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How to study the relationship between Tai Chi Chuan, Qigong and medicine – A review of research frameworks
Accepted Manuscript Title: How to study the relationship between Tai Chi Chuan, Qigong and medicine − a review of research frameworks Author: Pedro Jes´us Jim´enez Mart´ın Haoqing Liu Agust´ın Mel´endez Ortega PII: DOI: Reference:
S1876-3820(16)30412-7 http://dx.doi.org/doi:10.1016/j.eujim.2016.11.012 EUJIM 620
To appear in: Received date: Revised date: Accepted date:
5-6-2016 10-11-2016 11-11-2016
Please cite this article as: Mart´ın Pedro Jes´us Jim´enez, Liu Haoqing, Ortega Agust´ın Mel´endez.How to study the relationship between Tai Chi Chuan, Qigong and medicine − a review of research frameworks.European Journal of Integrative Medicine http://dx.doi.org/10.1016/j.eujim.2016.11.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
How to study the relationship between Tai Chi Chuan, Qigong and medicine - a review of research frameworks
Pedro Jesús Jiménez Martín Faculty of Physical Activity and Sport Sciences Madrid Polytechnic University C/ Martín Fierro, 7, 28040, Madrid. Spain E-mail: [email protected]
Haoqing Liu Founder and Director of the Higher School of Chikung-Taichi C/ Modesto Lafuente, 10, Bajo C. 28010. Madrid. Spain E-mail: [email protected]
Agustín Meléndez Ortega Faculty of Physical Activity and Sport Sciences Madrid Polytechnic University C/ Martín Fierro, 7, 28040, Madrid. Spain E-mail: [email protected]
Abstract Introduction: International organisations have included Tai Chi Chuan (TCC) and Qigong (QG) under the heading of “Traditional and Complementary Medicine” (TCM). The WHO (2002) definition of TCM not only includes the maintenance of health, but also prevention, diagnosis, improvement and the physical and mental treatment of disease. This study aims to review the research frameworks proposed in the scientific literature to approach TCC and QG theoretically as objects of research and ascertain if they have considered the conditions which should be taken into account when associating both activities with the concept of “medicine”. Method: Eight electronic data bases were searched in publications up to January 2016 Results: The research frameworks used to analyse TCC as a research object, focussed on the improvement of research designs, the identification of the variables pertaining to TCC which could condition the interpretation of the study results and the justification of its efficiency, effectiveness and costs. The article on QG is centred on the need to improve the research designs. Conclusion: The research frameworks proposed in the literature still have not addressed the conditions which permit the association of Tai Chi Chuan and Qigong with “medicine”. It is therefore important to begin to debate this question and analyse if by modifying the practice of TCC to embrace the principles of QG, (a practice traditionally associated with Chinese medicine), it will be able to offer similar or greater benefits than when practised as a martial arts or sports modality, or than other healthy physical activity programs. Key Words: Health, Chinese Medicine, Body-Mind Therapies, Energy Medicine, Tai Chi, Qigong, Complementary and Alternative Medicine; Research Methodology.
1. Introduction The World Health Organisation (WHO) has highlighted its interest in “Traditional and complementary medicine” (TCM) with the publication of two documents (published in 2002 [1] and 2013 [2]) describing its strategic objectives to situate this sector within the national health systems of different countries worldwide. Following the same tendency, in several countries various institutions and projects are being established to regulate, investigate and guide this sector. For example, the National Center for Complementary and Integrative Health (NCCIH) was created in
1999 in the United States of America [3,4]; the CAMbrella project was carried out in the European Union between 2010 and 2012 including researchers and academics from 12 European countries [5]; and the Cochrane Library Central Register of Controlled Trials (CENTRAL) [6] and the ISI Web of Knowledge [7] have included articles on this topic in their search results, thus showing the importance that it is acquiring at the scientific level. It is important to underline that in all these institutions and projects there is evidently a great need and concern to order and regulate this sector appropriately. There is concern to avoid fraudulent practices, create regulations, ensure the safety of the patient receiving treatment, confirm the real health benefits provided, improve the research, raise the level of qualifications of the professionals and establish a consensus on the terminology used. These are requirements which will not only enhance the prestige of these activities but will also help to eliminate “prejudice” and “rejection” on the part of many professional in the medical and scientific sectors. The same issue exists when the practice of Tai Chi Chuan (TCC) and Qigong (QG) are considered in the context of “medicine”: there is a large variety of activities or systems [8], insufficient regulation of professional practice and training, a need to recognise that adverse effects have been evident due to poor practices [8-12], and certain difficulties in scientifically confirming the real and potential scope of these activities for health and the treatment of disease. Faced with this reality, different authors are publishing articles with proposals for ordering, harmonising, improving and supporting the research and initiatives which are being undertaken with respect to TCC and QG [13-20]. These proposals perhaps arise from an awareness that not only the integration of these activities in health institutions,
but also their inclusion in the health programmes offered by physical activity and sports institutions, will depend on correctly resolving these issues. The aim of this study is to review the theoretical research frameworks which have been proposed in the scientific literature to situate TCC and QG as objects of study, and ascertain if they satisfy the conditions which should be taken into account when associating both activities with “medicine”. We understand medicine as it is defined by the WHO (2002) [1] “Traditional Medicine is the sum total of the knowledge, skills, and practices based on the theories, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as the prevention, diagnosis, improvement or treatment of physical and mental illness”, but also as an integrative medicine that connects conventional medicine with evidence-based complementary medicine. When the WHO includes TCC and QG in this definition, and also suggests including these practices in the national health systems, it is clear that it does not just consider the potential of both activities for wellness but also for treating “disease” with specific protocols and therefore going beyond the health benefits which any other physical sports activity can offer. 2. Methods 2.1. Eligibility Criteria We search for studies which presented a proposal for analysing how to approach TCC and QG as “research objects”, from an “outside point of view”, going beyond finding evidence on their possible beneficial effects, and selected articles which focussed on analysing the paradigms of context approach or research frameworks. 2.2. Search Strategy
Eight electronic data bases: Medline-Pubmed, Scirus, Cochrane, Pascal, ScienceDirect, SportDiscuss, Science Citation Index, Google Scholar and BIOSIS were used indicating the key words “Tai Chi” or “Tai Chi Chuan” or “T´ai Chi” or “Taiji” or “Tai Ji Quan” or “Qigong” or “Chikung” and “Challenges” or “Map” or “Scientific Research” or “Framework”, searching publications dated up to January 2016. 2.3. Study Selection Two researchers independently analysed the studies found to determine their inclusion and any disagreement was resolved by discussion. Although it was decided to discard the systematic reviews and meta-analysis of TCC and QG because they were considered to focus exclusively on presenting their conclusions on evidence of their beneficial health effects, three “meta-review” have been included (two on TCC and one on QG) which offered a very complete synthesis of all the existing problems with regard to the research design, and described how to approach reviews and meta-analyses by establishing an appropriate context for these activities. We have also included an article suggested by one of the peer reviewers.
