Efficacy of traditional Chinese exercise for sarcopenia: A systematic review and meta-analysis of randomized controlled trials

Abstract

Objective:

To conduct a systematic review and meta-analysis to evaluate the effectiveness of Traditional Chinese Exercise (TCE) for sarcopenia.

Methods:

A literature search was conducted in eight online databases from inception until September 2022. Based on the Cochrane risk of bias tool, randomized controlled trials (RCTs) with RoB score ≥ 4 were included for further analyses. The primary outcome was muscle strength and physical function, and the secondary outcomes were adverse events. Data collection and analyses were conducted by RevMan 5.4 Software. GRADE system was used to evaluate the certainty of evidence.

Results:

A total of 13 eligible RCTs with 718 subjects were identified and included in this study. Among them, 10 RCTs involved Yijinjing; 2 involved Tai Chi; and 1 involved Baduanjin. Meta-analyses showed that TCE had better clinical effects than control measures in the chair stand test (P < 0.00001, I² = 38%; Certainty of evidence: Moderate), squatting-to-standing test (P < 0.00001, I² = 0%; Certainty of evidence: Moderate), 6-m gait speed (P < 0.00001, I² = 13%; Certainty of evidence: Moderate), Time Up and Go Test (P = 0.03, I² = 81%; Certainty of evidence: Low), peak torque of the extensors (P = 0.03, I² = 0%; Certainty of evidence: Moderate), total work of the extensors (P = 0.03, I² = 35%; Certainty of evidence: Moderate), peak torque of the flexors (P = 0.03, I² = 47%; Certainty of evidence: Low), total work of the flexors (P = 0.02, I² = 42%; Certainty of evidence: Low), the average power of the flexors (P = 0.03, I² = 30%; Certainty of evidence: Moderate), and balance function (P < 0.00001, I² = 53%; Certainty of evidence: Low). In additional, no adverse events were reported in participants who receive TCE.

Conclusion:

The findings of the present systematic review, at least to a certain extent, provided supporting evidence for the routine use of TCE for sarcopenia.

Introduction

Sarcopenia, a skeletal muscle disorder, is related to the accelerated loss of physical function and muscle mass (Cruz-Jentoft and Sayer, 2019). It is a progressive and generalized disease that is common in the elderly and is associated with various adverse outcomes including fall down, functional decline, and bodily weakness (Cruz-Jentoft et al., 2019). It severely affects the normal physiological function and quality of life of the elderly, and even shortens their lifespan (Mohd Nawi et al., 2019). In recent years, the aging of the population has become a serious social problem all over the world, and sarcopenia has received increasing attention (Jensen et al., 2020). Exercise, nutrition, and pharmacotherapy are the mainstays of treatment for sarcopenia in the elderly (Cruz-Jentoft et al., 2014). There is currently no specific cure for sarcopenia. Some drugs may benefit muscles, such as hormones, but these drugs may cause serious adverse effects (Gaskin et al., 2003; Veldhuis et al., 2011). Exercise therapy is regarded as one of the major means of treating sarcopenia in the elderly, mainly including resistance exercise and aerobic exercise (Kakehi et al., 2022).

Traditional Chinese exercise (TCE) is a therapeutic, aerobic, and mind-body exercise, which originated from traditional Chinese medicine and can be traced back to approximately 3,000 years ago (Zhang et al., 2017). As a major integral part of non-pharmacological traditional Chinese medicine, TCE mainly includes Yijinjing, Tai Chi, Baduanjin, and Wuqinxi, and are characterized by gentle movements emphasizing physical and mental relaxation (Zhou et al., 2019; Zeng et al., 2020). Previous studies had reported the significant effects of TCE in improving patients’ physical status in various diseases including metabolic diseases (Zou et al., 2019), degenerative diseases (Fidan et al., 2019), cardiovascular diseases (Wu et al., 2020), respiratory disease (Reychler et al., 2019), endocrinopathies (Meng et al., 2018), and cancer (Wayne et al., 2018).

Currently, increasing numbers of clinical trials have reported that TCE has been used for treating sarcopenia. More and more randomized controlled trials (RCTs) demonstrated that TCE can significantly improve patients’ physical status (Zhu Y. et al., 2019). However, results from different studies are inconsistent, and sometimes are contrary due to different sample sizes or duration time. The conclusions from current studies have remained controversial, and the evidence provided by these studies are require assessment. Therefore, it is worth undertaking a systematic review and meta-analysis to investigate the effectiveness of TCE for patients with sarcopenia.

Methods

The present study is reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement (Moher et al., 2009).

