Yifang Chen
Xinyi Zuo
Yong Tang
Zhimiao Zhou3- 1Institution of Policy Studies, Lingnan University, Tuen Mun, Hong Kong SAR, China
- 2Sociology Department, School of Government, Shenzhen University, Shenzhen, Guangdong, China
- 3Shenzhen Senior High School, Shenzhen, China
Background: Tai Chi and Baduanjin are nonpharmacological interventions that are widely applied among cancer patients.
Objective: This meta-analysis aimed to assess the effect of Tai Chi and Baduanjin on breast cancer patients by summarizing and pooling the results of previous studies.
Methods: The PubMed, Embase, Web of Science, Scopus and Cochrane Library and several databases were searched up to December 1, 2023, to identify high-quality RCTs. Relevant terms such as Tai Chi and Baduanjin were used as keywords. Stata 15.0 software and Review Manager (version 5.3; Cochrane Training) were used to screen the studies, extract the data, code the data, and perform the meta-analysis. The mean differences (MDs) and standardized mean differences (SMDs) with 95% CIs were used to calculate continuous variables. The Cochrane risk of bias assessment tool was used to evaluate the risk of bias. The PICOS framework was used to develop the following eligibility criteria: (i) population - breast cancer patients; (ii) intervention - Tai Chi and Baduanjin intervention; (iii) comparison - Tai Chi and Baduanjin group and different intervention (e.g., regular intervention, routine rehabilitation training, waiting list, sham Qigong, usual care, no intervention); (iv) outcomes - cognitive ability, shoulder joint function, anxiety, depression, fatigue, sleep quality, quality of life; and (v) study design - randomized controlled trial.
Results: From January 2013 to December 2023, we included a total of 16 RCTs involving 1247 patients. A total of 647 patients were in the experimental group and were treated with Tai Chi and Baduanjin, while 600 patients were in the control group and were treated with traditional methods. The results of our meta-analysis indicate that Tai Chi and Baduanjin yield outcomes that are comparable to those of traditional treatment methods. Specifically, Tai Chi and Baduanjin significantly increased cognitive function, increased shoulder joint function, improved sleep quality indicators and improved quality of life indicators. Furthermore, Tai Chi and Baduanjin significantly reduced anxiety symptoms, depression symptoms, and fatigue symptoms among breast cancer patients. Sensitivity analysis was performed, a funnel plot was constructed. No publication bias was indicated by Egger’s or Begg’s test.
Conclusion: Overall, Tai Chi and Baduanjin are viable and effective nonpharmacological approaches for treating breast cancer patients, as they yield better results than traditional treatment methods. However, these findings should be interpreted with caution due to the limited number of controlled trials, small sample sizes, and low quality of the evidence.
Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023469301.
1 Introduction
1.1 Description of the condition
In 2020, the estimated number of new breast cancer cases and deaths increased respectively to 2.3 million(11.6%) and 685,000(6.9%) globally, among which China ranked first in new cases and deaths worldwide, accounting for approximately 18.4% of total new cases and 17.1% of total deaths globally in 2020 (1, 2). The high incidence and mortality rate have imposed a substantial burden on healthcare systems of countries with low resources (3). When women develop breast cancer, they experience a range of related painful experiences, such as anxiety (4, 5), depression (5, 6), fatigue (7–9), cognitive impairment (10, 11), shoulder function impairment (12, 13), sleep problems (14, 15), and poor quality of life (QoL) (16, 17). Conventional treatments such as surgery for breast cancer may have negative effects on survivors of breast cancer (18). Specifically, recent research has shown that surgery may lead to sleep disorders (19), life-threatening bleeding or infections (20), flap necrosis (21) and joint damage (22) in a significant percentage of patients with breast cancer. These side effects negatively affect survivors’ overall well-being and functionality, ultimately affecting their quality of life (17). Moreover, breast cancer survivors may face various complications after conventional treatments, such as surgery (total mastectomy and breast conservation), chemotherapy, and radiotherapy (23). Furthermore, breast cancer has been reported to be a risk factor for depression (6). Due to the alarming increase in the number of breast cancer patients worldwide and the lack of effective drug treatments for these diseases. Therefore, it is highly emergent to develop non-drug therapies and apply in the field of social work for the cancer patients are highly necessary. It may slow the distress of physical and psychological in breast cancer patients to combat personal and socioeconomic problems, to address the alarming increases in the incidences of cancer patients worldwide, and to overcome the lack of effective drug treatments for such diseases.
1.2 Description of the Taiji and Baduanjin invention
Nowadays, people’s attentional capabilities are increasingly strained by environmental factors such as time pressure (24) or multiple task demands (25), or even professional requirements (26). Since multitasking demands preoccupy large parts of people’s daily routines, the question of how to manage or to recover from the strain imposed by overload has become increasingly important, both for researchers and practitioners (27), Especially women (28). Formally, rest breaks are defined as temporal interruptions of an activity, serving the purpose of regenerating mental functions (29, 30). Conceptually, there are three fundamental aspects that are connected to taking a break, depending on the particular context: to find distance, to change activity mode (e.g., from thinking to sensing), and to recover or regain energy levels (31).
The practice of meditation has seen a tremendous increase in the western world since the 60s (32). Scientific interest in meditation has also significantly grown in the past years (33) and increasing evidence suggests the efficacy of meditation in health care and the field of stress management (34) and some potency to enhance positive feelings (35) increase pain tolerance, and reduce anxiety (36). TaiChi and Baduanjin also belong to meditation practice (37), This are different from other physical exercises like light gymnastics (38).