Please insert Table 1 here.
Studies were excluded which were not published in English, together with abstracts, posters, and summaries from conferences, almost all systematic reviews and metaanalyses because the present article aims to identify the research frameworks which analyse how these activities should be researched and not the “final product” i.e. their health benefits. Original studies which were carried out in the context of theories of complexity taking it for granted as the best research approach, and studies on adherence
to these activities which often included the term “framework” in their contents, were also omitted.
Please insert Fig. 1 here. 3. Results Seven articles were found which fulfilled the inclusion criteria: 5 on TCC, 1 on QG and 1 on TCC and QG. The research frameworks used to analyse TCC as a research object, focussed on the improvement of research designs, the identification of the variables pertaining to TCC which could condition the interpretation of the study results and the justification of its efficiency, effectiveness and costs. The article on QG is centred on the need to improve the research designs. a) Improvement of research designs: The main criticism of the research on these activities is that in spite of the volume of studies carried out, there is still only limited confirmation of their benefits. There are three main causes of this problem: the low quality of the research designs, the limitations in the methodology and the great heterogeneity they present. For example, there are at least 14 meta-analyses and 107 systematic reviews on TCC [14] and 2 meta-analyses and 20 systematic reviews on QG [15], published in English and Spanish. Topics covered are as varied as psychological effects and quality of life of the practitioners; improvement in the problems of pain, stiffness and function in knee osteoarthritis; balance and reduction in falls; improvement of aerobic capacity and the prevention of cardiovascular problems; increases in strength; diabetes; sleep; osteoporosis and rheumatoid arthritis; cancer and enhancement of the immune system; and fibromyalgia. A large number of these reviews, in fact, state that although there appears to be a positive influence on health in the variables analysed, and defend that these activities
can be non-pharmacological alternatives for treating determined pathologies, the deficiencies in the research designs of many studies are important enough to preclude their being able to strongly attest to the benefits affirmed. These deficits include small samples, omission of the inclusion and exclusion criteria for the participants, dropouts, poor protocols, inadequate controls, deficient statistical analyses, multiplicity in the research instruments used, a limited number of randomised controlled trials (RCTs), etc. [13-15]. The problem is aggravated when works like that of Lee, Oh and Ernst [16] underline that some of the systematic reviews on QG also reveal important deficits with regard to the low quality of the studies included and the methodology used to analyse them. And when other authors like Burschka et al. [13] state that the standard review instruments used (CONSORT, Jadad Score, PEDro rating scale, NICE, Delphi criteria list, ABC, etc.) focus exclusively on the reporting or assessment of research methods and omit fundamental aspects related to the activity itself: style practised, dose, experience of the instructors, posture height, time to execute each form, etc. In an attempt to correct these problems in the context of TCC, Wayne and Kaptchuk [18,19] present: 1) the research designs that would be the most suitable in these projects (RTCs that evaluate pragmatic and fixed protocol interventions, alongside communitybased observational studies, cross-sectional studies of long-term practitioners, and qualitative research; 2) some of the inherent aspects in the activity which condition the research designs and intervention protocols (Tai Chi pluralism, dosage, long-term versus short-term evaluations of efficacy and safety, and the benefits and limitations of commonly employed clinical research methods). b) Identification of the variables involved in TCC: From another viewpoint, Burschka et al. [13] and Wayne and Kaptchuk [18,19] underline that TCC (and we
would add QG) is a complex phenomenon which embraces such a diversity of physiological, psychological and ritual variables that to understand its potential in its entirety it is necessary to change the methodological research paradigm from the predominant reductionist vision of “linear” cause and effect, which can be observed in almost all the research, to the systemic vision of “circular” cause and effect contributed by complexity and ecological theories. Wayne and Kaptchuk [18,19] identify eight variables or “therapeutic components”, which in their opinion are those which characterise TCC as a complex ecological reality: 1) musculoskeletal strength, flexibility and efficiency; 2) breathing; 3) concentration, attention, and mindfulness; 4) imagery, visualisation, and intention, 5) physical touch and subtle energy, 6) psychosocial interactions; 7) alternative health paradigm and philosophy; and 8) rituals, icons, and environment. Larkey et col. [17] identify a set of key elements which they consider would help to clarify how TCC and QG can affect health outcomes in similar, and perhaps different ways compared to conventional exercise: type and degree of meditative focus, type of movement, description of breathing, and achievement of relaxed state. “Elements” which would mean that both activities could be identified as a new category of exercise, called “Meditative Movement” which would make available the necessary information to begin to compare findings across studies. c) Efficiency, Efficacy and Cost. Harmer [20] adds another aspect with regard to understanding the limitations which research faces in this field: the difficulty that TCC encounters to be officially incorporated into the health programmes offered by government and private agencies. He underlines the gulf which exists between the high level of interest these activities are attracting in medical researchers, clinicians and the
general public and the reluctance of funding agencies to promote large-scale TCC programmes. He cites the heterogeneity of the research as the cause. His solution is to introduce the concepts of “efficacy”, “effectiveness” and “costeffectiveness” which are used with reference to TCM into the field of TCC. “Efficacy”, in the sense of definitively confirming its positive effects using appropriate research designs, and if possible, randomised controlled trials; “effectiveness”, with regard to showing the acceptance and value attributed to these activities by the general population; and “cost-effectiveness”, by showing evidence of both the savings and the economic benefits that TCC and QG can contribute to the institutions which promote them.
