Complementary Therapies in Medicine (2011) 19, 311

available at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/ctim

Tai chi Qigong improves lung functions and activity

tolerance in COPD clients: A single blind, randomized
controlled trial
Aileen W.K. Chan b,, Albert Lee a, Lorna K.P. Suen b, Wilson W.S. Tam c

a
Department of Community and Family Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T.,
Hong Kong
b
The Nethersole School of Nursing, Faculty of Medicine, Esther Lee Building, The Chinese University of Hong Kong, Shatin, N.T.,
Hong Kong
c
School of Public Health and Primary Care, the Chinese University of Hong Kong, Hong Kong
Available online 17 January 2011

KEYWORDS Summary
Breathing exercise; Objective: To evaluate the effectiveness of a Tai chi Qigong (TCQ) program in enhancing res-
Chronic obstructive piratory functions and activity tolerance in clients with chronic obstructive pulmonary disease
pulmonary disease; (COPD).
Spirometry; Design: A single-blind, randomized controlled trial.
6-min walk test; Setting: Five general outpatient clinics in Hong Kong.
Tai chi Qigong Intervention: In total, 206 COPD clients were randomly assigned into one of the three groups,
namely, TCQ, exercise, and control group. Subjects in the TCQ group received a TCQ program
consisting of two 60-min sessions each week for three months. Subjects in the exercise group
were taught to practice breathing techniques combined with walking as an exercise. Subjects
in the control group were instructed to maintain their usual activities. Data collection was
performed at baseline and at the 6-week and 3-month marks.
Outcomes: Lung functions, 6-min walk test, and COPD exacerbation rate.
Results: Results of repeated measures of analysis of covariance demonstrated that there
were signicant interaction effects between time and group in forced vital capacity (p = .002,
2 = .06), forced expiratory volume in 1 s (p < .001, 2 = .02), walking distance (p < .001), and
exacerbation rate (p = .006, 2 = .06) at 3 months. Improvements were noted in the TCQ group.
No changes were observed in the exercise group, while a decline in lung functions was noticed
in the control group.

Abbreviations: 2 , effect size; 6MWT, 6-min walk test; ATS, American Thoracic Society; COPD, chronic obstructive pulmonary disease;
FEV1 , forced expiratory volume in 1 s; FVC, forced vital capacity; ITT, intention-to-treat; SaO2 , oxygen saturation; TCQ, Tai chi Qigong.
Corresponding author at: The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Rm 722,

Esther Lee Building, Shatin, N.T., Hong Kong. Tel.: +852 31634290; fax: +852 26035269.
E-mail address: aileenchan@cuhk.edu.hk (A.W.K. Chan).

