946695

research-article2020
CRE0010.1177/0269215520946695Clinical RehabilitationChen et al.

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

The effect of Qigong-based 1­–13

© The Author(s) 2020
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DOI: 10.1177/0269215520946695
https://doi.org/10.1177/0269215520946695

Parkinson’s disease: a systematic journals.sagepub.com/home/cre

review and meta-analysis

Shihui Chen1, Yanjie Zhang2,3 , Yong Tai Wang4,

Xiaolei Liu5, Wook Song2,6 and Xiru Du7

Abstract
Objective: This study was to evaluate the effects of Qigong on clinical motor symptoms, walking ability,
and balance of patients with Parkinson’s disease.
Data sources: Seven electronic databases (MEDLINE, Web of Science, CINAHL, SportDiscus, Scopus, China
National Knowledge Infrastructure, and Wanfang Database) were searched from inception to June 28, 2020.
Methods: Two reviewers independently selected and extracted the data from studies with randomized
controlled trial, and effect sizes were calculated by employing random-effect models with 95% confidential
interval (CI). We used Physiotherapy Evidence Database scale to evaluate the quality of included studies.
Results: A total of seven studies with 325 participants (180 males and 145 females) were included in this meta-
analysis. Results of this meta-analysis showed that Qigong had significantly positive effects on motor symptoms
(SMD = 0.59, 95% CI [0.24, 0.93]), walking ability (SMD = 0.78, 95% CI [0.10, 1.47]), and balance (SMD = 0.72,
95% CI [0.23, 1.20]) in patients with Parkinson’s disease. Subgroup analysis showed Qigong exercise had
significant difference on improving motor symptoms and walking ability compared to passive control (P < 0.01),
and no significant difference compared to active control. Subgroup analysis of Qigong exercise revealed a
significant difference on balance compared to both active and passive control (P < 0.05). In addition, meta-
regression result indicated that the effect of Qigong exercise on motor symptoms was influenced by age.
Conclusion: The findings from current meta-analysis supported Qigong exercise as a beneficial
alternative therapy may contribute to increasing motor function, walking ability, and balance for patients
with Parkinson’s disease.