4. Discussion Although the “context approach” has given rise to very important initiatives to give more robustness to research into these activities, we do not consider that they solve the problem of identifying the research framework that best adapts to TCC and QG when they are associated with the concept of “medicine”. It is important to tackle this question as both TCC and QG have been included in TCM under the heading of “Traditional Chinese Medicine” [1,2], or “Mind-body Medicine” in the case of TCC or “Energy Medicine” with regard to QG [3,4]. We consider that to state that both activities can act as “medicine” is a very serious matter as it presupposes not only that both TCC and QG can contribute to improving or treating diseases, but also that their scope goes beyond the health benefits that are provided by a multitude of other healthy physical and sports activities. If their therapeutic capacity is simply associated with improving health, all the healthy physical
and sports activities that are being offered should also be included under the umbrella of TCM if they provide the same benefits. For example, although Lan et col. [21] have published an article to show what is happening with TCC in medicine and health promotion, their work is focussed on discovering the different benefits that this activity brings to these areas, without questioning if these same benefits could be achieved with other different health-oriented physical and sports activities, or with activities which follow a smooth and slow pattern of exercise like TCC or QG. To achieve adequate contextualisation of how to analyse the relation of QG and TCC with “medicine”, two important questions must be answered:
4.1. How are QG and TCC related to “medicine”? The answer to this question lies in the historical evolution of both activities. The word “qigong” is a modern term which appeared in the year 1949. From a historical point of view, this term only appeared before in a totally exceptional and marginal manner in a Taoist text from the Tang dynasty (618–910 A.D.) and in another from the Song dynasty (960–1279 A.D.) with the meaning of “breathing techniques” [8]. The first name which was used in Chinese history to designate the different systems of health oriented energy body practices was “Yang Sheng”, as it was recorded for the first time in the work of the philosopher Zhuang Zi supposedly written in the Warring States period (484–221 B.C.)in the Eastern Zhou dynasty (771–221 B.C.) [22-24]. In that era, this term was actually used to designate a set of practices oriented towards personal health and included not only physical exercises with therapeutic aims but also diet, sexual hygiene, emotional self control and sleep, and the promotion of healthy life
habits. What should be underlined is that these exercises were already included in the Chinese medical tradition [22-25]. However, when the documents from this era (daoyin, yinshu, wuqinxi) that refer to these practices are read, it immediately becomes clear that they are very optimistic regarding the benefits that they believed could be achieved. We reason thus because according to Jiménez and Liu [26]: 1) The exercises that they presented were very simple, focussed exclusively on joint mobility and flexibility; 2) they did not include how to treat the physical impairment associated with the ageing process (falls, osteoporosis, etc.), nor specific organ or psychological diseases; 3) neither did they take into account, when dealing with the pathologies, important factors like age, gender, weight, family history, the time the disease had been present, the need for medication, etc.; 4) their dose was either very limited (three repetitions to cure a disease) or exaggerated (1000 repetitions three times a day for ten years), and 5) they offered no indications on the intensity, speed of execution or adaptations to be provided according to the particular difficulties of the practitioner. To summarise, although there was an awareness of the possibilities that physical activity could offer for taking care of one’s health and treating disease, they were proposals which lacked the sufficient experience, knowledge and assessment to be able to definitely affirm them. In time this term evolved into the form of “Yang Sheng Gong” which would remain unchanged until 1949 when it was replaced with “Qigong”. The new element which was added to the term “Yang Sheng” was the word “Gong” that was to identify that the practice had evolved into more complex systems involved studying, research and a system of learning, if the health benefits which they offered were to be achieved.
However, during this period the practitioners still did not possess the means to confirm the real effects of the activities on their health, leaving a great deal of room for “suggestion”. In fact it was not until the beginning of the 80s that experimental laboratory studies began to be carried out in China to discover the real effects of these practices on health [8, 27]. The adoption of the term “Qigong” in 1949 to designate these activities created a great deal of confusion because what traditionally had been a sector of practice clearly focused on improving health and preventing disease, was diluted within a heterogeneous mass of more than 5,000 activities which also included physical sports activities, dance, martial arts and even esoteric arts [8]. The cause of this can be found in the word “qigong” itself, as by including the term “qi”, the initial reference to “health” which characterised these activities was lost, and the reference became the notion of “life force”, something which was so subtle that it made it easy to include other activities (martial arts, esoteric and recreational activities, etc.) in the concept of “qigong” and to create systems in which the suggestion process was very present when it was time to mobilise “energy” [8]. Some of the most important considerations which arise from this information are: 1) Not all the practices identified with the term “Qigong” belong to the medical tradition or have a sufficiently long historical trajectory to have been able to adequately research the quality of their proposals; 2) some of the activities associated to Yang Sheng were designed with the aim of what nowadays we could call physical fitness rather than with medical objectives; and 3) not all the activities have researched the design of their exercise drills, nor the necessary adaptations for the particular pathologies of the participants, nor the appropriate dose.
If health orientated QG, as described, has a long historical trajectory in Traditional Chinese Medicine (TCM), the same cannot be said for TCC. The latter did not become a branch of QG and thus open up the possibility of being situated within TCM, until the year 1949 when this term was officially adopted in China. This statement is supported when observing that its founders always considered this activity like an “internal martial art” the key to which was in the mastering of the eight internal forces with martial aims, giving no importance to the possible therapeutic aspect or working with energy. In fact the fame of those masters was due to their martial expertise and not their knowledge for promoting health or cultivating energy. Therefore when we talk about “health”, at least up to 1949, it should be interpreted as the health that could derive from the practice of any physical or sports activity, that is, because of its contribution to strengthening the muscles or making the body more flexible, and in the case of the improvement of pulmonary pathologies which are associated with some masters, their contribution has to be limited to the fact that the slow and relaxed level of intensity was more appropriate for people affected by these problems than other types of physical exercise. In the 50s, TCC evolved towards competitive or sports modalities, known from this moment on as simplified forms aimed at competition and no longer as a martial art (chuan). This line of development of TCC is currently engaged in a struggle to introduce this practice into the Olympic disciplines, and its aims are mainly “sports performance” [28]. The development of TCC towards a sports discipline implied great progress in the direction of health, as by becoming a “sport or physical activity” if could be associated “at least” with the same health benefits that are offered by a multitude of other physical and sports activities.
Although it is true that many masters of this art have been TCM experts and even professionals, the authors of this article have not been able to find any written reference or author showing how the martial or sports principles which defined TCC began to be transformed into the health considerations demanded by QG (the true tradition associated with Chinese medicine) to be able to establish a new medical aspect for this activity. We think that it was from the 80s on, in the middle of the “QG boom” (Palmer, 2007), when this new evolution can be considered to have arisen. Among the most important considerations which emerge from this information we can cite: 1) Many TCC systems which are presently being developed follow a model of a martial or sports activity and not a medical one; 2) TCC does not possess such an ancient tradition as QG within TCM. It cannot be confirmed that it existed before 1949; 3) Many of the health benefits of this activity and which have been presented in the research, may be similar to those that can be obtained with many other physical and sports activities, as the TCC modality chosen is martial or sports oriented; and 4) To evaluate the true “therapeutic” potential of TCC, it is necessary to go beyond the sports or martial model, and confirm if the principles incorporated from QG and TCM endow it with added value.
4.2. What criteria should TCC and QG satisfy to serve as medicine? The first and most important criterion is that these activities are able to be modified and individualised depending on the pathologies and particular characteristics of each individual, and that they can be practised at any age with a minimum of quality. In the same way that medicines are different depending on the pathology, the activity should be modified according to the conditions presented.