0965-2299/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctim.2010.12.007
4 A.W.K. Chan et al.
Conclusion: Tai chi Qigong was able to improve respiratory functions and activity tolerance level
in COPD clients. The breathing and walking exercise helped maintain lung functions and slow
down disease progression.
2011 Elsevier Ltd. All rights reserved.
Introduction
Chronic obstructive pulmonary disease (COPD), already the
fourth leading cause of death, is increasingly diagnosed
worldwide.1 According to World Health Organization esti-
mates, 80 million people are suffering from COPD.2 Aside
from imposing burdens on the client, the condition is
also a large economic burden to the society. COPD is a
progressive lung disease characterized by a persistent block-
age of airow from the lungs.3 Its common symptoms are
breathlessness, abnormal sputum, and chronic cough. Daily
activities are affected as the condition gradually wors-
ens. Existing medications for COPD are mainly for reducing
symptoms rather than modication of lung functions.4,5
Studies have shown the effectiveness of community-based
pulmonary rehabilitation programs (PRP) in reducing exac-
erbations and hospital admissions.6,7 However, out-patient
PRPs are still not widely available, and closely super-
vised home programs, although possibly effective, are
costly.8,9 Ideally, clients need to develop skills in disease
management and improve their functional health status.
As recommended by Halpin,10 COPD clients should stay
physically active to reduce the impact of lung damage.
Regular exercise maintains tness and reduces disability,
and thus, Tai chi Qigong (TCQ) can be an alternative
exercise for COPD clients. This study aims to evaluate
the effectiveness of a 3-month TCQ program in improv-
ing respiratory functions and activity tolerance in COPD
clients.
Tai chi Qigong
TCQ is a combination of exercise and meditation.11 It con-
sists of a series of slow movements and deep breathing
that helps to promote circulation of Qi (vital energy)
in the meridians, regulate functions of the internal organs,
and improve physiological functions.12 The slow, controlled
graceful movements of TCQ, which integrates mental con-
centration and deep breathing, is believed to improve
circulation and breathing. Deep breathing draws the breath
down into the tantien (the main energy center of the body)
placing less pressure on lungs and increasing lung capacity.13
A study has shown that TCQ exercise is more efcient than
cycling in terms of ventilatory responses.14 TCQ also has ben-
ecial effects on cardio-respiratory function and expiratory
capacity.15 The TCQ movement guides breathing and circula-
tion to enhance the free ow of Qi through the body and
to increase general energy level.16 TCQ can be classied as
a low-intensity exercise, as its average exercise intensity is
3.1 MET (Metabolic Equivalent).17 It is a meditative breath-
ing and sensory skill that incorporates movement work most
quickly and effectively. TCQ is benecial and optimal for
people with low functional capacities.18,19 Overall, breath-
ing is the soul of TCQ.16 In view of the literature providing
evidence regarding the potential benets of TCQ on respi-
ratory functions,14,20 the effects of TCQ on COPD clients are
worthy of further investigation.
Methods
Study design
This study utilized a single-blind, randomized controlled
trial. The research assistants for data collection were
blinded to minimize researcher bias. Subjects were ran-
domly assigned to one of the three groups, namely, TCQ,
exercise, and control group. Random allocation was done
using a randomizer software.21 Both the total number of sub-
jects and number of groups were entered into the computer
randomizer, which then generated the random assignment of
subjects. This step helped avoid yielding a highly disparate
sample size in the study groups; instead, it preserved many
positive attributes of simple randomization.
Sample size
Sample size calculation was based on previous ndings on
the medium effect of TCQ exercise on HRQL using symptom
domain of St Georges Respiratory Questionnaire in COPD
clients.22 According to Cohen,23 with a medium effect size
of .05, a power of .80 at a 5% signicant level (two-sided),
52 subjects per group were required. In order to cover the
potential attrition rate of 25%,24,25 210 subjects (70 per
group) were targeted.
Selection of subjects
Subjects clinically diagnosed with COPD according to the
American Thoracic Society (ATS) standard guidelines26 were
eligible for inclusion in this study. Subjects were excluded
if they could not walk independently, suffered from severe
sensory or cognitive impairment, symptomatic ischemic
heart disease, or had practiced TCQ within a year prior to the
commencement of the study. Subjects were recruited from
ve different general out-patient clinics (GOPCs). Informed
consent was obtained from every eligible client who agreed
to participate. The study was approved by the Joint Clinical
Research Ethics Committee of the Chinese University of Hong
Kong and New Territory East Cluster. Approval for conducting
the study was also sought from the selected GOPCs.
Intervention protocol
Tai chi Qigong group
Subjects in the TCQ group completed a 3-month TCQ pro-
gram, which consisted of two 60-min sessions each week.
The program was a 13-form TCQ modied from the 18-form
Tajii Qigong27 developed by Master Lin Hou Sheng in 1982.28
Tai Chi Qigong improves physiological functions: A RCT
The revision was intend to allow the participants to learn
and master the movements in a shorter period of time. The
program emphasized on the elements of breathing and the
range of motion on upper limbs for enhancing lung expan-
sion. Subjects were instructed to inhale when hands were
rising or moving outwards, and exhale when hands were sink-
ing or moving inwards. The TCQ movements were performed
in a slow, graceful manner; in addition, breathing, body posi-
tion, and mental concentration were naturally coordinated.
Comments from two TCQ experts were sought regarding the
validity and feasibility of the modied TCQ when practiced
by COPD clients. In this study, the TCQ class was led by a
qualied TCQ instructor. Subjects were instructed to self-
practice TCQ daily for one hour in addition to the supervised
TCQ sessions. They were allowed to split the 1-h practic-
ing time into morning and afternoon sessions to prevent
fatigue. Along with TCQ pictures, a DVD was also given to
each subject to facilitate daily self-practice. A diary was
also provided to each subject for recording the frequency
of their self-practice sessions.
Exercise group
Subjects in the exercise group were taught pursed-lip
breathing (PLB) and diaphragmatic breathing (DB), coor-
dinated with self-paced walking as a physical exercise.
PLB requires breathing in through the nose and breathing
out slowly through pursed-lips. Expiration time was twice
as the inspiration time to slow down the breathing rate.
Meanwhile, DB helps to reduce the work of breathing and
improves ventilation and dyspnoea. In this study, subjects
were instructed to inhale through the nose, push the stom-
ach out, then exhale through pursed lips slowly, pulling
the stomach in. Return demonstrations of the breathing
techniques were performed by subjects to ensure proper
practice. Subjects were advised to perform breathing and
walking exercise for one hour, which could be split into
two or three sessions to prevent fatigue. Leaets with
pictures and instructions were given to the subjects to
facilitate daily self-practice. A diary was also given to
each subject for recording the frequency of their self-
practice sessions. The breathing techniques of subjects
were re-assessed at the 6-week and 3-month to ensure
that proper skills were maintained. The breathing exer-
cise is a conventional exercise commonly used in PRP.
The breathing component in this group was different from
that in the TCQ group, as TCQ group did not require
PB, and had no restriction on time for breathing in and
out.
Control group
Subjects in the control group were advised to maintain their
routine activities. No extra exercise was recommended.
All subjects continued their prescribed medical treat-
ment. Subjects in the exercise and control groups were
encouraged to join community activities arranged by
researchers to ensure consistent weekly gatherings.
Measurement
Data collection was performed at baseline and at the 6-week
and 3-month. Pre-bronchodilator spirometry, 6-min walk
5
test (6MWT), Borg scale, and oxygen saturation level (SaO2 )
were used because of their simplicity and sensitivity when
utilized for health evaluation purposes. Spirometry was
supervised by the same researcher for all subjects to ensure
proper skills and to avoid measuring discrepancy. Results
of forced expiratory volume in 1 s (FEV1 ) and forced vital
capacity (FVC) were recorded. The 6MWT protocol follow-
ing ATS guidelines was used.29 The longest distance walked
in meters over 6 min was recorded. The Borg Scale30 is a self-
rated dyspnoea and fatigue scale. The scale ranges from 0 to
10, wherein 0 indicates no dyspnoea or no fatigue at all, and
10 indicates extreme dyspnoea or extreme fatigue that can-
not be tolerated. In this work, subjects were asked to rate
their dyspnoea and fatigue levels before and after 6MWT.
The number of COPD exacerbations and hospital admissions
during the preceding six weeks period was recorded. Extra
usage of short acting beta2 agonist inhaler in the preceding
week was also recorded.
Data analysis
Data analyses were conducted using SPSS version 16.0.
Descriptive statistics were used to dene the demographic
characteristics of the sample. Repeated measures of analysis
of covariance were used to examine the outcome mea-
sures. A p-value of .05 (2-sided) was taken as the level
of signicance. The 95% condence intervals around the
mean differences were calculated. To preserve the value
of randomization, an intention-to-treat (ITT) analysis was
applied. Data of last observation were carried forward for
withdrawals.
Results
Demographic data
In total, 206 subjects were randomly assigned to each of
the following groups: the TCQ group (n = 70), exercise group
(n = 69), and control group (n = 67). Ages ranged from 55 to
88, with a mean of 73. Of the 206 subjects, 187 (91%) were
male and 19 (9%) were female. The mean duration of COPD
was 11 years. According to the ATS criteria, 43% were at a
severe stage of COPD, 42% were at a moderate stage, and
16% were at a mild stage. Demographic characteristics by
group allocation are shown in Table 1. We found no sig-
nicant difference in demographic data except in gender
(p = .021) as only one female subject (n = 1) was in the TCQ
group. Gender was, therefore, treated as covariate and its
confounding effect was controlled using repeated measures
analysis of covariance (RANCOVA).
Outcome measurements
Of the 206 subjects, 158 (TCQ group = 60, exercise
group = 50, control group = 48) completed the study. The
main reasons of attrition were death, increased dyspnoea,
hospital admissions, and no interest to continue (Fig. 1).
Baseline data showed statistical differences in the exacer-
bation rate (p < .001), wherein the TCQ group had higher
number of exacerbations in the preceding six weeks. No sig-
6 A.W.K. Chan et al.

