Submit a manuscript: http://www.tmrjournals.

com
DOI: 10.12032/TMRIN20190810
DOI:
Meta-analysis

Effect of Baduanjin on rehabilitation of patients with coronary heart disease:

A meta-analysis of 8 randomized controlled trials
Tian-Tian Gai1, Wei Fan1, Meng-Xi Gao1, Yu Cui1, Yan Wang2
1
Department of Graduate, Tianjin University of Traditional Chinese Medicine, Tianjin, China; 2Department of Nursing, Tianjin University of Traditional Chi-
nese Medicine, Tianjin, China.

*Correspondence to: Yan Wang, Department of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, China. E-mail:
yan2015wangly@163.com.

Highlights Editor’s summary

This study evaluated the impact of Baduanjin exercise
on rehabilitation of patients with coronary heart disease.
The current research results showed that Baduanjin im-
proved cardiopulmonary function and exercise tolerance
and alleviated patients' bad mood.
Baduanjin has the benefits of strengthening the muscles and
the bones, nourishing the vital energy, speeding up blood
circulation, coordinating the internal organs. Studies have
shown that, insisting on regular exercise of Baduanjin re-
duced the blood pressure, blood lipids and blood sugar in
exercisers and promoted the physical and mental health of
the elderly.

Citation: Gai TT, Fan W, Gao MX, et al. Effect of Baduanjin on rehabilitation of patients with coronary heart disease: A meta-analysis
of 8 randomized controlled trials. TMR Integrative Nursing, 2019, 3(4): 133-139. doi: 10.12032/TMRIN20190810.
Submitted: 26 December 2018, Accepted: 8 August 2019, Online: 10 August 2019.

| TMR Integr Nurs | August 2019 | vol. 3 | no. 4 | 133

Gai TT, et al. Effect of Baduanjin on rehabilitation of patients with coronary heart disease

ABSTRACT
t
Backgroud: As one of the traditional rehabilitation exercises recommended by the State Sports General Administration, Baduanjin is
widely used in the prevention and treatment of coronary heart disease. To systematically evaluate the impact of Baduanjin exercise on
rehabilitation of patients with coronary heart disease. A search in Cochrane Library, PubMed, EMbase, Web of science, China Biology
Medicine disc (CBM), CNKI, Wan Fang Date and VIP database was performed in order to collect randomized controlled trials (RCTs)
of Baduanjin in patients with coronary heart disease from inception to November 2018. Two reviewers independently screened litera-
tures, extracted data and assessed risk of bias of included studies, then, meta-analysis was performed by using RevMan 5.3. Results: A
total of 8 RCTs including 615 patients were considered. Compared with the control regime, Baduanjin improved the ejection fraction of
patients [MD = 2.99, 95% CI (1.54, 4.45), P < 0.001], increased the walking distance of six minutes [SMD = 2.29, 95% CI (0.44, 4.13),
P = 0.02], decreased the score of self-rating anxiety scale and self-rating depression scale [MD = -5.06, 95% CI (-6.63, -3.49), P <
0.001], [MD = -5.12, 95% CI (-8.73, -1.50), P = 0.006]. Conclusion: The current research results showed that Baduanjin improved car-
diopulmonary function and exercise tolerance and alleviated patients’ bad mood.
Key words: Traditional Chinese medicine, Baduanjin, Coronary heart disease, Meta-analysis

摘 要

背景：八段锦作为国家体育总局推荐的传统康复运动之一，被广泛应用于冠心病的防治中。为了系统地评
价八段锦对冠心病患者康复的影响，计算机检索 The Cochrane Library、PubMed、EMbase、Web of science、
CBM、CNKI、万方数据库和维普数据库，搜集八段锦应用于冠心病患者的随机对照试验，检索时限均为建
库至 2018 年 11 月份。由 2 位评价员独立筛选文献、提取资料并评价纳入研究的偏倚风险后，采用 RevMan5.3
进行 Meta 分析。
结果：纳入 8 个随机对照实验，共 615 例患者。相比对照组，八段锦可提高患者的射血分数[MD = 2.99，95%CI
（1.54，4.45），P < 0.001]，增加六分钟步行距离[SMD = 2.29，95%CI（0.44，4.13），P = 0.02]，焦虑自评
量表、抑郁自评量表评分降低 [MD = -5.06，95%CI（-6.63, -3.49），P < 0.001]、[MD = -5.12，95%CI（-8.73，
-1.50）P = 0.006]。
结论：当前研究结果显示，八段锦能改善患者心肺功能、提高患者运动耐量、缓解患者不良情绪。

