Review Effects of traditional Chinese mind-body exercises for patients with chronic fatigue syndrome: A systematic review and meta-analysis 2023 Kong et al

[Andy]

Background: Chronic fatigue syndrome (CFS) is a global public health concern. We performed this systematic review of randomised controlled trials (RCTs) to evaluate the effects and safety of traditional Chinese mind-body exercises (TCME) for patients with CFS.

Methods: We comprehensively searched MEDLINE, Embase, Web of Science, PsycINFO, Cochrane Library, CNKI, VIP databases, and Wanfang Data from inception to October 2022 for eligible RCTs of TCME for CFS management. We used Cochran's Q statistic and I2 to assess heterogeneity and conducted subgroup analyses based on different types of TCME, background therapy, and types of fatigue. We also assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

Results: We included 13 studies (n = 1187) with a maximal follow-up of 12 weeks. TCME included Qigong and Tai Chi. At the end of the treatment, compared with passive control, TCME probably reduces the severity of fatigue (standardised mean differences (SMD) = 0.85; 95% confidence interval (CI) = 0.64, 1.07, moderate certainty), depression (SMD = 0.53; 95% CI = 0.34, 0.72, moderate certainty), anxiety (SMD = 0.29; 95% CI = 0.11, 0.48, moderate certainty), sleep quality (SMD = 0.34; 95% CI = 0.10, 0.57, low certainty) and mental functioning (SMD = 0.90; 95% CI = 0.50, 1.29, low certainty). Compared with other active control therapies, TCME results in little to no difference in the severity of fatigue (SMD = 0.08; 95% CI = -0.18, 0.34, low certainty). For long-term outcomes, TCME may improve anxiety (SMD = 1.74; 95% CI = 0.44, 3.03, low certainty) compared to passive control. We did not identify TCME-related serious adverse events.

Conclusions: In patients with CFS, TCME probably reduces post-intervention fatigue, depression, and anxiety and may improve sleep quality and mental function compared with passive control, but has limited long-term effects. These findings will help health professionals and patients with better clinical decision-making.

PubMed listing only as link to journal doesn't work, https://pubmed.ncbi.nlm.nih.gov/37994837/

 

[Joan Crawford]

"probably" about sums it up...... along with "limited long-term effects".... Patients and their doctors kinda wants something stronger than probably

 

[Jonathan Edwards]

Patients and their doctors kinda wants something stronger than probably

But it isn't even probably. Using GRADE on studies of this sort is invalid.
It is a more a question of
'just about conceivable but unproven...'

 

[rvallee]

About the same likelihood of effective benefits as eating pumpkin pie.

Or auricular astrology. Or wearing a whole-body pig suit.

Mayhaps this is all nonsense.

 

[dave30th]

auricular astrology

Is this different from regular astrology??

 

[Jonathan Edwards]

Is this different from regular astrology??

It depends on listening to the stars rather than gazing.
Said to be more reliably unreliable.
For 250 dollars you could get a prediction on the next president which you could completely ignore - so worth the money.

 

[rvallee]

Is this different from regular astrology??

It's definitely distinct.

 

[Sean]

Or wearing a whole-body pig suit.

Indeed. Any properly qualified charlatan knows it has to be a chicken suit.

 

[Creekside]

Patients and their doctors kinda wants something stronger than probably

"Maybe kinda sorta?"

rvallee left out "clicking your heels together three times". After all, there's anecdotal evidence that that worked for a little girl and her little dog.

 

[Hutan]

The Cochrane Larun et al review gets a shout out - spreading disinformation across the globe.

As of yet, pharmacological interventions have suboptimal effects due to CFS’ unclear etiology and pathophysiology. Given their long-term adverse effects and financial burden [8,9], many patients seek complementary and alternative therapy to improve their symptoms and quality of life [10]. For CFS, a standard treatment program usually involves exercise therapy, which, according to a Cochrane systematic review, might improve CFS patients’ fatigue, sleep disturbance, physical function, and self-perceived general health [11]. However, this review excluded traditional Chinese mind-body exercises (TCME) such as Tai Chi and Qigong.