Furthermore, as the principles of health oriented QG should be the basis for the “medical” dimension of TCC, even within the groups that share the same pathologies, the activity should be individualised in its progression to the inner state (stress, anxiety, relaxation, etc.) of each participant. This is a demand which distances it from group practice which is evident in the majority of TCC and QG sessions, although it is also true that group activity can be positive in the case of martial or sports objectives. In the particular case of TCC, it would also be of interest to debate whether it would be more appropriate when practising this activity with medical aims to just use the term “Tai Chi” deleting “Chuan”. The reason is that the term “chuan” (fist) identifies the practice with a “martial art” reference while “Tai Chi” situates it more clearly in research on the inner work with “yin” and “yang”, the basic principles that underlie Chinese medicine; and therapeutic “qigong”. The founders of Tai Chi Chuan in the 16th and 17th centuries [29] created a system with martial aims where each movement and each turn, had an application for combat, and the sensations which were sought had this same aim. If the objective is health the reference to “combat” can be counterproductive in practice as “thinking about” blows, attacks and defences, makes it difficult to achieve deep relaxation: the basic principle for the practice of health oriented QG. Tai Chi as a “therapeutic activity” respecting the principles of QG, should give priority to harmony between the yin-yang, relaxation (what joints should be relaxed at each instant and where and how much this relaxation has to be directed), internal and external harmony (always favouring natural breathing, comfort, enjoyment and the coordination of body segments), the fluidity of uninterrupted movements without changes in pace and the performance of a calm, slow and smooth activity which ensures that at the end of the form there has not been a large increase in heart rate. Something
totally different to the tension, sweat, effort, increase in heart rate, discomfort or even suffering evident in any other physical sports activity or martial art. If the study by Larkey et col [17], identifies a set of “key elements” which could lead to contextualising how TCC and QG could be placed in the scope of medicine, their study is not focussed on this topic, as it simply describes the different formulas which can be found for working on each element (e.g. focussing meditation on mantras, images or movement; static or dynamic meditation, natural breathing or one that is coordinated with the movement, etc.) without considering if some of these formulas are more appropriate than others with regard to medicine (for example, it alludes to practices which have been banned in China like Qigong based on spontaneous movement because of the serious harmful effects that it may produce [8,9]). Moreover their proposal makes it difficult to include traditional TCC practices like the Chen style in which there are changes in rhythm, jumps and explosive movements, and which can also have beneficial effects on health according to scientific studies [30-34]. Lastly, to consider TCC and QG as “medicine” it is also important for the professionals to identify the adverse affects that can come about through errors or distortions in practice; especially in the particular case of QG because this activity is a delicate path which should be followed with the guidance of an expert in the field. QG represents internal work which affects the physiology of the organism, and therefore, is a serious endeavour which should be performed under certain conditions. Chen [9], Ng [10], Palmer [8] and Shan et al. [11] warn that the inappropriate practice of QG is capable of producing negative effects of a physiological nature: headaches, insomnia, chest pain, breathlessness, nauseas, tachycardia, hot flushes, increase in blood pressure, uncontrolled spasmodic movements in the chest and head, tremors, involuntary movements, etc. On the psychological plane it can produce: delirium,
paranoia, visual and auditory hallucinations, impaired consciousness, a feeling of being possessed, loss of mental faculties, incoherent speech, severe emotional disorders, etc. as well as mentioning more extreme effects such as refusing to eat and even suicide.
5. Conclusions The research frameworks proposed in the literature still have not dealt with the conditions necessary to be able to associate Tai Chi Chuan and Qigong with “medicine”. It is important to debate this question since prestigious international institutions have decided to catalogue these activities as “traditional and complementary medicine”. If health oriented QG has a long historical tradition in Traditional Chinese Medicine which goes back to the 4th century B.C., the same is not true of TCC as it cannot be stated that this activity became part of QG, and thus TCM until the year 1949, when this term was officially adopted in China. The introduction of TCC as another “branch” within QG opened up the possibility for a new line of therapeutic work in this discipline but also the necessity of transforming its practice to comply with the principles of health oriented Qigong. If the predominant format associated with research on TCC is fundamentally based on its martial art and sports facets, as reflected in most of the studies using the term “Tai Chi Chuan”, research needs to be done on whether the health benefits brought by this activity are equal to, or greater than, those provided by other physical and sports activities with a “slow and smooth” format, thus determining its true situation in the health context. There should also be research on whether the practice of TCC, modified to follow the principles of QG, is capable of contributing the same or greater benefits
than its martial art or sports oriented character or than other health oriented physical activities. Conflicts of interest The authors declare they have no conflicts of interest. Financial disclosure The study has received no financial support or funding.
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26. P.J. Jiménez, H. Liu, Qigong y Medicina en la China Antigua, Miraguano, Madrid, 2015. 27. J. Xu, Body, Discourse, and the Cultural Politics of Contemporary Chinese Qigong, J Asian Stud. 58 (1999) 961-991. 28. S. Brownell, S, Wushu and the Olympic Games. Combination of East and West or Clash of Body Cultures?, in: V. Lo (Ed.), Perfect Bodies. Sports, Medicine and Immortality, British Museum, London, 2012, pp. 59-69. 29. D. Wile, Lost T´ai Chi Classics from the Late Ch´ing Dynasty, State University of New York, New York, 1996. 30. S.C. Burgener, Y. Yang, R. Gilbert, S. Marsh-Yant, The effects of a multimodal intervention on outcomes of persons with earle-stage dementia. Am J Alzheimers Dis Other Demen. 23 (2008) 382-394. 31. K. Caldwell, M. Harrison, M. Adams, N.T. Triplett, Effects of Pilates and Taiji Quan training on self-efficacy, sleep quality, mood, and physical performance, of college students, J Bodyw Mov Ther. 13 (2009) 155-163. 32. S.C. Chen, K.C. Ueng, S.H. Lee, K.T. Sun, M.C. Lee, Effect of T'ai Chi Exercise on Biochemical Profiles and Oxidative Stress Indicators in Obese Patients with Type 2 Diabetes. J Altern Complement Med. 16 (2010) 11531159. 33. A. Evangelos, Y.Y. Christou, K.S. Rosengren, Taiji Training Improves Knee Extensor Strength and Force Control in Older Adults, J Gerontol. 58 (2003) 763–766. 34. A.K. Ramachandran, K.S. Rosengren, Y. Yang, E.T. Hsiao-Wecksler, Effect of Tai Chi on gait and obstacle crossing behaviours in middle-aged adults, Gait Posture. 26 (2007) 248–255.