Database and search strategies

We searched four international online databases (PubMed, EMBASE, Cochrane library, and Web of Science) and four Chinese online databases (VIP information database, Chinese National Knowledge Infrastructure (CNKI), Wan Fang Data Information Site, and Chinese Biomedical Literature Database) from inception to September 2022. Additionally, other relevant studies including references cited by previously published systematic reviews, conference proceedings, and dissertations were also manually searched in this study. The following search strategy was used for PubMed and was modified to suit other databases.

• 1.

  Traditional Chinese exercise

• 2.

  Qigong

• 3.

  Tai Chi

• 4.

  Yijinjing

• 5.

  Baduanjin

• 6.

  Kungfu

• 7.

  Wuqinxi

• 8.

  OR/1-7

• 9.

  Sarcopenia

• 10.

  Sarcopenias

• 11.

  OR/8-9

• 12.

  8AND11

Eligibility criteria

Types of studies

In the present study, we only included RCTs that evaluate the efficacy and safety of TCE for sarcopenia. As some studies used the birthday, ID number, or hospitalization number as the basis for random generation, these Quasi-RCTs studies were excluded. There is no limitation on language, blinding, or publication type of included studies.

Types of participants

All participants with a diagnosis of sarcopenia met one of the following criteria: (i) established definition of sarcopenia by the European Working Group on Sarcopenia in Older People (EWGSOP) (Cruz-Jentoft et al., 2010); (ii) established definition of sarcopenia by Roubenoff (2000); (iii) established definition by the Asia Working Group for Sarcopenia (AWGS) (Chen et al., 2014). Other diagnostic criteria with comparable definitions were also used.

Types of interventions

Traditional Chinese exercise monotherapy was used in the treatment groups. There is no limitation on the frequency, intensity, or course of TCE. The comparator was one of the followings: no training or health education. The included studies should include one of the following comparisons: (1) TCE vs. no training; (2) TCE vs. health education.

Types of outcome measures

The primary outcome was muscle strength and physical function, which was assessed by different measures including the Grip Strength Test, Chair Stand Test, Squatting-To-Standing Test, 6-m gait speed, Peak Torque of muscle, Total Work of muscle, Average Power of muscle, Timed-Up-and-Go Test, Berg Balance Scale. All of the outcome measurements were conducted at the endpoint of treatment by the researchers in each trial.

Study selection and data collection

Two investigators of our group selected the potential references by screening the title and abstract of each article. For those potentially eligible studies, full articles were downloaded from databases. The two investigators read the whole article independently and made the final decision on including the articles or not. For each eligible study, the following information was collected: the first author’s name and year of publication, final diagnosis, diagnosis criteria, study design, sample size, gender composition, the mean age of participants, interventions, duration of treatment, follow-up, main outcome measures, and its corresponding p-value. If the necessary data were expressed graphically or not recorded in the manuscripts, we tried to contact the original author for further information by phone or email or calculated by ourselves if available. Any disagreement between the two investigators was resolved through a discussion with the third author.

Risk of bias

We assessed the methodological quality of the RCTs included in the present study with the seven criteria recommended by the Cochrane Collaboration (Cumpston et al., 2019). The seven components were as follows: A. adequate sequence generation; B. concealment of allocation; C. blinding (participants and personnel); D. blinding (outcome assessor); E. incomplete outcome data addressed (ITT analysis); F. selective reporting; G. other biases. Each of these indicators was categorized as high risk of bias, low risk of bias, and unclear. For each item, a score of 1 or 0 was given depending on whether the study provided adequate information in the relevant domain. Only RCTs with a cumulative score of at least 4 out of 7 for the Cochrane RoB tool domains were included in this systematic review. Adequate sequence generation must achieve status as low risk of bias as it is the certain key criteria. Disagreements were settled by a discussion with the corresponding author.

Grading the certainty of the evidence

The updated GRADE system (Guyatt et al., 2013) was applied to assess the certainty of evidence using four grades: high, moderate, low, and very low. The low and very low certainty of evidence means that the true effect is likely to be substantially different from the estimate of effect, and we have little or very little confidence in the effect estimate. Any discrepancy about grading the certainty of the evidence was resolved through discussion with the corresponding author.

Data synthesis and analysis

The software Cochrane Collaboration Review Manager (RevMan 5.4) was used to summarize the data of eligible studies and performed meta-analysis. Weighted mean difference (WMD) was adopted to analyze the continuous data, and risk ratio (RR) was adopted to analyze the dichotomous data. The standard chi-square test and I² statistic were used to evaluate heterogeneity among trials. A fixed effect model or a random effect model was used to analyze pooled effects depending on heterogeneity. When there is no obvious heterogeneity, a fixed effect model was used (P > 0.1, I² < 50%), otherwise, the random effect model was applied. Subsequent sensitivity analyses were used to explore the possible sources of heterogeneity. A probability value of P < 0.05 was considered significant.