TCME emphasises the coordination and unification of breathing, mental relaxation, and body movements to improve physical and mental health status [12], with clinicians recommending Tai Chi and Qigong for managing CFS symptoms [13-15]. Researchers have shown its potential improvements in fatigue, anxiety, depression, and quality of sleep [16-19]. However, previous reviews of mind-body interventions for CFS included few studies addressing the effectiveness of TCME for patients with CFS, as they did not include Chinese literature databases [20]. A systematic review and meta-analysis of TCME for CFS did not show trustworthy evidence due to its inappropriate searching strategy and pooling analysis [21]. To address these gaps, we conducted a systematic review to assess the effects and safety of TCME for CFS management.

Tai Chi - the movement practice that looks like a slowed down version of a martial art
Qigong - as far as I can work out, tai chi is actually a sort of qigong. It seems to be a general term for exercise combined with breathing and a meditative state, and covers a wide range of forms.
If anyone has better knowledge, by all means tell us.

Our comparators were passive (waiting list, no treatment, and minimal education) or active controls (pharmacological therapy, cognitive behavior therapy, acupuncture, moxibustion, point application, and other exercises therapy without mind-body exercises), compared as TCME vs passive/active control, TCME plus active control vs active control only, or similarly in a RCT. Our outcomes of interest were any of the following: fatigue, sleep quality, anxiety, depression, and quality of life measured using any validated scale and adverse events.

 

[Hutan]

tldr: they did all the things:

We used RevMan, version 5.3 (The Cochrane Collaboration, Oxford, United Kingdom) to perform the meta-analysis. We calculated standardised mean differences (SMD) and 95% confidence intervals (CIs) for continuous variables measured by different measure instruments based on the mean changes between pre- and post-treatments and used a random effects models to pool the data. To assess heterogeneity, we used the Cochran’s Q statistic (considered to be statistically significant when P < 0.10) and I2 (where I2>30% indicated moderate heterogeneity, I2>50% substantial heterogeneity, and I2>75% considerable heterogeneity). We then conducted subgroup analyses based on different types of TCME, background therapy, and types of fatigue. If there were more than ten studies, we used the funnel plot to assess the possibilities of publication bias. For the meta-analysis, we considered P < 0.05 as statistically significant. In addition, we assessed the overall quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework by considering the risk of bias, inconsistency, indirectness, imprecision, and publication bias.

including this:

The author team was gender balanced and consists of junior, mid-career, and senior researchers from different disciplines and two countries. Our study population included both male and female subjects from different socioeconomic and cultural backgrounds.

but not this:

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

 

[Hutan]

We identified 402 records through the literature search, with 316 remaining after deduplication. We excluded 283 studies after screening the titles and abstracts and a further 20 after full-text screening, leaving 13 studies for inclusion in our review

There's potentially a lot of studies out there.

A large number of the studies were excluded because it was determined that they did not study chronic fatigue syndrome, although I haven't seen anything about how they identified chronic fatigue syndrome.

 

[alktipping]

I tried tai chi 26 years ago just the main stance became intolerable after a few minutes it stresses all your core muscles .I would not recommend this to anyone with M E or any other disorder that has exercise intolerance .

 

[Hutan]

We included 13 studies with 1187 participants, with a mean age of 40.33 (standard deviation (SD) = 4.36 years) [16-19,24-32], all from China, conducted between 2012 and 2022. TCME included Qigong (n = 10) [16-19,24,26-29,31,32] and Tai Chi (n = 3) [25,30,32]. Six studies compared TCME with passive control [16-19,28,31], another six compared TCME plus background therapy with the same background therapy [25-27,29,30,32], and three compared TCME with active control interventions including cognitive behavioral therapy [24], moxibustion [27], and point application [29]. The length of treatment varied between four and 16 weeks, while exercise duration ranged between 20 and 120 minutes (mean = 43.75 (SD = 24.16)). The common intensity of Qigong exercises was at least 30-minute/session, more than three sessions/week, and at least nine weeks. The longest follow-up time was 12 weeks. Patient important outcomes included fatigue, anxiety, depression, quality of life, and sleep quality

13 studies, 8 of them with a publication date in 2015 or later (and therefore new studies since Cochrane Larun et al's search).