1 6
 epartment of Kinesiology, Texas A&M University
D Institute on Aging, Seoul National University, Seoul,
Texarkana, TX, USA South Korea
2 7
Health and Exercise Science Laboratory, Institute of Sports College of Sport Arts, Guangzhou Sport University,
Science, Seoul National University, Seoul, South Korea Guangzhou, Guangdong, China
3
Physical Education Unit, School of Humanities and Social
Corresponding author:
Science, The Chinese University of Hong Kong–Shenzhen,
Yanjie Zhang, Health and Exercise Science Laboratory,
Shenzhen, Guangdong, China
4 Institute of Sports Science, Seoul National University, 1
College of Nursing and Health Sciences, University of Texas
Gwanak-ro, Gwanak-gu, Seoul, 08826, South Korea.
at Tyler, Tyler, TX, USA
5 Email: zhangyanjie@cuhk.edu.cn
Chinese Traditional Regimen Exercise Intervention Research
Center, Beijing Sport University, Beijing, China
2 Clinical Rehabilitation 00(0)
Keywords
Qigong, motor impairment, walking endurance, balance, Parkinson’s disease
Received: 17 November 2019; accepted: 10 July 2020
Introduction
Qigong, as a special physical therapeutic exercise,
is derived from traditional Chinese medicine,
combining the various posture movements and
breathing techniques with meditation.1,2 The most
popular health Qigong has been recognized by the
Chinese Health Qigong Association, including
Muscle-Tendon Change Classic (Yi Jin Jing), Five
Animals (Wu Qin Xi), Eight Section Brocade
(Baduanjin), Twelve Section Brocade (Twelve
Duanjin) and Da Wu.3,4 These movements empha-
size the same underlying principles by combining
two elements: Qi (vital energy) and Gong (skill of
working with the Qi). Qigong is considered an
“energy practice” or “energy cultivation” exercise,
it is thought to benefit health by relieving block-
age which may lead to stagnant Qi.5
Previous findings suggested Qigong intervention
offers benefits to balance, cardiopulmonary fitness
and functional capacities, both in healthy adults or
chronic heart disease patients.6,7 Considering the
curative effect of Qigong exercise in curing medical
ailments, recent studies reported promising results
by investigating the efficacy of Qigong exercise in
Parkinson’s disease.8–10 However, there is a lack of
robust evidence for systematic review to evaluate
the efficacy of Qigong exercise against Parkinson’s
disease. For example, a review study showed that
insufficient evidence was found to support the posi-
tive effects of Qigong plus medication on Motor
symptoms and quality of life, due to the limitation of
two studies.11 Subsequently, one recent meta-analy-
sis by Kwok et al.12 employing mind-body exercise
(Tai Chi, Qigong, and Yoga), which did not prove
whether Qigong is effective against Parkinson’s dis-
ease because of very few related articles. Thus, there
was lacking of a systematic review and meta-analy-
sis study about the effect of Qigong exercise on
Parkinson’s disease.
Given the expansion of research in the field of
Qigong intervention over the past years, the bene-
fits of Qigong-based exercise in patients with
Parkinson’s disease have not been systematically
evaluated. To fill this gap, the purpose of this study
was to use systematic review with meta-analysis to
investigate the exclusive efficacy of Qigong exer-
cise on motor function, walking ability, and balance
in adults with Parkinson’ disease.
Methods
The study was conducted in accordance with the
Preferred Reporting Items for Systematic Reviews
and Meta-analysis (PRISMA) guidelines,13 except
no registration before the study began. Literature
search from seven databases (MEDLINE, Web of
Science, CINAHL, SportDiscus, Scopus, China
National Knowledge Infrastructure, and Wanfang
Database) was extensively conducted from incep-
tion to June 28 2020. The following keywords were
used to obtain potential articles: Qigong, Baduanjin,
Yijinjing, Wuqinxi, Parkinson disease, and
Parkinson*. In addition, we also searched manu-
ally the relevant studies from the reference lists.
All these articles were published in English or
Chinese language.
The included articles met the following inclu-
sion criteria: (1) participants with diagnosed
Parkinson’s disease; (2) designed randomized
controlled trial (RCT); (3) Qigong-based exercise
(Baduanjin, Yijinjing, Wuqinxi, etc.) to treat
Parkinson’s disease in experimental group; (4) no
intervention or exercises (e.g. walking) other than
Qigong in control group; (5) reported at least one
of outcome measures, such as motor symptoms,
walking ability, balance; and (6) provided suffi-
cient data to calculate the effect size. The studies
were excluded if: (1) the subjects’ pathology was
a condition other than Parkinson; (2) presence of
other complications of chronic diseases; (3)
repeatedly published study; (4) other types of
publications (i.e. abstracts, case study, and
reviews studies); and (5) published in non-Eng-
lish or non-Chinese journals.
Chen et al.
The process of literature searches and duplicates
were conducted by two authors, they independently
selected the eligible articles after screening the
titles, abstracts and even the full-text articles. The
third author provided advice to reach a consensus