关键词：中医；八段锦；冠心病；Meta 分析

Abbreviations: CHD, Coronary heart disease; 6WMT, 6 minute walk test; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depres-
sion Scale; WHO, World Health Organization; NYHA, American New York Heart Association; CBM, China Biology Medicine disc;
RCTs, Randomized Controlled Trials; WMD, Weighted mean difference; SMD, Standard mean difference; RR, Relative risk; 9. 95%CI,
95% Confidence interval; . LVEF, Left ventricular ejection fraction.
Competing interests: The authors declare that there is no conflict of interests regarding the publication of this paper.
Copyright: © 2019 TMR Publishing Group. This is an open access article distributed under the terms of the Creative Commons Attrib-
ution Non Commercial license.
Executive Editor: Jing Liang
| TMR Integr Nurs | August 2019 | vol. 3 | no. 4 | 134
Gai TT, et al.
1. INTRODUCTION
Coronary heart disease (CHD) is a very common form of clinical
cardiovascular disease, which has become a serious threat to
human health and life safety. More than 17 million patients
worldwide died from cardiovascular disease each year, and it is
estimated that by 2020, 120 million people worldwide will die
from CHD [1, 2]. The incidence of CHD in China is increasing
year by year, which is serious for human life and health. Patients
with CHD are living in a state of life with illness, repeated onset
and repeated hospitalization, which brings huge economic bur-
den and labor loss to the country and the family. At the same
time, most patients have problems such as decreased exercise
tolerance and emotional anxiety, which seriously affects patient
quality of life and social adaptability [3].
The importance of cardiac rehabilitation has been a broad
consensus of all walks of life. The European Society of Cardi-
ology, the American Heart Association, and the American Col-
lege of Cardiology all recommend CHD patients for exercise
rehabilitation at the highest level of scientific evidence (Grade I)
[4 - 7]. Many evidence-based evidences abroad showed that
cardiac rehabilitation with exercise therapy as the core in cor-
recting cardiovascular risk factors, reducing cardiovascular
mortality, and improving the quality of life of patients with car-
diovascular disease [8 - 9]. According to traditional Chinese
medicine, Baduanjin has the benefits of strengthening the mus-
cles and the bones, nourishing the vital energy, speeding up
blood circulation, coordinating the internal organs. Studies have
shown that, insisting on regular exercise of Baduanjin reduced
the blood pressure, blood lipids and blood sugar in exercisers
and promoted the physical and mental health of the elderly. Oth-
er studies have shown that, Baduanjin can improve the cardio-
pulmonary function, restore health and improve the quality of
life of patients with CHD, but most of the existing research is a
small sample, and there is still no evidence of evidence-based
medicine [12 - 19]. Therefore, this study applied meta-analysis
method to further summarize and evaluate the difference in the
rehabilitation effect of Baduanjin in patients with CHD, to pro-
vide reliable evidence for future related research.
2. METHODS
2.1 Inclusion and exclusion criteria
2.1.1 Inclusion criteria. (i) Patients: The World Health Organiza-
tion (WHO) diagnostic criteria for CHD, American New York
Heart Association (NYHA) Ⅰ-Ⅱ, Heart rehabilitation patients
with WHO definition; (ii) Intervention: Intervention time ≥ 2
months, control group: routine intervention measures, and the
trail group performed Baduanjin exercise on this basis; (iii)
Outcomes: Ejection fraction, 6-minute walk test (6WMT),
Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale
(SDS); (iv) Study type. Randomized controlled trials (RCTs)
which were written in Chinese or English published publicly in
major databases at home and abroad.
2.1.2 Exclusion criteria. In the acute phase; patients with severe
diseases; cannot adhere to the completion Baduanjin exerciser.
2.2 Literature identification
| TMR Integr Nurs | August 2019 | vol. 3 | no. 4 |
Effect of Baduanjin on rehabilitation of patients with coronary heart disease
The Cochrane Library, PubMed, EMbase, Web of science, China
Biology Medicine disc (CBM), CNKI, Wan Fang Date and VIP
database, and collect randomized controlled trials of Baduanjin
in patients with CHD from inception to November 2018. The
search term as follows: Qigong, Baduanjin, Eight section bro-
cades, coronary heart disease, CHD, heart disease. The search
strategy determined after many pre-retrievals was conducted by
using the keywords MEDLINE (MeSH), EMBASE (EMTREE),
free words (synonyms or synonyms) and combining them with
Boolean operators. Manually search for references to relevant
literature. The databases were searched up to and including No-
vember 2018 using the search terms presented in Box 1.
#1 Qigong OR Baduanjin OR Ba Duan Jin OR Eight section
brocades
#2 heart disease OR coronary heart disease OR CHD
#3 randomized controlled trials OR randomized*
#4 #1 AND #2 AND #3
Box 1: Search strategy for studies on inter-examiner reliability using medi-
cal subject headings and text words
2.3 Literatures screening and data extraction
Two researchers independently searched, screened, extracted and
cross-checked. First, read the title and abstract of the article in-
dependently. If the inclusion criteria were met, read the full text.
In case of disagreement, the third researcher will assist in decid-
ing whether to include it. The data extraction content mainly
includes: (1) Basic information of the document, the title of the
article, the name of the author, and the time of publication. (2)
The basic characteristics of the research object, sample size, age,
baseline characteristics, etc.; (3) detailed process and details of
the intervention measures; (4) relevant outcome indicators.
2.4 Bias risk assessment
According to RCTs bias risk assessment in Cochrane Handbook
(5.1.0), two reviewers used the tool to evaluate literatures [20].
Mainly contents of assessment including: (1) the generation of
random sequences; (2) allocation concealment; (3) Whether
blind method is adopted; (4) the results of the integrity of the
data, including whether the pre-intervention baseline levels,
consistent quit/lost persons, whether intentional analysis; (5)
whether there are selective reporting findings; (6) whether there
are other sources of offset (whether there are similar baseline
levels).
2.5 Statistic analysis
Meta-analysis of the data was performed using RevMan 5.3
software. Firstly, the chi-square test was used to determine
whether there was heterogeneity between the studies. If P > 0.1,
I2 < 50%, the similar studies were homogenous, and the fixed
effect model was used for meta-analysis; if P ≤ 0.1, I2 ≥
50%, when it is judged clinically that there is consistency be-
tween the groups, a random effect model is selected. Descriptive
analysis should be used if the source of heterogeneity cannot be
judged. For continuous data, such as those obtained by the same
measurement tool, weighted mean difference (WMD) is used for
analysis; if different measurement tools or time are used for the
same variable, standard mean difference (SMD) is used for
135
Gai TT, et al. Effect of Baduanjin on rehabilitation of patients with coronary heart disease