Outcomes are mostly surveys, short followup times. There are a few molecules measured e.g. neuropeptide y.

Only one study[24] was categorised as having a high risk of bias in selective reporting outcome, and the others were at low risk of bias (Figure S1 in the Online Supplementary Document). We assessed the overall quality of evidence using the GRADE method

All studies except one judged to be of low risk of bias...

 

[Hutan]

The meta-analysis indicated that TCME probably results in a large reduction in the severity of post-intervention fatigue (SMD = 0.85; 95% CI = 0.64, 1.07, I2 = 54%, moderate certainty)

Two studies [16,31] with 110 participants assessed the effects of TCME on quality of life compared with passive control, using Qigong as the TCME intervention. TCME may result in a large improvement in post-intervention mental function (SMD = 0.90; 95% CI = 0.50, 1.29; I2 = 0%, low certainty), but did not improve post-intervention physical function (SMD = 0.11; 95% CI = -0.26, 0.49; I2 = 0%, low certainty)

Three studies [24,27,29] with 233 patients compared the effects of TCME via Qigong with active control. The active control interventions included cognitive behavioral therapy, moxibustion, and point application. The meta-analysis of three trials indicated that compared to other active control, TCME may result in little to no difference in the severity of post-interventions fatigue (SMD = 0.08; 95% CI = -0.18, 0.34; I2 = 0%, low certainty)

When you have an active control (CBT, moxibustion, point application), the exercise interventions have similar results. We've heard that before.

Long term followup

Only one study [18] with 115 participants reported that, compared to passive control, TCME may improve fatigue with a statistically significant difference (mean change on Chalder Fatigue Scale = 12.2 vs 5.3, P < 0.001), but the effectiveness of TCME on sleep quality was not statistically significant (mean change on Pittsburgh Sleep Quality Index = 1.7 vs 0.9, P = 0.064). Meanwhile, two studies [17,18] with 258 participants reported the effectiveness of TCME compared to the passive control at 12 weeks follow-up. Our pooled analysis showed that TCME may result in a large reduction in anxiety (SMD = 1.74; 95% CI = 0.44, 3.03; I2 = 39%, low certainty), but in little to no difference in depression (SMD = 0.96; 95% CI = -0.11, 2.04; I2 = 0%, low certainty) (Figure 2) compared with passive control.

12 weeks is hardly long term followup, but it looks like only two studies did it, or at least only two studies reported on some of their outcomes. One reported results for fatigue, sleep, anxiety and depression; one reported results for anxiety and depression. All versus a passive control.

The recording of adverse events seems pretty bad. Only one study recorded a range of adverse events, and they were of the muscle ache, knee pain and dizziness variety. One other study recorded mild muscle ache but it was not distinguishable from the adverse effects record in the CBT arm.

 

[Hutan]

So, here we go, for the discussion:

We evaluated the effectiveness and safety of TCME (Qigong and Tai Chi) for CFS. For post-intervention outcomes compared with passive control, moderate certainty evidence suggests that TCME probably reduce the severity of fatigue, depression, and anxiety, while low certainty evidence shows it may improve sleep quality and mental functioning. Low certainty evidence shows that TCME may result in little to no difference in the severity of post-interventions fatigue comparing to other active control therapies, yet its long-term effect is uncertain, as there is only low certainty evidence that TCME improves fatigue and anxiety at 12 weeks follow-up for CFS patients. TCME are generally safe due to the rare reports of minor adverse events.