Potentially relevant articles identified (n=520)
excluded after screening (abstract, summaries, poster or duplicate) (n=304)
Articles for detailed evaluation (n=306)
Excluded with reasons (n=209) Systematic reviews or meta-analysis of TCC (n=142) Systematic reviews or meta-analysis of QG (n=21) Original Studies and Complexity (n=5) Adherence to TCC and QG (n=41)
Included articles (n=7)
Challenge (n=2); Meta-review (n=2); Map (n=1); Framework (n=1)
Tai Chi Chuan (n=5)
Tai Chi Chuan - Qigong (n=1)
Fig. 1 Flowchart of publication selection process
Meta-review (n=1)
Qigong (n=1)
Tab. 1 Research Frameworks found and studies selected Research Frameworks Methodology and Design Studies Review in TCC
Variables for the study of TCC
Barriers to dissemination TCC
Studies Included Burschka et al. [13] Hempel and Skelle [14] Jiménez [15] Lee, Oh and Ernst [16] Burschka et al. [13] Larkey et al.[17] Wayne and Kaptchuk [18-19] Harmer [20]
S1876-3820(16)30412-7 http://dx.doi.org/doi:10.1016/j.eujim.2016.11.012 EUJIM 620
To appear in: Received date: Revised date: Accepted date:
5-6-2016 10-11-2016 11-11-2016
Please cite this article as: Mart´ın Pedro Jes´us Jim´enez, Liu Haoqing, Ortega Agust´ın Mel´endez.How to study the relationship between Tai Chi Chuan, Qigong and medicine − a review of research frameworks.European Journal of Integrative Medicine http://dx.doi.org/10.1016/j.eujim.2016.11.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
How to study the relationship between Tai Chi Chuan, Qigong and medicine - a review of research frameworks
Pedro Jesús Jiménez Martín Faculty of Physical Activity and Sport Sciences Madrid Polytechnic University C/ Martín Fierro, 7, 28040, Madrid. Spain E-mail: [email protected]
Haoqing Liu Founder and Director of the Higher School of Chikung-Taichi C/ Modesto Lafuente, 10, Bajo C. 28010. Madrid. Spain E-mail: [email protected]
Agustín Meléndez Ortega Faculty of Physical Activity and Sport Sciences Madrid Polytechnic University C/ Martín Fierro, 7, 28040, Madrid. Spain E-mail: [email protected]
Abstract Introduction: International organisations have included Tai Chi Chuan (TCC) and Qigong (QG) under the heading of “Traditional and Complementary Medicine” (TCM). The WHO (2002) definition of TCM not only includes the maintenance of health, but also prevention, diagnosis, improvement and the physical and mental treatment of disease. This study aims to review the research frameworks proposed in the scientific literature to approach TCC and QG theoretically as objects of research and ascertain if they have considered the conditions which should be taken into account when associating both activities with the concept of “medicine”. Method: Eight electronic data bases were searched in publications up to January 2016 Results: The research frameworks used to analyse TCC as a research object, focussed on the improvement of research designs, the identification of the variables pertaining to TCC which could condition the interpretation of the study results and the justification of its efficiency, effectiveness and costs. The article on QG is centred on the need to improve the research designs. Conclusion: The research frameworks proposed in the literature still have not addressed the conditions which permit the association of Tai Chi Chuan and Qigong with “medicine”. It is therefore important to begin to debate this question and analyse if by modifying the practice of TCC to embrace the principles of QG, (a practice traditionally associated with Chinese medicine), it will be able to offer similar or greater benefits than when practised as a martial arts or sports modality, or than other healthy physical activity programs. Key Words: Health, Chinese Medicine, Body-Mind Therapies, Energy Medicine, Tai Chi, Qigong, Complementary and Alternative Medicine; Research Methodology.
1. Introduction The World Health Organisation (WHO) has highlighted its interest in “Traditional and complementary medicine” (TCM) with the publication of two documents (published in 2002 [1] and 2013 [2]) describing its strategic objectives to situate this sector within the national health systems of different countries worldwide. Following the same tendency, in several countries various institutions and projects are being established to regulate, investigate and guide this sector. For example, the National Center for Complementary and Integrative Health (NCCIH) was created in
1999 in the United States of America [3,4]; the CAMbrella project was carried out in the European Union between 2010 and 2012 including researchers and academics from 12 European countries [5]; and the Cochrane Library Central Register of Controlled Trials (CENTRAL) [6] and the ISI Web of Knowledge [7] have included articles on this topic in their search results, thus showing the importance that it is acquiring at the scientific level. It is important to underline that in all these institutions and projects there is evidently a great need and concern to order and regulate this sector appropriately. There is concern to avoid fraudulent practices, create regulations, ensure the safety of the patient receiving treatment, confirm the real health benefits provided, improve the research, raise the level of qualifications of the professionals and establish a consensus on the terminology used. These are requirements which will not only enhance the prestige of these activities but will also help to eliminate “prejudice” and “rejection” on the part of many professional in the medical and scientific sectors. The same issue exists when the practice of Tai Chi Chuan (TCC) and Qigong (QG) are considered in the context of “medicine”: there is a large variety of activities or systems [8], insufficient regulation of professional practice and training, a need to recognise that adverse effects have been evident due to poor practices [8-12], and certain difficulties in scientifically confirming the real and potential scope of these activities for health and the treatment of disease. Faced with this reality, different authors are publishing articles with proposals for ordering, harmonising, improving and supporting the research and initiatives which are being undertaken with respect to TCC and QG [13-20]. These proposals perhaps arise from an awareness that not only the integration of these activities in health institutions,
but also their inclusion in the health programmes offered by physical activity and sports institutions, will depend on correctly resolving these issues. The aim of this study is to review the theoretical research frameworks which have been proposed in the scientific literature to situate TCC and QG as objects of study, and ascertain if they satisfy the conditions which should be taken into account when associating both activities with “medicine”. We understand medicine as it is defined by the WHO (2002) [1] “Traditional Medicine is the sum total of the knowledge, skills, and practices based on the theories, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as the prevention, diagnosis, improvement or treatment of physical and mental illness”, but also as an integrative medicine that connects conventional medicine with evidence-based complementary medicine. When the WHO includes TCC and QG in this definition, and also suggests including these practices in the national health systems, it is clear that it does not just consider the potential of both activities for wellness but also for treating “disease” with specific protocols and therefore going beyond the health benefits which any other physical sports activity can offer. 2. Methods 2.1. Eligibility Criteria We search for studies which presented a proposal for analysing how to approach TCC and QG as “research objects”, from an “outside point of view”, going beyond finding evidence on their possible beneficial effects, and selected articles which focussed on analysing the paradigms of context approach or research frameworks. 2.2. Search Strategy
Eight electronic data bases: Medline-Pubmed, Scirus, Cochrane, Pascal, ScienceDirect, SportDiscuss, Science Citation Index, Google Scholar and BIOSIS were used indicating the key words “Tai Chi” or “Tai Chi Chuan” or “T´ai Chi” or “Taiji” or “Tai Ji Quan” or “Qigong” or “Chikung” and “Challenges” or “Map” or “Scientific Research” or “Framework”, searching publications dated up to January 2016. 2.3. Study Selection Two researchers independently analysed the studies found to determine their inclusion and any disagreement was resolved by discussion. Although it was decided to discard the systematic reviews and meta-analysis of TCC and QG because they were considered to focus exclusively on presenting their conclusions on evidence of their beneficial health effects, three “meta-review” have been included (two on TCC and one on QG) which offered a very complete synthesis of all the existing problems with regard to the research design, and described how to approach reviews and meta-analyses by establishing an appropriate context for these activities. We have also included an article suggested by one of the peer reviewers.