Unlike in western cultures, the Chinese felt that individuals are part of a closely knit collectivity, whether a family or a village, and that the behavior of the individual should be guided by the expectations of the group (39). The relationship view versus the rule stance is well illustrated by the difference between the holistic approach to medicine characteristic of the Chinese and the effort to find effective rules and treatment principles in the West. Surgery was common in the West from a very early period because the idea that some part of the body could be malfunctioning was a natural one to the analytic mind (39). But the idea of surgery was “heretical to ancient Chinese medical tradition, which taught that good health depended on the balance and flow of natural forces throughout the body” (39).
Originating in China, Tai Chi is a mind-body physical activity known as “meditation in motion”, and it has been practiced by the Chinese for centuries (40). Tai Chi is based on Chinese martial arts and integrates meditation elements, thereby enhancing well-being and promoting physical and mental health (41). The gentle, mindful, slow, and continuous movements of Tai Chi make it a preferable complementary program for promoting wellness (42, 43). Considerable empirical evidence supports the numerous health benefits associated with regular Tai Chi practice (44–46). To address these challenges in terms of quality of life and mental health, Baduanjin exercise, known as Qigong exercise, has been recommended as an effective treatment method for patients after surgery (47–49). Baduanjin comprises eight distinct sections of movements that are performed routinely. This traditional Chinese exercise combines controlled breathing with bodily movements, aiming to improve physical fitness and mental well-being. Unlike traditional exercise methods, Baduanjin emphasizes the need for a balanced approach that not only enhances physical strength but also nurtures psychological well-being, focusing on harmonious physical and mental integration (47). Furthermore, Baduanjin exercise is easy to perform without equipment or field restrictions. Baduanjin is free of equipment or field restrictions, so it is easy for people to learn and practice (47). After the founding of the Chinese Health Qigong Association, Baduanjin underwent modifications to accommodate the needs of diverse individuals, particularly those who suffer from physical or psychological sickness (50). To date, people have developed numerous therapeutic methods. Among them, Tai Chi therapy (42, 47) and Baduanjin (47, 51, 52) therapy are nonpharmacological treatment methods that have been advocated due to their lack of side effects.
Recent meta-analyses have shown potential benefits of Taiji therapy for anxiety (53–55), fatigue (56), cognitive impairment (55), shoulder function (54), sleep problems (57, 58) and quality of life (QoL) (59). It is necessary to examine the potential benefits of these therapies. In conclusion, Tai Chi and Baduanjin therapy have been regarded as a positive treatment strategies for breast cancer patients in terms of cognitive function, shoulder joint function, and mental health. Moreover, they have also been widely used in health-related subjects due to their positive effects (59, 60).
1.3 Tai Chi and Baduanjin therapy on breast cancer patients
In addition to genetic factors, ageing (61), family history (62), reproductive factors (63), oestrogen (64), and lifestyle (65) are five significant risk factors for breast cancer. However, lifestyle is the only one of these risk factors that is modifiable. Tai Chi (54, 56) and Baduanjin (47, 60) have garnered increasing recognition as impactful lifestyle choices that can help prevent and improve breast cancer outcomes. It may also serve as a beneficial complement to cancer treatment, reducing the risk of both breast cancer-specific mortality and overall mortality (66, 67). The Tai Chi and Baduanjin interventions are increasingly used in oncology (48) to achieve psychosocial stabilization and provide support for cancer patients (58).
1.4 Research gap and aim
Firstly, there are inconsistent clinical results regarding the effects of Taijiquan and Baduanjin therapy on cognitive ability, fall prevention, shoulder joint ability and mental health. Myers et al. (68) conducted a systematic review of breast cancer patients and reported that Tai Chi improved cognitive ability. Meng et al. (69) conducted a systematic review of breast cancer patients and reported that Baduanjin improved cognitive ability. However, Wei et al. (70) find Tai Chi failed to show any between-group differences in cognitive function. Luo discovered Tai Ji had positive effects on shoulder function and strength of arm in breast cancer patients compared with the non-exercise therapy (54). Fong et al. find Tai Chi showed a favorable effect of on pain and ROM of the shoulder joint, but not on hand grip strength, flexibility, and upper limb function compared with no treatment (71). A study (70) revealed that Taijiquan and Qigong can act as primary interventions for balance training and fall prevention. However, Li reported that there was no significant decrease in falls for strength training or Tai Chi Quan compared to the stretching control group among postmenopausal women receiving chemotherapy (58). Luo et al. reported that Tai Chi therapy was effective for improving mental health in breast cancer patients (72). Ye et al. (73) reported that Baduanjin therapy was effective for improving mental health in breast cancer patients. As reported by several researchers (47, 74, 75), Tai Chi and Baduanjin can significantly improve mental health. However, another observational study detected no significant time × group interaction effects on stress and mental health (76). Therefore, recent meta-analyses have reported conflicting results. Luo et al. (54) discovered that Tai Chi can decrease the fatigue symptom to breast cancer patients while Liu et al. (56) Hold the opposite view. Sameh Gomaa et al. find Tai Chi improved sleep quality and depressive symptoms (77). Wei et al. discovered Tai Chi failed to show any between-group differences in sleep quality and depression symptoms (70). Liu et al. demonstrated that tai chi is no different from conventional supportive care interventions in improving fatigue, sleeping quality, depression symptom at either 3 months or 6 months (54). Clinical data examining the effects of Tai Chi and Baduanjin on cognitive impairment, shoulder function impairment, Prevent falls, mental health fatigue, sleeping quality and depression symptom remain controversial. A more comprehensive review is needed to systematically evaluate the effects of Tai Chi and Baduanjin on the physical and mental health of breast cancer patients.