when there were disagreements on the inclusion or
exclusion of articles occurred between the two
authors.
Two reviewers independently performed to
extract data from each eligible article, including
characteristics of the author and year of publication,
subjects’ characteristics, study design, interventions
and outcome measures (e.g. motor symptoms, walk-
ing ability, balance). Any disagreements between
two reviewers was solved by discussing with the
third author. Subsequently, methodological assess-
ment for each included article was independently
assessed by two reviewers using the Physiotherapy
Evidence Database (PEDro) scale.14 The maximum
score of PEDro scale was 10 points, and the score of
9–10 points, 6–8 points, 4–5 points and <4 points
were categorized as excellent, good, fair, and poor
quality respectively.
The comprehensive meta-analysis software (V2
software, Biostat, NJ) was employed to perform
the current meta-analysis. The Q-test and the I2
were employed to rate heterogeneity of combined
studies. The I2 statistic was calculated to measure
the effect of heterogeneity. The values for I2 at
25%, 50%, and 75% indicates low, moderate, and
high heterogeneity, respectively.15 If the heteroge-
neity was found, the random-effects model was
conducted to calculate the pooled effect size (ES)
of Standardized mean difference (SMD) with 95%
confidence interval (CI) that was used to assess the
change of outcome scales between groups. A posi-
tive value for ES indicates more favorable outcome
scores for the group of interest, a negative ES indi-
cates more favorable outcome for the control
group. Usually, researchers define ES as small
(0.2 < ES < 0.4), moderate (0.4 < ES < 0.6) and
large (ES > 0.6) with P < 0.05.16,17 The synthesized
results were presented in forest plots. Funnel plot
and Egger’s regression asymmetry test were
employed to examine the publication bias.18
Furthermore, sub-analyses were performed to
compare categorical variable (active vs passive
3
controls). And meta-regression was used to exam-
ine the mediating effect of age on motor symptoms
and Qigong exercise.
Results
We retrieved 728 articles from seven electric data-
bases and manual searches from bibliography lists
following the PRISMA guideline (Figure 1). There
were 609 articles after removing duplicates
(n = 119). The abstracts and titles of these records
were then screened, the remaining articles (n = 31)
were further assessed for eligibility according to
their full-texts. Finally, seven studies19–25 met the
inclusion criteria in this meta-analysis.
The seven studies including a total of 325 sub-
jects were summarized in Table 1. They were pub-
lished between 2006 and 2019. Sample size of
included studies ranged from 26 to 96 patients who
were adults (Male = 180, Female = 145). Mean ages
of the participants ranged from 57 to 67.5 years. All
the patients with Parkinson’s disease (Hoehn and
Yahr stage ranging from 1 to 4) were allowed to
take anti-Parkinson medication throughout the
studies, except for one study.21 Qigong interven-
tions (e.g. Baduanjin, Wuqinxi) were used in
experimental group for more than 8 weeks (from
8 weeks to 48 weeks), and practiced 2 to 7 times per
week. The time of each session was at least 30 min-
utes (from 30 minutes to 120 minutes). There were
three main outcome measures among the eligible
studies: (1) Level of motor symptoms was assessed
using the Movement Disorders Society-Unified
Parkinson’s disease Rating Scale Part III scale. (2)
Walking ability was assessed using the 6-m walk-
ing test and 10-m walking test. (3) Balance ability
was assessed using the Berg Balance Scale. All
studies reported no adverse effects during Qigong
intervention.
The methodological assessment of each study
was shown in Table 2. Six studies were classified as
good quality with low risk bias.19–21,23–25 According
to the assessment scale, all included studies described
the random allocation, similar key measures at base-
line, >85% of retention rate, statistical comparison
for measures between groups, and point estimates
and measures of variability. Nevertheless, the
4 Clinical Rehabilitation 00(0)
Figure 1. Process of study selection following the PRISMA.
concealed allocation was reported in four included
studies.19,20,23,25 The assessor blinding19,21,24 and
intention-to-treat analysis20,21,24 were reported in
three included studies, respectively. The quality of
included studies were from fair to good with score
ranging from 5 to 7 points.
Seven studies used the Movement Disorders
Society-Unified Parkinson’s disease Rating Scale-
III to assess the effect of Qigong on motor symp-
toms of patients with Parkinson’s disease. The
pooled meta-analysis results (Figure 2) indicated
that Qigong had a significant improvement on
motor symptoms for Parkinson’s disease patients
compared with the control group. Furthermore, the
Egger’s test indicated that no publication bias was
observed on motor symptoms of Parkinson’s dis-
ease patients. But the funnel plot was not sym-
metrical (Figures 3). It was likely that the limited
number of included studies and the heterogeneity
between studies caused the unsymmetrical plot.
 Chen et al.