So, you can either take the endorsement of this multi-study review with all the bells and whistles of the Cochrane tools and processes but no objective outcomes. It finds moderate certainty evidence that the exercise modalities reduce fatigue in the short term compared to people given no treatment. It finds that you can give people with CFS all sorts of treatments including these ones and the short term benefit is all about the same. There's little evidence at 12 weeks, but it is reported that there is low certainty evidence that these traditional exercise regimes help fatigue. And seemingly there is no evidence beyond 12 weeks.

Or you can pay heed to @alktipping's word of caution combined with the often hard-won community knowledge that exercise of any sort is not the answer to ME/CFS.

 

[Hutan]

More from the discussion

Existing systematic reviews methodology quality is suboptimal.

this was written to criticise another team's effort at a meta-analysis, due to

In their review, however, the authors neither conducted the pooled analysis on the severity of fatigue across studies reported with different instruments, nor subgroup analysis to explore sources of heterogeneity.

I think they all have some more fundamental problems. There's no mention of dropouts in the paper, no exclusion of studies on the ground of an intolerable risk of bias.

Future research could focus on recruiting CFS patients from various countries to address this issue, while simultaneously advancing fairness and accessibility in the global management of CFS.

And fair enough too. Cochrane seems to have rather negative feelings towards poorly-evidenced Chinese therapies; it seems to reserve its protectionist practices and promotion activities for poorly evidenced western mind-body therapies. Make pseudo-science accessible to all.
(This is not to criticise exercise of any cultural leaning. It's a good thing, we know that. It just does not fix ME/CFS and has a high risk of harming.)


They are trying harder than many reviews I have seen to encourage better studies

Future TCME RCTs should measure CFS’ long-term outcomes and objective outcomes (such as immune function status in CFS patients) conduct cost-benefit analysis, and evaluate its effects in CFS patients compared to other exercises (such as graded exercise therapy). Researchers should apply adequate allocation concealment methods and ensure outcome assessors are blinded. Future systematic review can explore the types, intensity, and duration of TCME on CFS’ treatment effect to find the most effective TCME in managing of CFS, while network meta-analyses could evaluate the effects of all CFS treatment, including TCME and other common strategies, such as pharmacological interventions, graded exercise therapy, or cognitive behavior therapy.

They mention the need for long-term outcomes and objective outcomes, although the type of objective outcomes they mention (immune function status) are horribly prone to cherry picking, with measures that aren't helpful quietly getting shelved. There's the usual note that 'we just need to tweak the offering, choose just the right sort of exercise for just the right intensity and time'.

 

[rvallee]

And fair enough too. Cochrane seems to have rather negative feelings towards poorly-evidenced Chinese therapies; it seems to reserve its protectionist practices and promotion activities for poorly evidenced western mind-body therapies

They've always been at love with West Asian mind-body therapies. Totally unlike those East Asian mind-body therapies.

 

[Hutan]

Yeah, it doesn't seem that qigong is anything particularly mysterious, it's just exercise e.g.

Qigong is exercise; qigong applied to a patient group to improve symptoms is exercise therapy. There's no reason for Cochrane to say there have been no recent trials of exercise therapy.

 

[Binkie4]

I tried tai chi 26 years ago just the main stance became intolerable after a few minutes it stresses all your core muscles .I would not recommend this to anyone with M E or any other disorder that has exercise intolerance .

I attended a weekly tai chi and qi gong class for 10 years prior to having ME. I loved it. Remembering the forms was intellectually challenging and I loved doing the rhythmic movements. It was a strengthening exercise and I learnt how strong my body core was in standing exercises: although a long time ago, I still think I benefit from those years.
I then needed a hip replacement. That meant a break from tai chi and my sense of balance deteriorated. I thought it would return with practice but it didn't: I never became comfortable with the upright posture. I found I sat out more and more.
The following year I became really ill and was given an ME diagnosis- and I couldn't do tai chi. I couldn't stand as required. Orthostatic intolerance was in the picture as it is for very many with ME.