Secondly, many studies included indicated that Tai Chi and Baduanjin had positive effects on cognitive function, shoulder joint function, depression, anxiety, fatigue, sleep quality, and quality of life, but none included the effect of both Tai Chi and Baduanjin therapy on seven outcome measures. Tai Chi, breast cancer patients, cognitive function, shoulder joint function (54) depression symptom (78), anxiety symptom (79), fatigue symptom (78), sleep quality (80), and quality of life (81). Wei observed Baduanjin exercise has a certain preventive effect on the decline of subjective cognitive ability of breast cancer patients during chemotherapy clearly (70). Baduanjin, breast cancer patients, cognitive function (82), shoulder joint function (58), depression symptom (83), anxiety symptom (83), fatigue symptom (84), sleep quality (70), and quality of life (60). This study investigates the effects of Tai Chi and Baduanjin on the cognitive ability, shoulder joint ability and mental health of breast cancer patients simultaneously.
Thirdly, it is important to investigate not only the effects of Tai Chi and Baduanjin but also the variables that may influence their effectiveness, including duration of treatment and target population. In this research, we used weeks and continental plate to divide Sub-group analysis, which was not available in previous studies. To address this gap, we conducted a comprehensive systematic review and meta-analysis to evaluate the impact of Tai Chi and Baduanjin on training breast cancer patients.
2 Materials and methods
This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, 2020) guidelines, as detailed in the Multimedia Appendix 3 Abstracts checklist and Multimedia Appendix 4 Checklist 2020 (85). The study was also registered in PROSPERO (CRD42023469301).
2.1 Selection criteria
For this study, eligibility criteria were established based on the PICOS principles. (1) P: The subjects had to exhibit at least one indicator of cognitive function, shoulder joint function, or mental health, and they had to be 18 years of age or older. (2) I: Tai Chi and Baduanjin were implemented among breast cancer patients in the experimental group without restrictions on the time of intervention. (3) C: The control group received a different intervention (e.g., regular intervention, routine rehabilitation training, waiting list, sham qigong, usual care, no intervention). (4) O: The outcomes included cognitive function, shoulder joint function and mental health in breast cancer patients. (5) S: The type of study was RCTs. The exclusion criteria were as follows: (1) reviews, case reports, non-RCTs, or articles without full-text availability; (2) animal experiments or duplicate publications; and (3) unavailable or incomplete data. Furthermore, we used the PICOS principles to identify eligible studies (Multimedia Appendix 1). All studies included were published in Chinese or English, and studies that interpreted results from the perspective of breast cancer patients were considered eligible.
2.2 Search strategy
To identify relevant literature, the following databases were searched: the UWE Library database, PubMed, MEDLINE, Embase, the Cochrane Library, Scopus, PsycINFO, SinoMed, Wanfang Data, China National Knowledge Infrastructure (CNKI), Yiigle, Wanfang MED ONLINE, and Web of Science. The search terms varied slightly across databases. Keywords such as “Cognitive Function or Shoulder Joint Function or Mental Health or Depression or Anxiety or Fatigue or Sleep Quality or Quality of life”, and “a pilot study or Randomized Controlled Trial or RCT,” and “Tai Chi and Baduanjin,” as well as “Breast Cancer Patients or Breast Cancer Women” were used to retrieve articles published from January 1, 2013, to December 1, 2023. The “snowball” method was employed to trace the references of the included studies. Moreover, the references of the included studies were manually searched to identify additional eligible articles. Academic unpublished literature was considered ineligible. The retrieval strategy for the PubMed database is provided in Multimedia Appendix 2.
The search strategies are presented in Figure 1. Four researchers (Zuo Xinyi, Tang Yong, Chen Yifang and Zhou Zhimiao) screened all the literature for eligibility. After the removal of duplicates, the initial screening of all studies was based on abstracts and titles. Subsequently, the researchers read the full texts of the remaining articles according to the predefined inclusion and exclusion criteria. Finally, they extracted data from the selected literature. Additionally, we retrieved grey literature (opengrey.eu) to further identify related publications.
Figure 1. Study selection flowchart (PRISMA, 2020).
2.3 Data extraction
After removing duplicate studies (using EndNote X9), four reviewers (Zuo Xinyi, Tang Yong, Chen Yifang and Zhou Zhimiao) independently screened the abstracts and titles of the studies. Subsequently, the full texts of the remaining studies were evaluated according to the predefined inclusion and exclusion criteria.
The first authors (Zuo Xinyi and Chen Yifang) used a modified version of the data extraction form in the Cochrane Handbook for Systematic Reviews of Interventions (86) to extract study characteristics. They also extracted data on the content, design, and delivery features of the interventions (definitions provided in the “Introduction”) by a modified template version for intervention description as well as replication (TIDieR) checklist and guide (87). On a random sample of three studies, the forms were first tested and then used by the first authors (Zuo Xinyi and Chen Yifang) for the completion of data extraction. Once the study was completed, the accuracy of the process was verified by the second author (Zhou Zhimiao). Finally, through thematic analysis (88), we determined in advance the content of the author, year, country, publication type, study design, sample size, mean age (SD), age, MMSE score, health condition, population group, setting, results as reported in the studies, and conclusions (Table 1); author, year, intervention type, modes of delivery, materials, procedures, activities, and/or processes, format of the intervention delivery, location, duration of intervention, length of sessions, frequency of sessions, intensity, measurement, follow-up, and Jadad score (Table 2).
Table 1. Study characteristics and findings of the included studies.