analysis; counting data is analyzed by relative risk (RR); all
analyses are calculated 95% confidence interval (95 % CI).
3. RESULTS
3.1 Results of literatures search
After computer-based retrieval of Chinese and English electronic
databases, there were a total of 144 Chinese and English studies.
Excluding the duplicated and cross-referenced literature and 58
articles that clearly did not meet the inclusion criteria, after
reading the title and abstract, 23 clinical controlled studies were
included, and 8 randomized controlled studies were finally in-
cluded by finding the full text, reading, and quality evaluation
[12 - 19]. A total of 615 patients. The process of screening was
shown in Figure 1.
40 to 70 years old. Intervention time is generally 12 weeks, one
research study intervention time is 8 weeks [14]. Basic charac-
ters of literatures included were presented in Table 1.
According to RCTs bias risk assessment in Cochrane Hand-
book (5.1.0), 8 articles were evaluated by two reviewers. The
details on random methods and procedure were reported in 5
Studies [12, 13, 16, 17, 19]. One research study details the
method of allocation hiding [12]. Due to the nature of the inter-
vention, it was not possible to blind the personnel to the treat-
ment Allocation. Results of bias risk assessment were presented
in Table 2.
3.3 Results of meta-analysis
3.3.1 Left ventricular ejection fraction (LVEF). In this study, four
studies were included to analyze the LVEF, 169 in the trial group
and 166 in the control group [12, 13, 15, 18]. The results of the
meta-analysis of the fixed-effects model (P = 0.62, I2 = 0%)
showed that the ejection fraction of the trial group with Baduan-
jin exercise was significantly better than that of the control
group, and the difference was statistically significant [MD =
2.99, 95%CI (1.54, 4.45), P < 0.0001] (Figure 2).

Figure 2: the effect of left ventricular ejection fraction (LVEF)

3.3.2 Six-minute walk test (6WMT). In this study, three studies

Figure 1: Flow diagram of included and excluded studies
3.2 Basic characteristics and bias risk assessment results in
the study
In this study, a total of 8 studies were included. The publication
time ranged from 2012 to 2018. The ages of sample ranged from
were included to analyze the LVEF, 123 in the trial group and
120 in the control group [12, 14, 18]. The follow-up time and the
unit of major outcomes which were inconsistent, we used the
standardized mean difference and random-effect model (P ＜
0.001, I2 = 97%). The results of the meta-analysis showed that
the six-minute walking distance of the trial group with Baduan-
jin exercise was better than that of the control group, and the
difference was statistically significant [SMD = 2.29, 95%CI
(0.44, 4.13), P = 0.02]. (Figure 3).