Results

Description of studies

A total of 1,087 studies were retrieved, of which 659 studies remained after excluding duplicates. After screening the title and abstract of the remaining studies, 583 studies were excluded; among which 124 studies were case reports or reviews, 274 were not clinical trials and 185 were irrelevant with the efficacy of TCE for sarcopenia. By reading the full text, 62 studies were excluded, including 46 studies that were not RCTs or not real RCTs, 16 that were high risk of bias studies with Cochrane score < 4. Eventually, 13 studies (Gong et al., 2011; Jin et al., 2011; Liu et al., 2012; Liu et al., 2014; Liu et al., 2016; Wang et al., 2016; Zhao et al., 2016; Zhu et al., 2016; Zhu et al., 2017; Zhu G. et al., 2019; Zhu Y. et al., 2019; Fang et al., 2020; Zhou et al., 2020; Peng et al., 2022) with Cochrane RoB score ≥ 4 were included in the present study. The process of screening is presented in a PRISMA flow chart (Figure 1).

FIGURE 1

Study characteristics

The detailed characteristics of the included 13 studies were summarized in Table 1. All eligible RCTs were conducted in China and 2 (Zhu et al., 2016; Zhu et al., 2017) of them were published in the English language. The diagnosis criteria included the established definition of sarcopenia reported by the EWGSOP, Roubenof et al., and the AWGS. The sample size of the included studies ranged from 12 to 77, enrolling a total of 718 participants, including 356 patients in treatment groups and 362 patients serving as controls. Comparisons of TCE therapies versus no training were conducted in seven studies [(Gong et al., 2011; Jin et al., 2011; Liu et al., 2016; Wang et al., 2016; Zhao et al., 2016; Fang et al., 2020; Peng et al., 2022)], while TCE therapies versus health education were conducted in six studies (Liu et al., 2012; Liu et al., 2014; Zhu et al., 2016; Zhu et al., 2017; Zhu G. et al., 2019; Zhu Y. et al., 2019; Zhou et al., 2020). As for interventions, Yijinjing was used in 10 studies (Gong et al., 2011; Jin et al., 2011; Liu et al., 2012; Liu et al., 2014; Liu et al., 2016; Wang et al., 2016; Zhao et al., 2016; Zhu et al., 2017; Fang et al., 2020; Peng et al., 2022), Baduanjin was used in 1 study (Zhou et al., 2020), and Tai chi was used in 2 studies (Zhu et al., 2016; Zhu Y. et al., 2019). The treatment duration ranged from 8 weeks to 18 months, and 8 weeks was used most widely. No study mentioned the length of follow-up. The outcomes index included the Grip strength test, chair stand test, squatting-to-standing test, 6-m gait speed, Time Up and Go Test, Isokinetic muscle strength test, balance function, and adverse effect.

Risk of bias

The assessment information of RoB is presented in Table 2. Of the 13 included studies, 1 met six Cochrane criteria (Fang et al., 2020), 1 met five (Liu et al., 2012), and 11 met four (Gong et al., 2011; Jin et al., 2011; Liu et al., 2014; Liu et al., 2016; Wang et al., 2016; Zhao et al., 2016; Zhu et al., 2016; Zhu et al., 2017; Zhu Y. et al., 2019; Zhou et al., 2020; Peng et al., 2022). All 14 included studies had random allocation using a random number table. Only 1 study (Fang et al., 2020) mentioned allocation concealment with sealed envelopes. 2 studies (Liu et al., 2012; Fang et al., 2020) mentioned the blinding of outcome assessment. All studies either had complete data or had dropouts with adequate explanations and appropriate methods to treat missing data. All studies had a low risk of other biases, which included funding bias, conflict of interest, and incomparable baseline characteristics between the groups. Funding bias means that the research was funded by relevant stakeholders, such as drug companies. In general, most of the 14 trials were deemed to have a relatively moderate risk.

Effectiveness

Grip strength test

The grip strength test was conducted in five studies (Wang et al., 2016; Zhao et al., 2016; Zhu et al., 2017; Zhu G. et al., 2019; Zhu Y. et al., 2019; Zhou et al., 2020). Pooled analysis of these five studies indicated that TCE had no significantly greater clinical effects in improving grip strength [MD = 1.43, 95% CI (−0.54, 3.41), P = 0.15, I² = 2%; Certainty of evidence: Moderate; Table 3; Figure 2].