Table 1. Characteristics of eligible RCTs included in meta-analysis.

Author Participants HY stage Mean age Medicine Duration Intervention Outcome measures Side effect
(year) (weeks) (instrument)
Experiment Control
19
Burini PD 2.5 65.2 Anti-Parkinson 7 Qigong (Guolin): Aerobic (cycle Motor function UPDRS III No
n = 26 (9M, 17F) medication 50 min/3 times/week ergometer): Balance BBS
45 min/3 times/week Walking ability 6MWT
Schmitz-Hübsch20 PD 1–4 63.8 Anti-Parkinson 8 Qigong (Baduanjin): No intervention Motor function UPDRS III No
n = 56 (43M, 13F) medication 60 min/2 times/week
Xiao21 PD 2.2 67.5 None 24 Qigong (Baduanjin): Walking: Motor function UPDRS III No
n = 96 (67M, 29F) 45 min/4 times/week 30 min/7 times/week Balance BBS
Walking ability 6MWT
Liu22 PD 2.6 57.1 Anti-Parkinson 10 Qigong (Baduanjin): No intervention Motor function UPDRS III No
n = 41 (15M, 26F) medication 60 min/5 times/week Balance BBS
23
Guo PD 2 64.5 Anti-Parkinson 12 Qigong (Baduanjin+Wuqinxi): No intervention Motor function UPDRS III No
n = 40(16M, 24F) medication 120 min/2 times/week Walking ability 10MWT
+60 min/5 times/week
Lee24 PD 1–3 65.7 Anti-Parkinson 8 Qigong (Qi dance): No intervention Motor function UPDRS III No
n = 32 (17M, 15F) medication 60 min/2 times/week Balance BBS
Zhang25 PD 1–3 65 Anti-Parkinson 48 Qigong (Wuqinxi): No intervention Motor function UPDRS III No
n = 34 (13M, 21F) medication 60 min/2 times/week Balance BBS
Walking ability 10MWT

M: male; F: female; HY: Hoehn and Yahr; 6MWT: 6-minute walk test; 10MWT: 10-minute walk test; BBS: Berg Balance Scale; PD: Parkinson’s disease; RCT: randomized controlled trial; UPDRS III:
movement disorders society-unified Parkinson’s disease Rating Scale-III.
5
6 Clinical Rehabilitation 00(0)

Table 2. Methodological quality of the included studies (PEDro analysis).

Study Score Methodological PEDro item number

quality
1 2 3 4 5 6 7 8 9 10 11
Burini19 7 Good + + + + + + + +
Schmitz-Hübsch20 7 Good + + + + + + + +
Xiao21 7 Good + + + + + + + +
Liu22 5 Fair + + + + + +
Guo23 6 Good + + + + + + +
Lee24 7 Good + + + + + + + +
Zhang25 6 Good + + + + + + +

Studies were classified as having excellent (9–10), good (6–8), fair (4–5) or poor (<4) quality. Scale of item score: +, present.
The PEDro scale criteria are (1) eligibility criteria; (2) random allocation; (3) concealed allocation; (4) similarity at baseline on
key measures; (5) participant blinding; (6) instructor blinding; (7) assessor blinding; (8) more than 85% retention rate of at least
one outcome; (9) intention-to-treat analysis; (10) between-group statistical comparison for at least one outcome; and (11) point
estimates and measures of variability provided for at least one outcome.

Figure 2. Forest plot for the effect of Qigong intervention on motor symptoms.