Please insert Table 1 here.
Studies were excluded which were not published in English, together with abstracts, posters, and summaries from conferences, almost all systematic reviews and metaanalyses because the present article aims to identify the research frameworks which analyse how these activities should be researched and not the “final product” i.e. their health benefits. Original studies which were carried out in the context of theories of complexity taking it for granted as the best research approach, and studies on adherence
to these activities which often included the term “framework” in their contents, were also omitted.
Please insert Fig. 1 here. 3. Results Seven articles were found which fulfilled the inclusion criteria: 5 on TCC, 1 on QG and 1 on TCC and QG. The research frameworks used to analyse TCC as a research object, focussed on the improvement of research designs, the identification of the variables pertaining to TCC which could condition the interpretation of the study results and the justification of its efficiency, effectiveness and costs. The article on QG is centred on the need to improve the research designs. a) Improvement of research designs: The main criticism of the research on these activities is that in spite of the volume of studies carried out, there is still only limited confirmation of their benefits. There are three main causes of this problem: the low quality of the research designs, the limitations in the methodology and the great heterogeneity they present. For example, there are at least 14 meta-analyses and 107 systematic reviews on TCC [14] and 2 meta-analyses and 20 systematic reviews on QG [15], published in English and Spanish. Topics covered are as varied as psychological effects and quality of life of the practitioners; improvement in the problems of pain, stiffness and function in knee osteoarthritis; balance and reduction in falls; improvement of aerobic capacity and the prevention of cardiovascular problems; increases in strength; diabetes; sleep; osteoporosis and rheumatoid arthritis; cancer and enhancement of the immune system; and fibromyalgia. A large number of these reviews, in fact, state that although there appears to be a positive influence on health in the variables analysed, and defend that these activities
can be non-pharmacological alternatives for treating determined pathologies, the deficiencies in the research designs of many studies are important enough to preclude their being able to strongly attest to the benefits affirmed. These deficits include small samples, omission of the inclusion and exclusion criteria for the participants, dropouts, poor protocols, inadequate controls, deficient statistical analyses, multiplicity in the research instruments used, a limited number of randomised controlled trials (RCTs), etc. [13-15]. The problem is aggravated when works like that of Lee, Oh and Ernst [16] underline that some of the systematic reviews on QG also reveal important deficits with regard to the low quality of the studies included and the methodology used to analyse them. And when other authors like Burschka et al. [13] state that the standard review instruments used (CONSORT, Jadad Score, PEDro rating scale, NICE, Delphi criteria list, ABC, etc.) focus exclusively on the reporting or assessment of research methods and omit fundamental aspects related to the activity itself: style practised, dose, experience of the instructors, posture height, time to execute each form, etc. In an attempt to correct these problems in the context of TCC, Wayne and Kaptchuk [18,19] present: 1) the research designs that would be the most suitable in these projects (RTCs that evaluate pragmatic and fixed protocol interventions, alongside communitybased observational studies, cross-sectional studies of long-term practitioners, and qualitative research; 2) some of the inherent aspects in the activity which condition the research designs and intervention protocols (Tai Chi pluralism, dosage, long-term versus short-term evaluations of efficacy and safety, and the benefits and limitations of commonly employed clinical research methods). b) Identification of the variables involved in TCC: From another viewpoint, Burschka et al. [13] and Wayne and Kaptchuk [18,19] underline that TCC (and we
would add QG) is a complex phenomenon which embraces such a diversity of physiological, psychological and ritual variables that to understand its potential in its entirety it is necessary to change the methodological research paradigm from the predominant reductionist vision of “linear” cause and effect, which can be observed in almost all the research, to the systemic vision of “circular” cause and effect contributed by complexity and ecological theories. Wayne and Kaptchuk [18,19] identify eight variables or “therapeutic components”, which in their opinion are those which characterise TCC as a complex ecological reality: 1) musculoskeletal strength, flexibility and efficiency; 2) breathing; 3) concentration, attention, and mindfulness; 4) imagery, visualisation, and intention, 5) physical touch and subtle energy, 6) psychosocial interactions; 7) alternative health paradigm and philosophy; and 8) rituals, icons, and environment. Larkey et col. [17] identify a set of key elements which they consider would help to clarify how TCC and QG can affect health outcomes in similar, and perhaps different ways compared to conventional exercise: type and degree of meditative focus, type of movement, description of breathing, and achievement of relaxed state. “Elements” which would mean that both activities could be identified as a new category of exercise, called “Meditative Movement” which would make available the necessary information to begin to compare findings across studies. c) Efficiency, Efficacy and Cost. Harmer [20] adds another aspect with regard to understanding the limitations which research faces in this field: the difficulty that TCC encounters to be officially incorporated into the health programmes offered by government and private agencies. He underlines the gulf which exists between the high level of interest these activities are attracting in medical researchers, clinicians and the
general public and the reluctance of funding agencies to promote large-scale TCC programmes. He cites the heterogeneity of the research as the cause. His solution is to introduce the concepts of “efficacy”, “effectiveness” and “costeffectiveness” which are used with reference to TCM into the field of TCC. “Efficacy”, in the sense of definitively confirming its positive effects using appropriate research designs, and if possible, randomised controlled trials; “effectiveness”, with regard to showing the acceptance and value attributed to these activities by the general population; and “cost-effectiveness”, by showing evidence of both the savings and the economic benefits that TCC and QG can contribute to the institutions which promote them.