Table 2. Intervention characteristics—Adapted from the template for intervention description and replication (TIDieR) checklist and guide.
The following data were extracted from the included studies: (1) the information of the literature included (name of author, publication year, country, publication type and study design); (2) the characteristics of the subjects (sample size, participant mean age, participant age, Mini-mental State Examination (MMSE) score, participant health conditions and population group); (3) the interventions (setting, intervention type, design (how)—the modes of delivery, content (what)—the materials, procedures, activities, and/or processes, delivery (who, where when, how much)—format of the intervention delivery, the location, duration of intervention, length of sessions, frequency of sessions, intensity); (4) the information on quality of the study (Jadad score); and (5) the main outcomes (results as reported in studies, conclusion, measurement and follow-up).
2.4 Quality and bias assessment
Using the Cochrane Collaboration Risk of Bias tool, authored by Higgins et al. (86) in 2008, four researchers—Zuo Xinyi, Tang Yong, Chen Yifang and Zhou Zhimiao—independently evaluated the potential for bias in the included studies. Furthermore, to assess the overall quality of the literature, we employed the Jadad scale (103). This risk of bias tool encompasses seven distinct domains: 1. allocation concealment, 2. random sequence generation, 3. blinding of subjects and experimenters, 4. blinding of outcome assessors, 5. selective reporting, 6. integration of resulting data, and 7. other potential sources of bias. Each study was classified as having an unclear, low, or high risk of bias for each domain. Additionally, to assess the degree of publication bias, we conducted the Egger and Begg tests; through these comprehensive assessments, we aimed to ensure the reliability and validity of our findings (76).
2.5 Statistical analysis
Data analysis was conducted utilizing Review Manager 5.3 software and Stata 15.1. To visually represent the findings, forest plots were generated. The studies included in the analysis measured outcomes as continuous variables, with the same indicator assessed using diverse tools. To standardize these measurements, the outcomes are expressed as standard mean differences (SMDs). Statistical significance was determined at α = 0.05. Through this rigorous analytical process, we aimed to provide a comprehensive understanding of the results. Heterogeneity was evaluated using I² statistics, with categories defined as high (>75%), moderate (50-75%), low (<50%), or as outlined (104) in 2002. When high heterogeneity was observed, a sensitivity analysis was conducted using the leave-one-out approach to pinpoint potential sources. During this analysis, multiple weeks were compared as subpoints to ensure the robustness of the findings. Additionally, Begg’s test (105) and Egger’s test (106) in 1997 were utilized to assess the likelihood of publication bias, thereby enhancing the overall reliability of our results. When the meta-analysis included at least 10 studies, a funnel plot (107, 108) was used to assess potential publication bias. Specifically, this study focused on examining the standard mean difference (SMD) along with its corresponding 95% confidence interval (CI) (109). If the overall effect yielded a p value less than 0.05, it was interpreted as statistically significant evidence favouring the effects of MBIs.
2.6 Subgroup analyses
We conducted subgroup analyses on the basis of intervention country (inside or outside China) and intervention duration (weeks).
3 Results
3.1 Selection of studies
Figure 1 outlines the study selection process, and the results are presented in Figure 1. After searching through thirteen databases, a total of 2,253 records were found. All studies were imported into EndNote X8 (Bld, 10063) (110), and duplicates were removed. Following the removal of 924 duplicates and a rigorous screening process that eliminated 1,313 articles, 16 trials (70, 82, 89–102) with 1,256 participants were ultimately included. Studies were excluded if they did not report sd values (75), were missing data for the control group (111), were review articles (68), or were not within the scope of this meta-analysis (112). All the studies included indicated that Tai Chi and Baduanjin had positive effects on cognitive function, shoulder joint function, depression, anxiety, fatigue, sleep quality, and quality of life. The primary outcomes of interest were as follows: cognitive function scores, as assessed by the Functional Assessment of Cancer Therapy-Cognitive Function Perceived Cognitive Impairment (Fact-Cog PCI), The Functional Assessment of Cancer Therapy-Breast (FACT-B), The Functional Assessment of Cancer Therapy-General (FACT-G); shoulder joint function, as assessed by the shoulder active Rom, Lovett Constant-Murley, Neer; depression symptoms, as assessed by the Center for Epidemiologic Studies-Depression (CES-D), the 20-item, Beck Depression Inventory (BDI), self-rating depressive scale (SDS), hospital anxiety and depression scale (HADS); anxiety symptoms, as assessed by the Self-rating Anxiety Scale (SAS), Hospital Anxiety and Depression Scale (HADS); fatigue symptoms, as assessed by the British Standard Institution (BSI), The Fatigue Symptom Inventory (FSI), Multidimensional Fatigue Symptom Scale type: Primary indicator (MFSI-SF); sleep quality, as assessed by the Pittsburgh Sleep Quality Index (PSQI); quality of life, as assessed by the 36-item Medical Outcomes Survey Short Form (SF-36), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), Brief table of quality of life assessment recommendation by WHO (WHOQOLBREF), Functional Assessment of Cancer Therapy—Breast(FACT-B), physical components of quality of life and mental components of quality of life.
3.2 Study characteristics
Tables 1, 2 present the general features of the included studies. All 16 studies were published before 2024. The sample sizes ranged from 11 to 100, and a total of 1247 breast cancer patients over the age of 18 were enrolled, with 654 participants in the experimental group and 602 in the control group. None of the breast cancer patients had been diagnosed with a psychiatric disorder. The interventions were based on Tai Chi and Baduanjin, with durations ranging from 5 weeks to 24 weeks. The weekly intervention time varied between 20 minutes and 90 minutes. Both individual and group training methods were utilized (70, 82, 89–102). All studies (70, 82, 89–102) were further categorized into Tai Chi and Baduanjin therapy.