Considering that the active intervention (i.e. walk-
ing) was used in control group, a subgroup analysis
was conducted to investigate the effect of Qigong on
motor symptoms through comparing with the differ-
ent interventions (Figure 4). Two sets of data were
collected from active interventions, and five sets of
data were collected from no-interventions. The syn-
thesized result showed that Qigong intervention pro-
duced a significant improvement on motor symptoms
compared with the passive intervention.
Four studies assessed the walking ability using
6-m walking test and 10-m walking test (Figure 5).
Compared with control group, the pooled results
indicated that there was significant improvement
on walking ability through practicing Qigong exer-
cise compared with control group (Figure 5). The
Egger’s test indicated that no publication bias was
observed on walking ability of Parkinson’s disease
patients. But the funnel plot was not symmetrical
(Figures 6). It was likely that the limited number of
included studies and the heterogeneity between
studies caused the unsymmetrical plot. Moreover, a
subgroup analysis result demonstrated a significant
improvement on walking ability was favor of the
Chen et al. 7

Figure 3. Funnel plot for the effect of Qigong on motor symptoms compared with control group.

Figure 4. Forest plot for the effect of Qigong on motor symptoms compared with active intervention and no-
intervention group.

Qigong intervention compared with the passive
intervention (Figure 7).
Figure 8 depicts the forest plot of five trials
reporting the balance using the Berg Balance Scale.
The synthesized results showed that Qigong has a
significant larger effect on balance for Parkinson’s
disease but with moderate heterogeneity. The
Egger’s test indicated that no publication bias was
observed on balance of Parkinson’s disease patients.
But the funnel plot was not symmetrical (Figures 9).
It was likely that the limited number of included
studies and the heterogeneity between studies
caused the unsymmetrical plot. Furthermore, sub-
group meta-analysis results revealed that signifi-
cant advantageous effects of Qigong exercise over
both active intervention and passive intervention in
8 Clinical Rehabilitation 00(0)

Figure 5. Forest plot for the effect of Qigong intervention on walking ability.

Figure 6. Funnel plot for the effect of Qigong on walking ability compared with control group.

improving of balance in Parkinson’s disease patients
were observed (Figure 10).
Additionally, meta-regression analysis showed
that age negatively influenced the effect size of
motor symptoms (β = −0.118, P < 0.01) (Figure 11),
indicating that Qigong exercise had a decreased
effect on motor symptoms with advancing age.
Discussion
To our knowledge, the present study is the first com-
prehensive systematic review and meta-analysis study
to examine the effects of Qigong-based RCTs on
adults with Parkinson’s disease (Hoehn and Yahr: 1–4
stage). Our findings suggested that Qigong exercise
may result in significant improvements in motor
symptoms, walking ability and balance for Parkinson’s
disease patients. There were no negative reports in
terms of Qigong exercises from the included studies,
therefore, the Qigong-based exercises could be inte-
grated as one of therapeutic treatments to promote the
motor functions of patients with Parkinson’s disease.
The previous study shows that Parkinson’s
disease patient is associated with obvious
Chen et al. 9

Figure 7. Forest plot for the effect of Qigong on walking ability compared with active intervention and no-
intervention group.

Figure 8. Forest plot for the effect of Qigong intervention on balance.

symptoms in resting tremor, bradykinesias,
rigidity and declined postural reflexes,26 which
compromise patient’s physical performance.
Qigong-based exercise may alleviate these
symptoms by relaxing mind and body muscles,
and improving physical functions.27 The results
of this study confirmed these findings, and indi-
cated that Qigong-based exercise could signifi-
cantly improve the motor symptoms and walking
ability of patients with Parkinson’s disease.
Although some of the findings from our study
were inconsistent with previous study11 that
reported no significant differences between
Qigong and other therapy treatments on motor
symptoms and walking ability. Our beliefs are
based on the seven good quality Qigong-based
RCTs studies with larger effect sizes as evidence
to support our conclusions.
In addition, our study also separated no-inter-
vention controlled group and active controlled
group to examine the effect of Qigong exercise
on motor symptoms by the categorical analysis.
Results showed that a significant larger effect
(ES = 0.78) of Qigong exercise in improvement
of motor symptoms was observed compared with
the passive intervention, but no significant advan-
tage over active exercise intervention. Our find-
ings, however, provide a strong evidence to
support that the alternative application of Qigong-
based exercise in active intervention can restore
10 Clinical Rehabilitation 00(0)

Figure 9. Funnel plot for the effect of Qigong on balance compared with control group.