4. Discussion Although the “context approach” has given rise to very important initiatives to give more robustness to research into these activities, we do not consider that they solve the problem of identifying the research framework that best adapts to TCC and QG when they are associated with the concept of “medicine”. It is important to tackle this question as both TCC and QG have been included in TCM under the heading of “Traditional Chinese Medicine” [1,2], or “Mind-body Medicine” in the case of TCC or “Energy Medicine” with regard to QG [3,4]. We consider that to state that both activities can act as “medicine” is a very serious matter as it presupposes not only that both TCC and QG can contribute to improving or treating diseases, but also that their scope goes beyond the health benefits that are provided by a multitude of other healthy physical and sports activities. If their therapeutic capacity is simply associated with improving health, all the healthy physical
and sports activities that are being offered should also be included under the umbrella of TCM if they provide the same benefits. For example, although Lan et col. [21] have published an article to show what is happening with TCC in medicine and health promotion, their work is focussed on discovering the different benefits that this activity brings to these areas, without questioning if these same benefits could be achieved with other different health-oriented physical and sports activities, or with activities which follow a smooth and slow pattern of exercise like TCC or QG. To achieve adequate contextualisation of how to analyse the relation of QG and TCC with “medicine”, two important questions must be answered:
4.1. How are QG and TCC related to “medicine”? The answer to this question lies in the historical evolution of both activities. The word “qigong” is a modern term which appeared in the year 1949. From a historical point of view, this term only appeared before in a totally exceptional and marginal manner in a Taoist text from the Tang dynasty (618–910 A.D.) and in another from the Song dynasty (960–1279 A.D.) with the meaning of “breathing techniques” [8]. The first name which was used in Chinese history to designate the different systems of health oriented energy body practices was “Yang Sheng”, as it was recorded for the first time in the work of the philosopher Zhuang Zi supposedly written in the Warring States period (484–221 B.C.)in the Eastern Zhou dynasty (771–221 B.C.) [22-24]. In that era, this term was actually used to designate a set of practices oriented towards personal health and included not only physical exercises with therapeutic aims but also diet, sexual hygiene, emotional self control and sleep, and the promotion of healthy life
habits. What should be underlined is that these exercises were already included in the Chinese medical tradition [22-25]. However, when the documents from this era (daoyin, yinshu, wuqinxi) that refer to these practices are read, it immediately becomes clear that they are very optimistic regarding the benefits that they believed could be achieved. We reason thus because according to Jiménez and Liu [26]: 1) The exercises that they presented were very simple, focussed exclusively on joint mobility and flexibility; 2) they did not include how to treat the physical impairment associated with the ageing process (falls, osteoporosis, etc.), nor specific organ or psychological diseases; 3) neither did they take into account, when dealing with the pathologies, important factors like age, gender, weight, family history, the time the disease had been present, the need for medication, etc.; 4) their dose was either very limited (three repetitions to cure a disease) or exaggerated (1000 repetitions three times a day for ten years), and 5) they offered no indications on the intensity, speed of execution or adaptations to be provided according to the particular difficulties of the practitioner. To summarise, although there was an awareness of the possibilities that physical activity could offer for taking care of one’s health and treating disease, they were proposals which lacked the sufficient experience, knowledge and assessment to be able to definitely affirm them. In time this term evolved into the form of “Yang Sheng Gong” which would remain unchanged until 1949 when it was replaced with “Qigong”. The new element which was added to the term “Yang Sheng” was the word “Gong” that was to identify that the practice had evolved into more complex systems involved studying, research and a system of learning, if the health benefits which they offered were to be achieved.
However, during this period the practitioners still did not possess the means to confirm the real effects of the activities on their health, leaving a great deal of room for “suggestion”. In fact it was not until the beginning of the 80s that experimental laboratory studies began to be carried out in China to discover the real effects of these practices on health [8, 27]. The adoption of the term “Qigong” in 1949 to designate these activities created a great deal of confusion because what traditionally had been a sector of practice clearly focused on improving health and preventing disease, was diluted within a heterogeneous mass of more than 5,000 activities which also included physical sports activities, dance, martial arts and even esoteric arts [8]. The cause of this can be found in the word “qigong” itself, as by including the term “qi”, the initial reference to “health” which characterised these activities was lost, and the reference became the notion of “life force”, something which was so subtle that it made it easy to include other activities (martial arts, esoteric and recreational activities, etc.) in the concept of “qigong” and to create systems in which the suggestion process was very present when it was time to mobilise “energy” [8]. Some of the most important considerations which arise from this information are: 1) Not all the practices identified with the term “Qigong” belong to the medical tradition or have a sufficiently long historical trajectory to have been able to adequately research the quality of their proposals; 2) some of the activities associated to Yang Sheng were designed with the aim of what nowadays we could call physical fitness rather than with medical objectives; and 3) not all the activities have researched the design of their exercise drills, nor the necessary adaptations for the particular pathologies of the participants, nor the appropriate dose.
If health orientated QG, as described, has a long historical trajectory in Traditional Chinese Medicine (TCM), the same cannot be said for TCC. The latter did not become a branch of QG and thus open up the possibility of being situated within TCM, until the year 1949 when this term was officially adopted in China. This statement is supported when observing that its founders always considered this activity like an “internal martial art” the key to which was in the mastering of the eight internal forces with martial aims, giving no importance to the possible therapeutic aspect or working with energy. In fact the fame of those masters was due to their martial expertise and not their knowledge for promoting health or cultivating energy. Therefore when we talk about “health”, at least up to 1949, it should be interpreted as the health that could derive from the practice of any physical or sports activity, that is, because of its contribution to strengthening the muscles or making the body more flexible, and in the case of the improvement of pulmonary pathologies which are associated with some masters, their contribution has to be limited to the fact that the slow and relaxed level of intensity was more appropriate for people affected by these problems than other types of physical exercise. In the 50s, TCC evolved towards competitive or sports modalities, known from this moment on as simplified forms aimed at competition and no longer as a martial art (chuan). This line of development of TCC is currently engaged in a struggle to introduce this practice into the Olympic disciplines, and its aims are mainly “sports performance” [28]. The development of TCC towards a sports discipline implied great progress in the direction of health, as by becoming a “sport or physical activity” if could be associated “at least” with the same health benefits that are offered by a multitude of other physical and sports activities.