Table 1 Basic characteristics of the included studies

Sample Intervention
Author Year Area Times Outcomes
T/C T/C
Yu M 2018 Beijing 60/60 BDJ + CE/CE In a 45-min, twice a week, 12 weeks ①②
Xin YR 2018 Hebei 44/44 BDJ + CE/CE In one hour, three times a week, 12 weeks ②
Li RL 2017 Fujian 30/30 BDJ/WT 8 weeks ①
Shi XM 2017 Tianjin 32/32 BDJ + CE/CE In one hour, three times a week, 12 weeks ②
Wu YH 2016 Hunan 30/30 BDJ + MT/MT In a 45-min, five times a week, 12 weeks ③④
Wang R 2016 Fujian 25/25 BDJ + MT/MT 12 weeks ③④
Xiong XH 2016 Hunan 33/30 BDJ + CE/CE In a 30-min, five times a week, 12 weeks ①②
Lin J 2012 Jiangsu 25/25 BDJ + MT/MT In a 40-min, five times a week, 12 weeks ③④
T: Trail Group; C: Control Group; BDJ: Baduanjin exercise; CE: Conventional exercise; WT: Walking training; MT: Medical treate-
ment; ①6MWT; ②LVEF; ③SAS; ④SDS. LVEF, Left Ventricular Ejection Fraction; 6WMT, 6 Minute Walk Test; SAS,
Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.
3.3.3 Self-Rating Anxiety Scale (SAS). In this study, three stud- 80 in the control group [16, 17, 19]. The results of the me-
ies were included to analyze the SAS, 80 in the trial group and ta-analysis of the fixed-effects model ( P = 0.19, I 2 = 41%)
| TMR Integr Nurs | August 2019 | vol. 3 | no. 4 | 136
Gai TT, et al. Effect of Baduanjin on rehabilitation of patients with coronary heart disease

showed that the SAS score of the trial group was lower than that
of the control group, and the difference was statistically signifi- 3.4 Sensitivity analysis and publication bias
cant [MD = -5.06, 95%CI (-6.63, -3.49), P ＜ 0.001] (Figure By changing the model and eliminating individual studies one
4). by one, a meta-analysis was performed on the remaining studies
to test the stability of the results. After the operation is complet-
3.3.4 Self-rating depression scale (SDS). In this study, three ed, the effect values are relatively close, indicating that the re-
studies were included to analyze the SDS, 80 in the trial group sults of this study are relatively stable. The funnel plot of left
and 80 in the control group [16, 17, 19]. The results of the me- ventricular ejection fraction between the two groups is shown in
ta-analysis of the random-effects model (P = 0.002, I2 = 83%) Figure 6. The funnel plot is more symmetrical, indicating no
showed that the SDS score of the trial group was lower than that significant publication bias (Figure 6).
of the control group, and the difference was statistically signifi-
cant [MD = -5.12, 95%CI (-8.73, -1.50), P = 0.006] (Figure 5).
Table 2 Assessment of bias risk
Integrity of Selective
Study Randomization Allocation Blinded Other origin of risk
outcomes reporting
Yu M 2018 Random number table Allocation Hiding Unclear Integral No Unclear
Xin YR 2018 Random number table Unclear Unclear Integral No Unclear
Li RL 2017 Unclear Unclear Unclear Integral No Unclear
Shi XM 2017 Unclear Unclear Unclear Integral No Unclear
Wu YH 2016 Random number table Unclear Unclear Integral No Unclear
Wang R 2016 Computer random Unclear Unclear Integral No Unclear
Xiong XH 2016 Unclear Unclear Unclear Integral No Unclear
Lin J 2012 Computer random Unclear Unclear Integral No Unclear

Figure 3: The effect of 6 minute walk test (6WMT)

Figure 4: The effect of self-rating anxiety scale (SAS)