FIGURE 2

Isokinetic muscle strength test

Two studies (Gong et al., 2011; Liu et al., 2016) assessed the effect of TCE on the isokinetic muscle strength of participants, and the tests include the Peak torque of the extensors and flexors, the total work of the extensors and flexors, and average power of the extensors and flexors. Meta-analysis indicated that TCE significantly improve participants’ performance in the peak torque of the extensors [MD = 10.12, 95% CI (0.90, 19.35), P = 0.03, I² = 0%; Certainty of evidence: Moderate; Figure 3A], the total work of the extensors [MD = 113.42, 95% CI (13.95, 212.89), P = 0.03, I² = 35%; Certainty of evidence: Moderate; Figure 3B], the average power of the extensors [MD = 4.99, 95% CI (−0.14, 10.12), P = 0.17, I² = 48%; Figure 3C], the peak torque of the flexors [MD = 5.57, 95% CI (0.60, 10.55), P = 0.03, I² = 47%; Certainty of evidence: Low; Figure 3D], the total work of the flexors [MD = 61.79, 95% CI (10.11, 113.47), P = 0.02, I² = 42%; Certainty of evidence: Low; Figure 3E], and the average power of the flexors [MD = 3.25, 95% CI (0.32, 6.19), P = 0.03, I² = 30%; Certainty of evidence: Moderate; Figure 3F].

FIGURE 3

Chair stand test

Meta-analysis of four studies (Jin et al., 2011; Wang et al., 2016; Zhu et al., 2017; Zhu G. et al., 2019; Zhou et al., 2020) showed a significant effect of TCE on chair stand test [MD = 2.45, 95% CI (1.88, 3.01), P < 0.00001, I² = 38%; Certainty of evidence: Moderate; Figure 4].

FIGURE 4

Squatting-to-standing test

Meta-analysis of three studies (Jin et al., 2011; Wang et al., 2016; Zhu et al., 2017; Zhu G. et al., 2019) indicated that TCE could improve participants’ performance in the squatting-to-standing test [MD = 2.58, 95% CI (2.12, 3.04), P < 0.00001, I² = 0%; Certainty of evidence: Moderate; Figure 5].

FIGURE 5

6-m gait speed

Meta-analysis of three studies (Jin et al., 2011; Zhao et al., 2016; Peng et al., 2022) showed a significant effect of TCE in improving the 6-m gait speed of participants [MD = 0.31, 95% CI (0.30, 0.32), P < 0.00001, I² = 13%; Certainty of evidence: Moderate; Figure 6].

FIGURE 6

Time up and go test

Pooled analysis of three studies (Zhu et al., 2016; Fang et al., 2020; Zhou et al., 2020) showed that TCE significantly improved the preference of participants in the Time Up and Go Test [MD = −1.91, 95% CI (−3.64, −0.19), P = 0.03, I² = 81%; Certainty of evidence: Low; Figure 7].

FIGURE 7

Balance function

Meta-analysis of four studies (Zhu et al., 2016; Fang et al., 2020; Zhou et al., 2020; Peng et al., 2022) showed a significant effect of TCE in improving balance function according to Berg balance scale [SMD = 1.37, 95% CI (0.92, 1.83), P < 0.00001, I² = 53%; Certainty of evidence: Low; Figure 8]. The Biodex system was used to assess the balance function in 1 study (Liu et al., 2014), and the results indicated that Yijinjing had significantly greater clinical effects in improving balance function with open eyes (P < 0.05).

FIGURE 8

Adverse events

Side effects of TCE were evaluated in two studies (Liu et al., 2012; Liu et al., 2014), but adverse events were not observed in these two studies.

Discussion

This study is the first meta-analysis assessing the efficacy of TCE for sarcopenia. Thirteen studies with 718 subjects were identified. The methodological quality of included RCTs was moderate totally. The quality of the evidence of primary outcomes was low to moderate according to the GRADE profiler. The main findings of the present study were that the TCE had a greater clinical effect in improving the severity of sarcopenia compared with no training or health education.

In this study, the primary outcomes of TCE for sarcopenia were muscle strength and physical function, since the decrease in muscle strength and physical function were the primary problem caused by sarcopenia (Hanach et al., 2019). The results of the pooled analysis indicated that TCE had no significantly greater clinical effects in improving grip strength, but had significantly greater clinical effects in physical function according to various outcomes including chair stand test, squatting-to-standing test, 6-m gait speed, Time Up and Go Test, peak torque of the extensors, total work of the extensors, peak torque of the flexors, total work of the flexors, the average power of the flexors, and balance function. In Western society, as many as 42% of individuals under 60 years of age have difficulties performing the activities of daily life, 15–30% report being unable to lift or carry 10 pounds or more, and more than 30% are confronted with physical disabilities (Zhou et al., 2019). Therefore, the positive results of TCE in improving physical function have great clinical significance.