3.3 Risk of bias and quality assessment
Figures 2 and 3 provides an assessment of the risk of bias. All 16 articles (70, 82, 89–102) provided detailed descriptions of the randomization methods. Four studies reported the blinding method, and all of them were single-blinded trials (82, 89, 91, 95). The dropout rate was reported in two articles (89, 96). The average Jadad score for all included studies was 4.1875, indicating fair to mild quality.
Figure 2. Risk of bias graph.
Figure 3. Risk of bias summary of included studies.
3.4 Meta-analyses
3.4.1 Cognitive function scores
Four studies involving 209 breast cancer patients (141 in the experimental group and 138 in the control group) evaluated the effect of Tai Chi and Baduanjin on cognitive function in breast cancer patients. Due to the utilization of various evaluation tools, the SMD was utilized as the pooled measure for effect size. The pooled results revealed no heterogeneity among the studies (P =.66, I2 = 0%). As shown in Figure 4, the Tai Chi and Baduanjin groups had significantly higher cognitive ability scores than the control group (SMD 1.00, 95% CI 0.66 to 1.35; P<.00001).
Figure 4. Forest plot for MMSE scores.
3.4.2 Shoulder joint function scores
Five studies involving 456 breast cancer patients (228 in the experimental group and 228 in the control group) evaluated the effect of Tai Chi and Baduanjin on the Shoulder Joint Function scores of breast cancer patients based on the shoulder active Rom, Lovett Constant-Murley, Neer. Due to the utilization of various evaluation tools, the SMD was utilized as the pooled measure for effect size. The pooled results revealed a high degree of heterogeneity among the studies (P=.07, I2 = 51%), necessitating the use of a random effects model for the meta-analysis. As shown in Supplementary Figure 5, there were significantly higher shoulder joint function scores in the Tai Chi and Baduanjin groups than in the control group (SMD 7.34, 95% CI 6.32 to 8.35; P<.00001).
3.4.3 Anxiety indicators
Four studies involving 340 breast cancer patients (171 in the experimental group and 169 in the control group) evaluated the effect of Tai Chi and Baduanjin on anxiety symptoms among breast cancer patients based on the SAS and HADS. Due to the utilization of various evaluation tools, the SMD was utilized as the pooled measure for effect size. The pooled results revealed a high degree of heterogeneity among the studies (P<.00001, I2 = 90%), necessitating the use of a random effects model for the meta-analysis. As shown in Supplementary Figure 6 the Tai Chi and Baduanjin groups had significantly lower anxiety scores than the control group (SMD - 2.22, 95% CI - 3.15 to - 1.29; P<.00001).
3.4.4 Depression indicators
Four studies involving 318 breast cancer patients (158 in the experimental group and 160 in the control group) evaluated the effect of Tai Chi and Baduanjin on depression symptoms in breast cancer patients based on the CES-D, BDI, SDS, and HADS. Due to the utilization of various evaluation tools, the SMD was utilized as the pooled measure for effect size. The pooled results revealed a high degree of heterogeneity among the studies (P=.02, I2 = 88%), necessitating the use of a random effects model for the meta-analysis. A shown in Supplementary Figure 7, the Tai Chi and Baduanjin groups had significantly lower depressions scores than the control group (SMD - 1.44, 95% CI -2.46 to -0.41; P<.006).
3.4.5 Fatigue indicators
Four studies involving 282 breast cancer patients (141 in the experimental group and 141 in the control group) evaluated the effect of Tai Chi and Baduanjin on fatigue symptoms in breast cancer patients based on the BSI, FSI, and MFSI-SF. Due to the utilization of various evaluation tools, the SMD was utilized as the pooled measure for effect size. The pooled results revealed a high degree of heterogeneity among the studies (P=.17, I2 = 41%), necessitating the use of a random effects model for the meta-analysis. As shown in Supplementary Figure 8, the Tai Chi and Baduanjin groups had lower fatigue scores than the control group (SMD - 1.02, 95% CI -1.52 to -0.53; P<.0001).
3.4.6 Sleep quality indicators
Three studies involving 222 breast cancer patients (110 in the experimental group and 112 in the control group) evaluated the effect of Tai Chi and Baduanjin on sleep quality indicators in breast cancer patients based on the PSQI. Due to the utilization of various evaluation tools, the SMD was utilized as the pooled measure for effect size. The pooled results revealed a high degree of heterogeneity among the studies (P=.001, I2 = 85%), necessitating the use of a random effects model for the meta-analysis. As shown in Supplementary Figure 9, the Tai Chi and Baduanjin groups had higher sleep quality scores than the control group (SMD - 1.44, 95% CI -2.57 to -0.31; P=.01).
3.4.7 Quality of life indicators
Nine studies involving 749 breast cancer patients (372 in the experimental group and 377 in the control group) evaluated the effect of Tai Chi and Baduanjin on breast cancer patients’ quality of life indicators based on the SF-36, EORTC QLQ-C30, WHOQOLBREF, FACT-B, physical components of quality of life and mental components of quality of life. Due to the utilization of various evaluation tools, the SMD was utilized as the pooled measure for effect size. The pooled results revealed a high degree of heterogeneity among the studies (P=<.0001, I2 = 93%), necessitating the use of a random effects model for the meta-analysis. Supplementary Figure 10 shows that there was a significant increase in the quality-of-life scores of the Tai Chi and Baduanjin groups than the control group (SMD 6.94, 95% CI 5.60 to 8.27; P<.00001).