Figure 5: The effect of self-rating depression scale (SDS)

| TMR Integr Nurs | August 2019 | vol. 3 | no. 4 | 137

Gai TT, et al.
4. DISCUSSION
CHD has a high incidence of the most vulnerable to disease in
older age groups, and in recent years getting younger and
younger. According to the survey, chronic non-communicable
diseases such as CHD and other cardiovascular diseases are still
the leading causes of death among residents in China and the
world [21 - 22], seriously affecting people's physical and mental
health and quality of life. Based on the basic theory of Chinese
medicine, Baduanjin has a set of fitness exercises compiled with
eight movements. It is easy to learn and has significant medical
and health benefits. In the “Chinese expert consensus on rehabil-
itation and secondary prevention of CHD”, it is pointed out that
traditional Chinese medicine exercises such as Tai Chi and
Baduanjin are beneficial to the recovery of the body function of
patients with CHD [23].
Figure 6: The funnel plot
4.1 Baduanjin exercise can improve cardiopulmonary func-
tion
Patients with CHD are usually accompanied by a decline in car-
diopulmonary function, which seriously affects their viability
[24]. The ejection fraction is a common indicator for judging
cardiac function [25]. The results of this study showed that the
left ventricular ejection fraction of the trial group performed
with Baduanjin exercise was higher than that of the control
group, and there was statistical difference, which was consistent
with the results of Ding X et al. [26]. Baduanjin exercise belongs
to low-intensity aerobic exercise. Periodic aerobic exercise can
change the myocardial micro-structure, make the myocardial
fibers thicker, improve the elasticity of the valve, enhance the
level of sympathetic excitation, increase the catecholamines in
the blood, and then enhances myocardial contractility and im-
proves heart pumping capacity [27]. Yu M tested the lung func-
tion and found that the indicators of Forced expiratory volume
(in one second)/Forced vital capacity, Forced Expiratory Volume
(in one second)/Vital Capacity and maximal voluntary ventila-
tion in trial group were significantly improved compared with
the control group, indicating that Baduanjin exercise has a ten-
dency to improve lung function and more high-quality research
to be verified [12].
4.2 Baduanjin exercise can improve exercise tolerance
| TMR Integr Nurs | August 2019 | vol. 3 | no. 4 |
Effect of Baduanjin on rehabilitation of patients with coronary heart disease
Most patients with CHD have a risk of decreased exercise toler-
ance and loss of self-care ability. 6WMT is simple and easy to
perform, and the intensity is close to the daily activities of pa-
tients with CHD, the exercise endurance prediction and evalua-
tion of patients with CHD are widely used [28]. The results of
this study showed that the six-minute walk test distance of the
trial group with Baduanjin exercise was higher than that of the
control group, and there was a statistical difference. It can be
seen that Baduanjin had a good effect on exercise endurance of
CHD patients after 6MWT measurement. Baduanjin can pro-
mote people's metabolism and improve muscle strength, which
can be one of the suitable and effective ways of exercising CHD
patients.
4.3 Baduanjin exercise can alleviate patients' bad emotions
There are data showing that more than 40% of patients with
CHD have anxiety and depression, and most patients with CHD
have potential anxiety and depression risks [29]. Unfavorable
emotions can lead to excessive stress response, decreased body
resistance, and endocrine dysfunction in patients with CHD,
which not only increase the risk of recurrent CHD, but also in-
crease the incidence of other diseases [30]. The results of this
study showed that the SAS and SDS scores of the trial group
who completed the exercise of Baduanjin were significantly
decreased, and the difference was statistically significant com-
pared with the control group. It requires us to relax into the static
state while exercising Baduanjin. In a completely quiet state, the
patient's autonomic nervous system to relax. With the adjustment
of breathing during exercise, the psychological factors such as
anxiety, depression and nervousness are alleviated and released,
which plays a positive role in the mental health of patients.
5. CONCLUSION
In conclusion, we systematically evaluate the impact of Baduan-
jin exercise on rehabilitation of patients with CHD. As one of the
traditional Chinese medicine rehabilitation therapy exercises,
Baduanjin can improve the cardiopulmonary function, improve
the exercise tolerance and alleviate the bad mood of patients.
Subject to the limitations of sample size and research quality, we
are looking forward to getting the large samples data, mul-
ti-center RCTs, more strictly design and higher methodological
quality to verify the results from this study.
Authors’ contributions
Conceived this editorial: Gai TT and Wang Y.
Searched and sorted information: Gai TT and Cui Y.
Drafted the manuscript: Gai TT, Fan W, Cui Y, Gao MX.
Critically reviewed the whole manuscript: Wang Y.
Approved the authorships and submission: Wang Y and Gai TT.
Acknowledgments
None.
Financial support and sponsorship
None.
Patient consent
Not applicable.
138
Gai TT, et al.
Ethics approval
Not applicable.
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