Traditional Chinese exercise were formed by the concept of viewing the situation as a whole, the Five-Zang manifestation theory and meridian doctrine as theoretical guidance, and body movement as presentation. They are aimed to enhance fitness and prevent and treat diseases (Yang et al., 2021). TCE may be used to delay sarcopenia by regulating the synthesis and degradation of muscle-related proteins, replenishing, nutrients, promoting blood circulation, and eliminating inflammation (Colleluori and Villareal, 2021). The potential mechanism of TCE for enhancing muscle strength and physical function is related to the activation of key signaling pathways (Liu et al., 2021). After high-intensity interval static exercise, the PGC-1α/FNDC5/UCP1 signaling pathway was activated, PGC-1α was up-regulated, mitochondria increased, muscle fiber thickening was observed, and the skeletal muscle atrophy state was improved in aging rats (Liu et al., 2021). Compared with general exercise, TCE are more like gymnastic exercise consisting of various components such as endurance, resistance, balance, flexibility, breathing, and meditation, which emphasize the appropriate form and intensity of exercise, resulting in a better response (Villareal et al., 2017; Colleluori and Villareal, 2021).

The major strength of the current systematic review is that it has adhered to appropriate systematic review guidelines. However, there are also some limitations. First, some methodological limitations exist in the primary studies. Only one study (Fang et al., 2020) reported the concealment of allocation. Trials with adequate concealment had an average of 18% less “beneficial” effect than trials with inadequate or unclear concealment of allocation (Cumpston et al., 2019). Performance bias and detection bias can be effectively avoided by the use of blinding. However, some studies were unable to be blinded because participants have a high degree of understanding of TCE moves. Only two studies reported the blinding of outcome assessment. Second, formal pretrial sample size calculation was not conducted in most clinical trials and the majority of the included trials had relatively small sample sizes. Trials with insufficient statistical power may induce the high a risk of overestimating therapeutic efficacy (Kjaergard et al., 2001). Third, no study describes the duration of follow-up, making it difficult to assess the long-term efficacy of TCE treatment for sarcopenia. Fourth, we only searched for papers published in Chinese or English databases, thus the eligible studies published in other languages may be left out, which may limit the generalizability of the findings. Fifth, a statement published in September 2004 requiring that all clinical trials must be registered to be considered for publication (De Angelis et al., 2004). The transparency of clinical trials would be improved with registration, which would ultimately strengthen the validity and value of the scientific evidence base (Wang et al., 2019a). However, none of the included studies had been registered formally.

The finding from the present systematic review revealed that TCE may be beneficial for sarcopenia patients. However, as the low-quality studies included cannot be reproduced, there is a need for conducting further rigorous RCTs on TCE for sarcopenia. Recommendations for further research are as follows: (1) the protocol of further clinical trials should be registered in the international clinical trials registry platform prospectively, and should follow the requirement of the Clinical Trial Data Sharing Statement (Taichman et al., 2016) by the International Committee of Medical Journal Editors; (2) the quality of study designs including randomization, allocation concealment, and blinding should be improved. CONSORT statement (Moher et al., 2009) should be applied throughout the whole process of the study including trial design, reporting, and publication; (3) international cooperation should be conducted in further studies to complete more qualified studies and ensure generalizability of research findings; (4) greater consistency in outcome measures should be warranted; (5) adequate sample size plays an important positive role in improving the methodologic quality, intervention effects, and publication bias (Kjaergard et al., 2001; Moher et al., 2009). Thus, it is necessary to conduct formal pretrial sample size calculations in further studies.

The significance of the present systematic review possibly lies in the following aspects: (1) to reveal current problems in the treatment of sarcopenia and identify areas worthy of improvement and development in the future (Chan et al., 2012). Several studies have reported the effectiveness of TCE in the treatment of sarcopenia, however, no previous study has evaluated the quality of this evidence. (3) to report a specific area of Traditional Chinese Medicine in the English language as these experiences are not readily accessible to western clinicians because of language barriers (Wang et al., 2019b).

Conclusion

The present finding indicated that TCE provided statistically significant benefits for sarcopenia. Therefore, the findings of the present systematic review, at least to a certain extent, provided supporting evidence for the routine use of TCE for sarcopenia.