In conclusion, the included studies used the following assessment tools: the Fact-Cog PCI, FACT-B, FACT-G, shoulder active Rom, Lovett Constant-Murley, Neer, CES-D, BDI, SDS, HADS, SAS, HADS, BSI, FSI, MFSI-SF, PSQI, SF-36, EORTC QLQ-C30, WHOQOLBREF, FACT-B, physical components of quality of life and mental components of quality of life. Seven outcomes were evaluated: cognitive function, shoulder joint function, depression, anxiety, fatigue, sleep quality, and quality of life. The Tai Chi and Baduanjin groups had significantly greater total scores for cognitive function than the control group (CG) (SMD 1.00, 95% CI: [0.66, 1.35], P<.00001, I2 = 0%) (Figure 4). Compared with the control group (CG), the Tai Chi and Baduanjin groups had significantly greater total shoulder joint function scores (SMD 7.34, 95% CI: [6.32, 8.35], P<.00001, I2 = 51%) (Supplementary Figure 1). In addition, the Tai Chi and Baduanjin groups had lower anxiety scores than the CG (SMD - 2.22, 95% CI: [- 3.15, - 1.29], P <.00001, I2 = 90%) (Supplementary Figure 2). The Tai Chi and Baduanjin groups had lower depression levels than the CG (SMD - 1.44, 95% CI: [-2.46, -0.41], P = .006, I2 = 88%) (Supplementary Figure 3). The Tai Chi and Baduanjin groups had lower fatigue levels than the CG (SMD - 1.02, 95% CI: [-1.52, -0.53], P <.0001, I2=41%) (Supplementary Figure 4). The Tai Chi and Baduanjin groups had better sleep quality than the CG (SMD - 1.44, 95% CI: [-2.57, -0.31], P = .01, I2 = 85%) (Supplementary Figure 5). The Tai Chi and Baduanjin groups had better quality of life scores than the CG (SMD - 1.44, 95% CI: [5.60, 8.27], P <.00001, I2 = 93%) (Supplementary Figure 6).
3.5 Subgroup analyses
Analyses of subgroups including shoulder function, anxiety, depression, fatigue, sleep quality, and quality of life scores were performed in accordance with the intervention country (outside China or not) and duration of the intervention (weeks).
3.5.1 Intervention country (China or not in China)
In terms of depression, obvious differences were observed in the SMDs between studies performed in China (70, 90, 102) (P=.002) and studies performed outside of China (96) (P = .67). The Tai Chi and Baduanjin interventions had a significant effect in studies performed in China (SMD = - 1.71, 95% CI: - 2.80 to - 0.62, P = .002) (see Supplementary Figure 7). For sleep quality, obvious differences were observed in the SMDs between studies performed in China (82, 102) (P = .01) and studies performed outside of China (96)(P = .49). The Tai Chi and Baduanjin interventions had a significant effect in studies performed in China (SMD = 一1.65, 95% CI: 一2.95 to 一0.35, P = .01) (see Supplementary Figure 8). For quality of life, obvious differences were observed in the SMDs between studies performed in China (70, 82, 91, 92, 94, 95, 99) (P <.00001) and studies performed outside of China (94, 97) (P = .23). The Tai Chi and Baduanjin interventions had a significant effect in studies performed in China (SMD = 7.51, 95% CI: 6.09 to 8.93, P <.00001) (Supplementary Figure 9).
3.5.2 Intervention duration (weeks)
In terms of shoulder function, 4 out of the 5 studies indicated a significant effect (91, 92, 94, 95) with an intervention period of ≥10 weeks [SMD = 7.63, 95% CI: (6.59 to 8.67), P <.0001]. For the remaining study (100), the pooled effect was SMD = 1.40 (95% CI: −3.31, 6.11; P = .56) within the intervention period. In contrast to the control treatment, Tai Chi and Baduanjin had different effects on shoulder function based on the intervention duration. There was a significant difference in shoulder function in interventions that lasted for longer than 10 weeks (Supplementary Figure 10).
Among the 4 studies on anxiety indicators, 1 study (93) with an intervention duration > 12 weeks reported a pooled effect of SMD = −4.64 [95% CI: (−6.59 to −2.69)], P <.00001]. For 3 studies (70, 89, 90) in which the intervention duration was ≤ 12 weeks, the pooled effect was SMD = −1.51 [95% CI (−2.577, −0.45), P = .005]. An intervention period of more than 8 weeks was found to have an obvious effect on reducing breast cancer patients’ levels of anxiety (Supplementary Figure 11).
Of the 4 studies regarding depression indicators, 3 studies (70, 90, 96) had an intervention duration of > 8 weeks and reported a pooled effect of SMD = −1.53 [95% CI: (−2.59 to −0.47), P = .005]. For 1 study (102) in which the intervention cycle was ≤ 8 weeks, the pooled effect was SMD = −0.20 [95% CI (−3.98, 3.58), P = .006]. An intervention period of more than 8 weeks was found to have an obvious effect on reducing breast cancer patients’ levels of depression (Supplementary Figure 12).
Among the 4 studies reporting fatigue indicators, 3 (70, 96, 98) had an intervention duration > 8 weeks and reported a pooled effect of SMD = −1.30 [95% CI: (−1.88 to −0.73), P <.00001]. For 1 study (102) in which the intervention cycle was ≤ 8 weeks, the pooled effect was SMD = −0.20 [95% CI (−1.19, 0.79), P = .69]. An intervention period of more than 8 weeks was found to have an obvious effect on reducing breast cancer patients’ levels of fatigue (Supplementary Figure 13).
