Research paper
Current evidence on traditional Chinese exercises for cancer-related fatigue: a quantitative synthesis of randomized controlled trials

https://doi.org/10.1016/j.eujim.2016.05.007Get rights and content

Abstract

Introduction

Cancer-related fatigue (CRF) is the most frequent and debilitating symptom faced by cancer patients. Traditional Chinese exercises (TCEs) combine the characteristics of physical activities and psychosocial interventions for treating CRF. However, the effectiveness of TCEs on CRF management remains controversial. This systematic review was conducted to summarize the current evidence of TCEs on the management of CRF.

Methods

Randomized controlled trials (RCTs) were identified in eight databases (PubMed, Embase, CENTRAL, AMED, Science Direct, Thomson Reuters Web of Science, PsyclNFO, and ALT HealthWatch). Adult cancer patients receiving TCEs combined either with or without other treatments were eligible for inclusion. TCEs were limited to widely used modalities including Tai Chi, Qigong, Baduanjin, Wuqinxi, Yijinjing, and Liuzijue. The primary outcome was CRF. Risk of bias for each of the included studies was judged based on the quality assessment method as recommended by the 2011 Cochrane Handbook. Review Manager 5.3 (RevMan 5.3) was employed to generate pooled estimates of effect size. Random-effects modelling was used to calculate pooled weighted mean differences (WMDs) or standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs). Because trial results were presented as either change scores from baseline to follow-up or only final values, meta-analyses were completed for both types of measures.

Results

Nine studies with 703 patients were included. Methodological limitations were identified in the analyzed studies. When measured as the change scores at the short-term follow-up, the pooled results suggested that TCEs had a significant positive effect on CRF (SMD 1.03; 95% CI [0.61, 1.44]; P < 0.00001). Data synthesis was also performed for studies using follow-up values only, and the results indicated that TCEs failed to improve CRF, both at short-term (SMD ⿿0.00; 95% CI [⿿0.42, 0.41]; P = 0.99) and long-term follow-up (SMD 0.05; 95% CI [⿿0.26, 0.35]; P = 0.77).

Conclusions

The study findings suggest that the evidence on the effectiveness of TCEs for CRF management is inconclusive. Due to the small number of included studies and their methodological limitations, further well-designed RCTs with sufficient intervention durations and follow-up periods are needed to provide more reliable evidence.

Introduction

The National Comprehensive Cancer Network (NCCN) defines cancer-related fatigue (CRF) as ⿿a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.⿿[1] Eighty to ninety-nine percent of cancer patients declare that CRF is a more frequent and debilitating symptom than pain, depression, or nausea [1], [2]. CRF may limit patients⿿ abilities to participate in their daily activities, subsequently resulting in significant emotional problems such as depression and hopelessness [2]. At present, an optimal treatment for CRF has not been found. The guidelines for managing CRF, published by the NCCN, suggest that CRF management options may include the use of physical activities and psychosocial interventions, such as yoga, swimming and cognitive behavioural therapy [1]. Traditional Chinese exercises (TCEs) are special types of physical exercises that combine breathing exercises, mind control and slow and gentle position adjustments to induce and inspire human⿿s inherent potential, to prevent and cure disease, to increase mental ability, and to extend lifespan [3], [4]. TCEs include Qigong, Tai Chi, Baduanjin, Yijinjing, Liuzijue, Wuqinxi and so forth. Mechanism of TCEs can be explained through the mind-body practice [5] which combines the characteristics of physical activities and psychosocial interventions for producing the therapeutic effects. TCEs are widely used by patients with chronic diseases. Several studies have indicated the health benefits of TCEs, such as improving cardiovascular outcomes, decreasing stress hormones and enhancing immune function [6], [7], [8], [9]. A recent meta-analysis indicated that Tai Chi/Qigong can produce a positive impact on quality of life, immune function and cortisol level in cancer patients [10]. However, the findings from current studies in terms of the effetiveness of TCEs on CRF seem contradictory [11], [12], [13], [14], [15]. This systematic review was conducted to summarize the current research evidence of TCEs on CRF, and to conclude implications for future research and practice.

Section snippets

Types of studies

Randomized controlled trials (RCTs).

Types of participants

Patients with a confirmed diagnosis of cancer. Adult cancer survivors (aged 18 years or above) were included, regardless of sex, type of cancer diagnosis, tumour grade, and type of anti-neoplastic treatment.

Types of interventions

TCEs were limited to the widely used forms, including Tai Chi (

­), Qigong (
), Baduanjin (
), Wuqinxi (
), Yijinjing (
), and Liuzijue (
). The TCEs intervention in the included studies can be one of the six forms, or a combination of any of the six. Patients

Trial characteristics

This study returned 549 relevant references. Among which, 157 were duplicated, and 383 did not meet the eligibility criteria. Finally, nine studies meeting the inclusion criteria were included in the qualitative synthesis [11], [12], [13], [14], [15], [18], [19], [20], [21], and six of them were included in the quantitative synthesis [11], [12], [15], [18], [19], [20] (Fig. 1). As showed in Table 1, two trials adopted a three-armed parallel group design [14], [20], and the other seven trials

Discussion

In this review, 9 trials with 703 cancer patients were identified. The study findings suggested that the current evidence on the effectiveness of TCEs for CRF management is inconclusive. Also, based on current evidence, TCEs had no positive impact on depression among cancer patients. However, the small samples and different degrees of methodological limitations in most of the included studies limited the evidence strength of the review.

TCEs are special types of exercises which coordinate yin

Conclusions

Current evidence demonstrates that the effectiveness of TCEs for managing CRF is unclear. There is also no evidence to suggest that TCEs are effective in improving depression in cancer patients. Because of the limited number of the included studies and their methodological flaws, the evidence is inconclusive and future large scale RCTs with satisfactory intervention durations and follow-up periods are needed to provide more reliable research evidence.

Conflict of interests

There were no conflicts of interest to disclose.

Acknowledgements

Liu Yang, Hai-Li Ma and Jing-Yu Tan contributed to the study conception and design. Hai-Li Ma and Liu Yang contributed to the completion of the articles, data extraction, data calculation and preparation of figures and tables. Tao Huang and Qiao-Jing Liao proof-read the article. All authors approved the final manuscript.

This work was supported by the Natural Science Foundation of Fujian Province of China (2016J01773) and the 2015 Annual Scientific Research Task of the Chinese Medical Qigong

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