References

• 1

  Chan K. Shaw D. Simmonds M. S. Leon C. J. Xu Q. Lu A. et al (2012). Good practice in reviewing and publishing studies on herbal medicine, with special emphasis on traditional Chinese medicine and Chinese materia medica.J. Ethnopharmacol.140469–475. 10.1016/j.jep.2012.01.038

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 2

  Chen L. K. Liu L. K. Woo J. Assantachai P. Auyeung T. W. Bahyah K. S. et al (2014). Sarcopenia in Asia: Consensus report of the Asian working group for Sarcopenia.J. Am. Med. Dir. Assoc.1595–101. 10.1016/j.jamda.2013.11.025

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 3

  Colleluori G. Villareal D. T. (2021). Aging, obesity, sarcopenia and the effect of diet and exercise intervention.Exp. Gerontol.155:111561. 10.1016/j.exger.2021.111561

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 4

  Cruz-Jentoft A. J. Sayer A. A. (2019). Sarcopenia.Lancet3932636–2646. 10.1016/s0140-6736(19)31138-9

  • CrossRef
  • Google Scholar

• 5

  Cruz-Jentoft A. J. Baeyens J. P. Bauer J. M. Boirie Y. Cederholm T. Landi F. et al (2010). Sarcopenia: European consensus on definition and diagnosis: Report of the European working group on Sarcopenia in older people.Age Ageing39412–423. 10.1093/ageing/afq034

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 6

  Cruz-Jentoft A. J. Bahat G. Bauer J. Boirie Y. Bruyère O. Cederholm T. et al (2019). Sarcopenia: Revised European consensus on definition and diagnosis.Age Ageing4816–31. 10.1093/ageing/afy169

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 7

  Cruz-Jentoft A. J. Landi F. Schneider S. M. Zúñiga C. Arai H. Boirie Y. et al (2014). Prevalence of and interventions for Sarcopenia in ageing adults: A systematic review. Report of the international Sarcopenia initiative (EWGSOP and IWGS).Age Ageing43748–759. 10.1093/ageing/afu115

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 8

  Cumpston M. Li T. Page M. J. Chandler J. Welch V. A. Higgins J. P. et al (2019). Updated guidance for trusted systematic reviews: A new edition of the cochrane handbook for systematic reviews of interventions.Cochrane Database Syst. Rev.10:Ed000142. 10.1002/14651858.Ed000142

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 9

  De Angelis C. Drazen J. M. Frizelle F. A. Haug C. Hoey J. Horton R. et al (2004). Clinical trial registration: A statement from the international committee of medical journal editors.Lancet364911–912. 10.1016/s0140-6736(04)17034-7

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 10

  Fang L. Li Z. Tao X. Luo J. (2020). A clinical study on the effect of Yi Jin Jing on the risk of fall in elderly patients with Sarcopenia balance disorder.Chin. J. Rehabil. Med.35319–323.

  • Google Scholar

• 11

  Fidan O. Seyyar G. K. Aras B. Colak E. Aras O. (2019). The effect of Tai Chi and Qigong on health-related quality of life in Parkinson’s disease: A systematic review and meta-analysis of systematic reviews.Int. J. Rehabil. Res.42196–204. 10.1097/mrr.0000000000000358

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 12

  Gaskin F. S. Farr S. A. Banks W. A. Kumar V. B. Morley J. E. (2003). Ghrelin-induced feeding is dependent on nitric oxide.Peptides24913–918. 10.1016/s0196-9781(03)00160-8

  • CrossRef
  • Google Scholar

• 13

  Gong L. Yan J. Liu Y. Fang L. Zhang H. Xu J. et al (2011). Effect of the Tui Na gongfu method Yi Jin Jing on isometric muscle strength in elderly patients with Sarcopenia.Acad. J. Shanghai Univ. Trad. Chin. Med.2555–58.

  • Google Scholar

• 14

  Guyatt G. Oxman A. D. Sultan S. Brozek J. Glasziou P. Alonso-Coello P. et al (2013). GRADE guidelines: 11. Making an overall rating of confidence in effect estimates for a single outcome and for all outcomes.J. Clin. Epidemiol.66151–157. 10.1016/j.jclinepi.2012.01.006

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 15

  Hanach N. I. McCullough F. Avery A. (2019). The impact of dairy protein intake on muscle mass, muscle strength, and physical performance in middle-aged to older adults with or without existing Sarcopenia: A systematic review and meta-analysis.Adv. Nutr.1059–69. 10.1093/advances/nmy065

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 16

  Jensen L. Monnat S. M. Green J. J. Hunter L. M. Sliwinski M. J. (2020). Rural population health and aging: Toward a multilevel and multidimensional research Agenda for the 2020s.Am. J. Public Health1101328–1331. 10.2105/ajph.2020.305782

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 17

  Jin D. Xu J. Zhao J. Hu Y. Wang D. (2011). Effects of the Yi Jin Jing on the daily activity capacity and physical fitness of patients with Sarcopenia.Chin. J. Inform. Tradit. Chin. Med.1814–16.