Among the 3 studies regarding sleep quality indicators, 2 (82, 96) had an intervention duration > 8 weeks and reported a pooled effect of SMD = −2.88 [95% CI: (−4.39 to −1.38), P = .0002]. For 1 study (102) in which the intervention cycle was ≤ 8 weeks, the pooled effect was SMD = 0.40 [95% CI (−1.30, 2.10), P = .65]. An intervention period of more than 8 weeks was found to have increase sleep quality among breast cancer patients (Supplementary Figure 14).
Among the 9 studies reporting quality of life indicators, 1 (150) had an intervention duration > 12 weeks and had a pooled effect of SMD = −7.78 [95% CI: (−17.89 to 2.33), P = .13]. For 8 studies (70, 82, 92, 94, 95, 97–99) in which the intervention cycle was ≤ 12 weeks, the pooled effect SMD = 7.20 [95% CI (5.85, 8.54), P <.00001]. An intervention period of more than 8 weeks was found to have an obvious effect on increasing quality of life among breast cancer patients (Supplementary Figure 15).
3.6 Sensitivity analysis
In the sensitivity analysis (Table 3), the study of Li et al. (90) was excluded, and we observed an obvious change in heterogeneity, which decreased from 91% to 0%. Similarly, when excluding the study by Liao et al. (2022) (82), the heterogeneity level decreased to 0%. Based on these observations, we hypothesize that the outcomes of depression and sleep quality indicators may be the primary sources of heterogeneity in this study. Other potential reasons for heterogeneity include differences in patient populations, inconsistencies in clinical indicators between domestic and overseas studies, and specific treatment methods. The patient characteristics, specific treatment modalities, and applied clinical indicators across the literature are as follows: Li et al. (90), Shanxi (China), aged 37-57 years, breast cancer patients, Baduanjin intervention, shoulder function, anxiety, depression; Liao et al. (2022) (82), Guangzhou (China), aged 46-60 years, breast cancer patients, Baduanjin intervention, sleep quality, and quality of life. The factors mentioned above are all potential sources of heterogeneity in this study.
Table 3. Sensitivity analysis for depression and sleep quality indicators.
3.7 Publication bias
We conducted a thorough analysis of the funnel plots for cognitive function (Supplementary Figure 13), shoulder function (Supplementary Figure 14), anxiety (Supplementary Figure 15), depression (Supplementary Figure 16), fatigue (Supplementary Figure 17), sleep quality (Supplementary Figure 18), and quality of life (Supplementary Figure 19). The plots were found to be symmetrical, strongly suggesting the absence of publication bias. Furthermore, the P values exceeded.04, indicating a lack of significant publication bias. Additionally, Egger’s regression test (P=.018) and Begg’s test (P=.02) confirmed the absence of publication bias. All in all, it seems challenging to detect, let alone define, publication bias in the present context because the study conditions and designs appear relatively heterogeneous.
4 Discussion
4.1 Principal findings
This study systematically evaluated the efficacy of Tai Chi and Baduanjin in breast cancer patients, drawing upon data from 16 studies with a total of 1247 participants. Our findings revealed that Tai Chi and Baduanjin significantly improved cognitive function (SMD = 1.00), shoulder function scores (SMD = 7.34), sleep quality (SMD = -1.44) and quality of life (SMD = 6.94) and reduced depression (SMD = -1.44), anxiety (SMD = -2.22) and fatigue scores (SMD = -1.02). These findings suggest that Tai Chi and Baduanjin are highly effective alternatives for treating breast cancer patients. However, caution is advised in interpreting these results because of the statistical heterogeneity mentioned in the research. To investigate the impact of individual studies on overall risk, sensitivity analysis was conducted to identify the main sources of heterogeneity. Notably, there were large variations in sample size (range: 11–100), intervention type, intervention duration (range: 5–24 weeks), weekly intervention hours (range: 20–90 min/week), and type of control group. (e.g., regular intervention, routine rehabilitation training, waiting list, sham qigong, usual care, no intervention). We acknowledge that cultural background, measurement instruments, and other confounding factors may have contributed to the heterogeneity observed in this systematic review. To the best of our knowledge, this is the first meta-analysis and systematic review to evaluate the effectiveness of Tai Chi and Baduanjin therapy on seven outcome indicators in breast cancer patients. In our study, Tai Chi and Baduanjin therapy significantly improved cognitive function and shoulder function and alleviated depression, anxiety, fatigue and quality of life symptoms.
4.2 comparison with previous work
Previous studies have explored the effects of Tai Chi and Baduanjin in cognitive ability (69, 70), alleviating shoulder function impairment (55, 59) and improving mental health problems (72, 73) in breast cancer patients. However, previous studies have reported inconsistent findings regarding the effects of Tai Chi and Baduanjin therapy on improving cognitive function (70), shoulder function (71), reducing falls (75), improving stress and mental health problems (81), improving fatigue, sleeping quality, depression symptom (70) in breast cancer patients. To the best of our knowledge, this systematic review included recent literature (2013-2023) and is the first systematic review and meta-analysis to evaluate examined the effect of Tai Chi and Baduanjin of seven outcome indicators in breast cancer patients. In our study, Tai Chi and Baduanjin were found to significantly alleviate anxiety, depression, and sleep problems and improve cognitive impairment, shoulder function impairment, fatigue, and quality of life (QoL). This systematic review also divided subgroup analysis of the weeks and continental plates, which was not available in the previous systematic review.
