural killer cells. Stress and Health 2001;17(1):17-24.

Purpose: Effects upon immunological responses
Type of Study: Randomized controlled trial
Methods: Young, healthy male subjects were recruited on a voluntary basis from a university. Out of 31 volunteers, 11 were excluded because of medical reasons or prior experience with complementary therapy. The 20 remaining subjects were randomized to receive either Qi therapy (QT)(n=10) or placebo QT (n=10). The same QT master administered both treatments. Although he used the same hand motions for both treatments, he focused his mind on healing during the real QT treatment and just counted numbers during the placebo treatment. Treatment consisted of five minutes of rest, followed by 10 minutes of either real or placebo QT, five minutes of rest (time 1), then one hour of rest in a waiting room (time 2). Measurements of anxiety, mood, serum cortisol, melatonin, neutrophils and natural killer (NK) cell activity were taken at baseline, time 1 and time 2.
Results: Significant effects for time and group-by-time interaction were reported for anxiety (p<.000, p<.05) and mood (p<.000, p<.01). One hour after anxiety had decreased by 23% with QT and 8% with placebo while mood disturbance score decreased 55% with QT and 21% with placebo. A significant time effect was obtained in cortisol level (p<.05), with it decreasing from pre to post in both groups, but no significant differences were detected between groups. A significant group-by-time interaction for melatonin was reported (p<.001), with the QT group showing a significant increase and the placebo group showing a decrease. Neutrophil function as measured by superoxide generation, was increased by 36% with QT, but decreased by 8% with placebo (group by time interaction, p <0.0001). Natural killer (NK) cell toxicity increased 27% in the QT group, which returned to baseline within an hour, but there were no changes with the placebo group (all p values less than .05).

²⁰Ryu H, Jun C, Lee B, Choi B, Kim H, Chung H. Effect of Qigong training on proportions of T lymphocyte subsets in human peripheral blood. American Journal of Chinese Medicine 1995;23(1):27-36.

Purpose: Effects upon immune system functions
Type of Study: Non-randomized controlled trial
Methods: Healthy male volunteers (N=75) were divided into five groups based on their duration of Qigong training that they had previously received:

• Group 1: One to four months (n=12)
• Group 2: Five to 12 months (n=21)
• Group 3: Thirteen to 24 months (n=17)
• Group 4: Over 25 months (n=12)
• Control: No training (n=13)

Subjects in the active trainee groups practiced Chun Do Su Bup, a kind of Qigong training incorporating sound exercise, motion and meditation, and were led by a master daily for one hour for an unclear number of days. Blood sampling was done each day before training. Two sets of absolute numbers and ratios of T lymphocytes were assessed: CD4 (helper-inducer)/CD8(suppressor-cytotoxic)and CD4 naïve/CD4 memory cells..
Results: The ratio of CD4⁺/CD8⁺ T lymphocytes increased dependently during the course of the 12 months of observed training. Significant differences associated with duration of training were observed at five to 12 months, 13-24 months and above 25 months (p<.05) when compared to the control group. The absolute number of CD8⁺ T lymphocytes was decreased in groups with Qigong training compared to the control, with significant differences found in five to 12, 13-24 and over 25 months (p<.05). The absolute number of CD4⁺ T lymphocytes increased in Qigong training groups, though the differences were not significant. No change occurred in the total number of white blood cells between the trainees and normal controls.
Note: The authors acknowledged that further studies were needed to determine if the increase in the proportion of CD4⁺ T memory cells was due to increased antigen or other factors rather than the Qigong training itself.

²¹Lee M, Jeong S, Kim Y , Park K, Lee M, Ryu H, et al. Qi-training enhances respiratory burst function and adhesive capacity of neutrophils in young adults: a preliminary study. The American Journal of Chinese Medicine 2003;31(1):141-8.

Purpose: Effects upon immune system functions
Type of Study: Clinical series (uncontrolled study)
Methods: Nine young, healthy male subjects volunteered for the study. They were required to abstain from smoking, caffeine and alcohol for six hours prior to the study, and could not have history of chronic disease, malnutrition or malignancy. Subjects performed one hour of Chun Do Sun Bup Qi-training directed by a master instructor. The training consisted of 10 minutes rest, sound reciting for 15 minutes, slow motions for 15 minutes and meditation for 20 minutes. Blood was drawn at baseline, 10 minutes following Qi-training (post 1) and two hours following Qi-training (post 2) to assess superoxide production and adhesion capacity of neutrophils.
Results: Superoxide generation was enhanced significantly from baseline to post 1 (p<.001), but returned to baseline levels by post 2. Significant effects of Qi-training were also observed for reaction velocity (p=.02) and neutrophil adhesive capacity (p=.04) between baseline and post 1, with reaction velocity returning to baseline levels by post 2 and neutrophil adhesion capacity remaining elevated. After Qi-training (baseline to post 1), significant increases were found in the number of white blood cells (p<.001), monocytes (p<.001), and lymphocytes (p=.026).
Positive effects upon immune functions, fatigue, self-esteem, health and quality of life have been reported in a few randomized controlled trials^22-27. Some of these trials were blinded to the participants, but none were blinded to the evaluators.

Reference List

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2. Loh S-H. Qigong therapy in the treatment of metastatic colon cancer. Alternative Therapies in Health & Medicine 1999 Jul;5(4):111-2.
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6. Wirth DP, Cram JR, Chang RJ. Multisite electromyographic analysis of therapeutic touch and Qigong therapy. J of Alternative and Complementary Medicine 1997;3(2):109-18. Note: Human study.
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16. Mustian KM, Katula JA, Gill DL, Roscoe JA, Lang D, Murphy K. Tai Chi Chuan, health-related quality of life and self-esteem: a randomized trial with breast cancer survivors. Support Care Cancer 2004 Dec;12(12):871-6.
17. Galantino ML, Capito L, Kane RJ, Ottey N, Switzer S, Packel L. The effects of Tai Chi and walking on fatigue and body mass index in women living with breast cancer: a pilot study. Rehabilitation Oncology. 2003;21(1):17-22.
18. Chen KW, Turner FD. A case study of simultaneous recovery from multiple physical symptoms with medical Qigong therapy. J Altern Complement Med 2004 Feb;10(1):159-62.
19. Lee M, Huh H, Hong S, Jang H, Ryu H, Lee H, et al. Psychoneuroimmunological effects of Qi-therapy: preliminary study on the changes of level of anxiety, mood, cortisol and melatonin and cellular function of neutrophil and natural killer cells. Stress and Health 2001;17(1):17-24.
20. Ryu H, Jun C, Lee B, Choi B, Kim H, Chung H. Effect of Qigong training on proportions of T lymphocyte subsets in human peripheral blood. American Journal of Chinese Medicine 1995;23(1):27-36.
21. Lee M, Jeong S, Kim Y , Park K, Lee M, Ryu H, et al. Qi-training enhances respiratory burst function and adhesive capacity of neutrophils in young adults: a preliminary study. The American Journal of Chinese Medicine 2003;31(1):141-8.
22. Liang Y, Cai Y, Wang Z. The effects of Chinese traditional breathing training on the exercise test, resistance breathing and quality of life in chronic obstructive pulmonary disease patients. Chinese Medical Jouranl 1998 Apr;111(4):318.
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