Figure 10. Forest plot for the effect of Qigong on balance compared with active intervention and no-intervention
group.

the motor symptoms of patients with Parkinson’s
disease.
Furthermore, we found that there was a signifi-
cant association between alleviating motor symp-
toms and patients’ age. A meta-regression analysis
showed a tendency that Qigong exercise had a
decreased effect on motor symptoms with aging,
although there were limited number of studies.
This finding is consistent with the previous study
that patient’s age of Parkinson’s disease contrib-
utes a major factor for disease severity.28
Concurrently, given that previous review11 did
examine the effect of Tai Chi exercise on walking
ability and balance, the present study showed
similar results that Qigong-based exercise could
provide significant benefits to patients with
Parkinson’s disease in improving walking ability
and balance. Although the different interventions
Chen et al.
Figure 11. Association between mean age and motor symptoms changes in studies of Qigong exercise.
were applied in control group, the results consist-
ently showed that Qigong-based exercise was
superior to passive intervention to improve walk-
ing ability, and was superior to both active inter-
vention and passive intervention to improve
balance in Parkinson’s disease patients. These
results also mean that Qigong exercise can
improve aerobic endurance and reduce the risk of
falling through elevating their walking and bal-
ance ability,27,29 eventually resulting in significant
improvement in the quality of life for Parkinson’s
disease patients.
Based on the beneficial effects of Qigong-based
exercise in this current study, some possible ration-
ales may be explained these findings. Muscle ten-
sion caused by an uncoordinated contraction of
active and antagonistic muscles influences a series
of motor symptoms of patient with Parkinson’s dis-
ease. Given that the movements of Qigong exercise
includes physical coordination, self-massage,
weight-shifting and continuous along with breathing
and relaxation training throughout the whole process
of Qigong practice.30 Long-term practicing Qigong-
based exercise can enhance patients’ mind-body
connection and improve the synergistic contraction
of active muscles and antagonist muscles possibly
by activing body function through vital energy (Qi)
11
in Qigong exercise.31 Moreover, continuous motor
changes and stimulation during practicing Qigong
can activate more muscle activity contributing to
improving motor function.32
There are several inevitable limitations in our
study. (1) Qigong-based exercise includes many
different styles, to some extent, difference in
Qigong exercise program may result in variability
between studies, which may affect the accuracy of
the results.33 (2) the method of combination of
Qigong-based exercise and anti-Parkinson medi-
cation was used in almost of studies, it may be dif-
ficult to conclude whether the beneficial effects
were attributed to Qigong-based exercise alone, or
a synergy of the two variables. (3) due to lack of
follow-up studies, it is not clear how long the
effects of Qigong intervention will last in patients
with Parkinson’s disease. The previous study was
also with the same limitations.11
In conclusion, the present study provides the latest
evidence to support the implementation of Qigong-
based exercises as alternative treatment to promote
motor function, walking ability, and balance in adults
with Parkinson’s disease. Recommendations regard-
ing the Qigong-based exercise and its effect on other
outcomes, such as falls risk, sleep quality and aerobic
functions, are also made for the future studies.
12
Clinical messages
•• Qigong-based exercise can improve motor
symptoms, walking ability and balance for
Parkinson’s disease patients.
•• Qigong-based exercise as a safe/alterna-
tive therapy treatment can be integrated
into daily Parkinson’s disease to promote
their quality of life.
•• The effects of Qigong exercise on motor
symptoms decline with aging.
Authors’ contributions
S.C. and Y.Z. contributed to study conception; S.C.,
X.L. and Y.Z. contributed to search strategy, study selec-
tion and data extraction; S.C., X.L. and Y.Z. contributed
to article assessment; and S.C., Y.W. and Y.Z. contrib-
uted to manuscript preparation. All authors analyzed the
results, and revised the final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iD
Yanjie Zhang https://orcid.org/0000-0002-7964-2326
Supplemental material
Supplemental material for this article is available
online.
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