  • Google Scholar

• 18

  Kakehi S. Wakabayashi H. Inuma H. Inose T. Shioya M. Aoyama Y. et al (2022). Rehabilitation nutrition and exercise therapy for Sarcopenia.World J. Mens. Health401–10. 10.5534/wjmh.200190

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 19

  Kjaergard L. L. Villumsen J. Gluud C. (2001). Reported methodologic quality and discrepancies between large and small randomized trials in meta-analyses.Ann. Intern. Med.135982–989. 10.7326/0003-4819-135-11-200112040-00010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 20

  Liu Y. Fang L. Yan J. Fang M. Zhang H. Cheng J. et al (2012). Effect of Yijinjing on quality of life in elderly people with Sarcopenia.J. Shanghai Univ. Tradit. Chin. Med.2658–60.

  • Google Scholar

• 21

  Liu Y. Guo C. Liu S. Zhang S. Mao Y. Fang L. (2021). Eight weeks of high-intensity interval static strength training improves skeletal muscle atrophy and motor function in aged rats via the PGC-1α/FNDC5/UCP1 pathway.Clin. Interv. Aging16811–821. 10.2147/cia.S308893

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 22

  Liu Y. Wang Z. Fang L. Yan J. Fang M. Zhu Q. et al (2014). Effects of Yijinjing on the homeostasis ability of elderly patients with Sarcopenia.J. Hebei Tradit. Chin. Med. Pharmacol.299–11.

  • Google Scholar

• 23

  Liu Y. Yan J. Wang Z. Zhu Q. Fang M. Zhang H. et al (2016). Effect of Yi Jin Jing on skeletal muscle contractile function in elderly Sarcopenia.Acad. J. Shanghai Univ. Tradit. Chin. Med.3042–45.

  • Google Scholar

• 24

  Meng D. Chunyan W. Xiaosheng D. Xiangren Y. (2018). The effects of Qigong on type 2 diabetes mellitus: A systematic review and meta-analysis.Evid. Based Complement. Alternat. Med.2018:8182938. 10.1155/2018/8182938

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 25

  Mohd Nawi S. N. Khow K. S. Lim W. S. Yu S. C. (2019). Screening tools for Sarcopenia in community-dwellers: A scoping review.Ann. Acad. Med. Singap.48201–216.

  • Pubmed Abstract
  • Google Scholar

• 26

  Moher D. Liberati A. Tetzlaff J. Altman D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The prisma statement.BMJ339:b2535. 10.1136/bmj.b2535

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 27

  Peng T. Zhu M. Lin X. Yuan J. Zhou F. Hu S. et al (2022). The effect of new Yi Jin Jing on lower limb motor and balance function in elderly patients with Sarcopenia.Massage Rehabil. Med.1321–26.

  • Google Scholar

• 28

  Reychler G. Poncin W. Montigny S. Luts A. Caty G. Pieters T. (2019). Efficacy of yoga, tai chi and qi gong on the main symptoms of chronic obstructive pulmonary disease: A systematic review.Respir. Med. Res.7513–25. 10.1016/j.resmer.2019.04.002

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 29

  Roubenoff R. (2000). Sarcopenia: A major modifiable cause of frailty in the elderly.J. Nutr. Health Aging4140–142.

  • Pubmed Abstract
  • Google Scholar

• 30

  Taichman D. B. Backus J. Baethge C. Bauchner H. de Leeuw P. W. Drazen J. M. et al (2016). Sharing clinical trial data–A proposal from the international committee of medical journal editors.N. Engl. J. Med.374384–386. 10.1056/NEJMe1515172

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 31

  Veldhuis J. D. Erickson D. Wigham J. Weist S. Miles J. M. Bowers C. Y. (2011). Gender, sex-steroid, and secretagogue-selective recovery from growth hormone-induced feedback in older women and men.J. Clin. Endocrinol. Metab.962540–2547. 10.1210/jc.2011-0298

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 32

  Villareal D. T. Aguirre L. Gurney A. B. Waters D. L. Sinacore D. R. Colombo E. et al (2017). Aerobic or resistance exercise, or both, in dieting obese older adults.N. Engl. J. Med.3761943–1955. 10.1056/NEJMoa1616338

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 33

  Wang B. Ma S. Hu Y. (2016). The effect of fitness qigong Yi Jin Jing exercises on the rehabilitation effect of patients with Sarcopenia.Chin. J. Gerontol.36898–899.