Although it is true that many masters of this art have been TCM experts and even professionals, the authors of this article have not been able to find any written reference or author showing how the martial or sports principles which defined TCC began to be transformed into the health considerations demanded by QG (the true tradition associated with Chinese medicine) to be able to establish a new medical aspect for this activity. We think that it was from the 80s on, in the middle of the “QG boom” (Palmer, 2007), when this new evolution can be considered to have arisen. Among the most important considerations which emerge from this information we can cite: 1) Many TCC systems which are presently being developed follow a model of a martial or sports activity and not a medical one; 2) TCC does not possess such an ancient tradition as QG within TCM. It cannot be confirmed that it existed before 1949; 3) Many of the health benefits of this activity and which have been presented in the research, may be similar to those that can be obtained with many other physical and sports activities, as the TCC modality chosen is martial or sports oriented; and 4) To evaluate the true “therapeutic” potential of TCC, it is necessary to go beyond the sports or martial model, and confirm if the principles incorporated from QG and TCM endow it with added value.
4.2. What criteria should TCC and QG satisfy to serve as medicine? The first and most important criterion is that these activities are able to be modified and individualised depending on the pathologies and particular characteristics of each individual, and that they can be practised at any age with a minimum of quality. In the same way that medicines are different depending on the pathology, the activity should be modified according to the conditions presented.
Furthermore, as the principles of health oriented QG should be the basis for the “medical” dimension of TCC, even within the groups that share the same pathologies, the activity should be individualised in its progression to the inner state (stress, anxiety, relaxation, etc.) of each participant. This is a demand which distances it from group practice which is evident in the majority of TCC and QG sessions, although it is also true that group activity can be positive in the case of martial or sports objectives. In the particular case of TCC, it would also be of interest to debate whether it would be more appropriate when practising this activity with medical aims to just use the term “Tai Chi” deleting “Chuan”. The reason is that the term “chuan” (fist) identifies the practice with a “martial art” reference while “Tai Chi” situates it more clearly in research on the inner work with “yin” and “yang”, the basic principles that underlie Chinese medicine; and therapeutic “qigong”. The founders of Tai Chi Chuan in the 16th and 17th centuries [29] created a system with martial aims where each movement and each turn, had an application for combat, and the sensations which were sought had this same aim. If the objective is health the reference to “combat” can be counterproductive in practice as “thinking about” blows, attacks and defences, makes it difficult to achieve deep relaxation: the basic principle for the practice of health oriented QG. Tai Chi as a “therapeutic activity” respecting the principles of QG, should give priority to harmony between the yin-yang, relaxation (what joints should be relaxed at each instant and where and how much this relaxation has to be directed), internal and external harmony (always favouring natural breathing, comfort, enjoyment and the coordination of body segments), the fluidity of uninterrupted movements without changes in pace and the performance of a calm, slow and smooth activity which ensures that at the end of the form there has not been a large increase in heart rate. Something
totally different to the tension, sweat, effort, increase in heart rate, discomfort or even suffering evident in any other physical sports activity or martial art. If the study by Larkey et col [17], identifies a set of “key elements” which could lead to contextualising how TCC and QG could be placed in the scope of medicine, their study is not focussed on this topic, as it simply describes the different formulas which can be found for working on each element (e.g. focussing meditation on mantras, images or movement; static or dynamic meditation, natural breathing or one that is coordinated with the movement, etc.) without considering if some of these formulas are more appropriate than others with regard to medicine (for example, it alludes to practices which have been banned in China like Qigong based on spontaneous movement because of the serious harmful effects that it may produce [8,9]). Moreover their proposal makes it difficult to include traditional TCC practices like the Chen style in which there are changes in rhythm, jumps and explosive movements, and which can also have beneficial effects on health according to scientific studies [30-34]. Lastly, to consider TCC and QG as “medicine” it is also important for the professionals to identify the adverse affects that can come about through errors or distortions in practice; especially in the particular case of QG because this activity is a delicate path which should be followed with the guidance of an expert in the field. QG represents internal work which affects the physiology of the organism, and therefore, is a serious endeavour which should be performed under certain conditions. Chen [9], Ng [10], Palmer [8] and Shan et al. [11] warn that the inappropriate practice of QG is capable of producing negative effects of a physiological nature: headaches, insomnia, chest pain, breathlessness, nauseas, tachycardia, hot flushes, increase in blood pressure, uncontrolled spasmodic movements in the chest and head, tremors, involuntary movements, etc. On the psychological plane it can produce: delirium,
paranoia, visual and auditory hallucinations, impaired consciousness, a feeling of being possessed, loss of mental faculties, incoherent speech, severe emotional disorders, etc. as well as mentioning more extreme effects such as refusing to eat and even suicide.
5. Conclusions The research frameworks proposed in the literature still have not dealt with the conditions necessary to be able to associate Tai Chi Chuan and Qigong with “medicine”. It is important to debate this question since prestigious international institutions have decided to catalogue these activities as “traditional and complementary medicine”. If health oriented QG has a long historical tradition in Traditional Chinese Medicine which goes back to the 4th century B.C., the same is not true of TCC as it cannot be stated that this activity became part of QG, and thus TCM until the year 1949, when this term was officially adopted in China. The introduction of TCC as another “branch” within QG opened up the possibility for a new line of therapeutic work in this discipline but also the necessity of transforming its practice to comply with the principles of health oriented Qigong. If the predominant format associated with research on TCC is fundamentally based on its martial art and sports facets, as reflected in most of the studies using the term “Tai Chi Chuan”, research needs to be done on whether the health benefits brought by this activity are equal to, or greater than, those provided by other physical and sports activities with a “slow and smooth” format, thus determining its true situation in the health context. There should also be research on whether the practice of TCC, modified to follow the principles of QG, is capable of contributing the same or greater benefits
than its martial art or sports oriented character or than other health oriented physical activities. Conflicts of interest The authors declare they have no conflicts of interest. Financial disclosure The study has received no financial support or funding.
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Potentially relevant articles identified (n=520)
excluded after screening (abstract, summaries, poster or duplicate) (n=304)
Articles for detailed evaluation (n=306)
Excluded with reasons (n=209) Systematic reviews or meta-analysis of TCC (n=142) Systematic reviews or meta-analysis of QG (n=21) Original Studies and Complexity (n=5) Adherence to TCC and QG (n=41)
Included articles (n=7)
Challenge (n=2); Meta-review (n=2); Map (n=1); Framework (n=1)
Tai Chi Chuan (n=5)
Tai Chi Chuan - Qigong (n=1)
Fig. 1 Flowchart of publication selection process
Meta-review (n=1)
Qigong (n=1)
Tab. 1 Research Frameworks found and studies selected Research Frameworks Methodology and Design Studies Review in TCC
Variables for the study of TCC
Barriers to dissemination TCC
Studies Included Burschka et al. [13] Hempel and Skelle [14] Jiménez [15] Lee, Oh and Ernst [16] Burschka et al. [13] Larkey et al.[17] Wayne and Kaptchuk [18-19] Harmer [20]