4.3 Limitations
This study has some limitations that should not be ignored. First, given the nature of systematic reviews, a clear causal relationship cannot be established, as Tai Chi can but only play a supportive role that is preventive and somewhat curative but always in conjunction with other therapeutic methods. Additionally, stress outcome indicators had some impact on the psychological health of breast cancer patients. However, as the only study reported these indicators, a comprehensive comparison could not be made; thus, these indicators were not included in this review. Third, due to the design restrictions in the study, the randomization and blinding methods of the included studies were seldom described in detail. Only five (82, 91, 97, 98, 101) studies were found to detail the randomization method. In contrast, randomization was only mentioned in other studies, and no explanation of the method used was provided. Among them, double-blinding was only implemented in three (96, 97, 101) studies.
4.4 Implications
Complementary therapies, particularly mind-body practice, are interventions with great effectiveness for managing treatment side effects and breast cancer symptoms and side effects of complementary therapies (113). Tai Chi (114) and Baduanjin (115) are therapies that complement each other and integrate physical and psychological components. These ancient Chinese mind-body exercises combine breathing exercises, meditation, relaxation techniques, and physical movement (116). Tai Chi and Qigong are two of the most popular traditional aerobic exercises used to treat breast cancer (42). The most common cancers diagnosed among Chinese females was breast cancer, with an, age-standardized incidence rate(ASIR) of 39.1 per 100,000 (117). Of all countries, China faces the largest economic cost of cancers at INT $6.1 trillion, followed by the US (INT $5.3 trillion) and India (INT $1.4 trillion) (118). Our findings have also found that Tai Chi and Baduanjin can have a positive impact on increasing in cognitive ability, shoulder joint function, quality of life, sleep quality and decreasing in anxiety, depression, fatigue symptom among breast cancer patients. With this in mind, we suggest that nursing home caregivers, social workers, and psychologists consider using Tai Chi and Baduanjin in their work, and collaborate with Tai Chi and Baduanjin professionals, it will both physical and psychological health improvements to the breast cancer patients and reduce the financial burden on our country at the same time.
5 Outlook
In the future, more research is needed to improve participant motivation, reduce dropout rates, and sustain the benefits of Tai Chi and Baduanjin therapy. Given the study limitations, subgroup analyses for intervention types were not feasible. Therefore, it is essential to conduct in depth, stratified comparisons and discussions of different types of interventions. To validate the effectiveness of Tai Chi and Baduanjin therapy for breast cancer patients, researchers should conduct high-quality studies with large sample sizes. All in all, we should recognize that this research is good to stimulate future research on the many possibilities of Tai Chi and its potential therapeutic benefits as a holistic and preventive approach to a healthy lifestyle, as compared to the more analytical and curative focus in Western discussions. And the take-home message is that Tai Chi is a form of mental relaxation capable of restoring attention and inner resources (25), which is movement-oriented, as it focuses on forms of gentle motion particularly beneficial for older individuals or patients aiding the healing process. Finally, it is a social act that promotes the feeling of togetherness by bringing people together in the true sense of the word (39).
6 Conclusion
Overall, Tai Chi and Baduanjin therapy may be associated with an increase in quality of life among breast cancer patients. However, a definitive conclusion could not be reached on the safety and effectiveness of Tai Chi and Baduanjin therapy for improving cognitive ability, shoulder joint abilities, and mental health among breast cancer patients. The overall quality of evidence across all meta-analyses was found to be very low. This was primarily due to concerns about the overall bias within most included studies, high evidence heterogeneity, and reported effect size imprecision. Given these limitations, psychologists, social workers, psychiatrists, and patients should approach Tai Chi and Baduanjin therapy as complementary treatments rather than as replacements for existing interventions. To more robustly evaluate the effectiveness and safety of Tai Chi and Baduanjin for improving specific cognitive abilities, social well-being, and pain among individuals of different age groups, regardless of cognitive status, further reviews and additional studies are needed. It is essential to assess the impact, safety profile, and long-term effects of this therapy to determine its potential as a sustainable and effective intervention in various settings.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author.
Author contributions
CY: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. ZX: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. TY: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. ZZ: Data curation, Formal analysis, Methodology, Resources, Writing – original draft.
Funding
The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by funding from the Shenzhen Philosophy and social science planning project (SZ2024D007) and Shenzhen University-Lingnan University Joint Research Programme (SZU-LU Joint Research Programme) (2023004).
Acknowledgments
The authors (XZ, YT, YC and ZZ) have confirmed the submission of this manuscript, the key message of the manuscript, and the uniqueness of the study. We would like to thank the reviewers for their helpful remarks.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fonc.2024.1434087/full#supplementary-material
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Keywords: Tai Chi and Baduanjin, rest breaks, meditation, relaxation, mindfulness, mental health, breast cancer patients
Citation: Chen Y, Zuo X, Tang Y and Zhou Z (2024) The effects of Tai Chi and Baduanjin on breast cancer patients: systematic review and meta-analysis of randomized controlled trials. Front. Oncol. 14:1434087. doi: 10.3389/fonc.2024.1434087
Received: 17 May 2024; Accepted: 16 September 2024;
Published: 28 October 2024.
Edited by:
İsmail Toygar, Mugla University, TürkiyeReviewed by:
Michael B. Steinborn, Julius Maximilian University of Würzburg, GermanyAnna Koymapianoy, University General Hospital Attikon, Greece
Copyright © 2024 Chen, Zuo, Tang and Zhou. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Xinyi Zuo, czExMzY3ODhAcy5lZHVoay5oaw==
†These authors have contributed equally to this work