  • Google Scholar

• 34

  Wang Y. Lou X. T. Shi Y. H. Tong Q. Zheng G. Q. (2019a). Erxian decoction, a Chinese herbal formula, for menopausal syndrome: An updated systematic review.J. Ethnopharmacol.2348–20. 10.1016/j.jep.2019.01.010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 35

  Wang Y. Shi Y. H. Xu Z. Fu H. Zeng H. Zheng G. Q. (2019b). Efficacy and safety of Chinese herbal medicine for depression: A systematic review and meta-analysis of randomized controlled trials.J. Psychiatr. Res.11774–91. 10.1016/j.jpsychires.2019.07.003

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 36

  Wayne P. M. Lee M. S. Novakowski J. Osypiuk K. Ligibel J. Carlson L. E. et al (2018). Tai Chi and Qigong for cancer-related symptoms and quality of life: A systematic review and meta-analysis.J. Cancer Surviv.12256–267. 10.1007/s11764-017-0665-5

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 37

  Wu B. Ding Y. Zhong B. Jin X. Cao Y. Xu D. (2020). Intervention Treatment for myocardial infarction with Tai Chi: A systematic review and meta-analysis.Arch. Phys. Med. Rehabil.1012206–2218. 10.1016/j.apmr.2020.02.012

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 38

  Yang S. Liu T. Xiong J. Teng Y. Guo Y. Yu S. et al (2021). Traditional Chinese exercise potential role as prevention and adjuvant therapy in patients with COVID-19.Complement. Ther. Clin. Pract.43:101379. 10.1016/j.ctcp.2021.101379

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 39

  Zeng Z. P. Liu Y. B. Fang J. Liu Y. Luo J. Yang M. (2020). Effects of Baduanjin exercise for knee osteoarthritis: A systematic review and meta-analysis.Complement. Ther. Med.48:102279. 10.1016/j.ctim.2019.102279

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 40

  Zhang Y. Huang L. Su Y. Zhan Z. Li Y. Lai X. (2017). The effects of traditional Chinese exercise in treating knee osteoarthritis: A systematic review and meta-analysis.PLoS One12:e0170237. 10.1371/journal.pone.0170237

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 41

  Zhao Y. Zhao Y. Guo Y. Dou Y. Zhao J. He Y. (2016). The effect of Tuina combined with resistance exercise on activities of daily living in patients with Sarcopenia.Chin. J. Rehabil.31989–994.

  • Google Scholar

• 42

  Zhou S. Zhou Y. Sun X. Xu Q. (2020). A study on the prevention of falls in elderly people with Sarcopenia in Baduanjin.Sport Sci. Technol.4127–58.

  • Google Scholar

• 43

  Zhou Z. Zhou R. Li K. Zhu Y. Zhang Z. Luo Y. et al (2019). Effects of tai chi on physiology, balance and quality of life in patients with type 2 diabetes: A systematic review and meta-analysis.J. Rehabil. Med.51405–417. 10.2340/16501977-2555

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 44

  Zhu Y. Nan P. Zhou M. Liu P. Qi X. Wang N. et al (2019). Tai Chi and whole-body vibrating therapy in Sarcopenic men in advanced old age: A clinical randomized controlled trial.Eur. J. Ageing16273–282. 10.1007/s10433-019-00498-x

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 45

  Zhu G. Luo K. Shen Z. Gao F. Fu Y. Shen Q. (2019). The effect of Yi Jin Jing on the balance function of sarcopenia.Zhejiang J. Tradit. Chin. Med.53351–352.

  • Google Scholar

• 46

  Zhu G. Shen Z. Shen Q. Jin Y. Lou Z. (2017). Effect of Yi Jin Jing (Sinew-transforming Qigong Exercises) on skeletal muscle strength in the elderly.J. Acupunct. Tuina Sci.15434–439.

  • Google Scholar

• 47

  Zhu Y. Peng N. Zhou M. (2016). Effect of tai chi on muscle strength and function of the lower extremities in the elderly.Chin. J. Integr. Tradit. Western Med.3649–53.

  • Google Scholar

• 48

  Zou L. Zhang Y. Sasaki J. E. Yeung A. S. Yang L. Loprinzi P. D. et al (2019). Wuqinxi Qigong as an alternative exercise for improving risk factors associated with metabolic syndrome: A meta-analysis of randomized controlled trials.Int. J. Environ. Res. Public Health16:1396. 10.3390/ijerph16081396

  • Pubmed Abstract
  • CrossRef
  • Google Scholar