Table 1 Demographic data and baseline characteristics of study sample by group allocation.

TCQ (n = 70) Exercise (n = 69) Control (n = 67) ANOVA p-Value

Age (years: mean (SD) 71.7(8.2) 73.6 (7.5) 73.6 (7.4) .24
Gender: .02*
Male (%) 69 (99) 61(88) 58 (87)
Female (%) 1 (1) 8 (12) 9 (13)
Yrs of COPD: mean (SD) 10.3 (9.3) 10.6 (8.8) 12.4 (10.6) .39
BMI: mean (SD) 21.5 (3.6) 21.7 (3.9) 22.0 (4.2) .79
Live with: .30
Alone (%) 4 (5.7) 4 (5.8) 8 (11.9)
Family (%) 66 (94.3) 65 (94.2) 59 (88.1)
Education level: .38
Illiteracy (%) 9 (12.9) 10 (14.5) 14 (20.9)
Primary (%) 41 (58.6) 47 (68.1) 37 (55.2)
Secondary (%) 18 (25.7) 9 (13.0) 15 (22.4)
Tertiary or above (%) 2 (2.9) 3 (4.3) 1 (1.5)
Religion: .85
Yes (%) 28 (40.0) 30 (43.5) 26 (38.8)
No (%) 42 (60.0) 39 (56.5) 41 (61.2)
Smoking Status: .79
Second hand smoker (%) 1 (1.4) 2 (2.9) 3 (4.5)
Never smoke (%) 2 (2.9) 4 (5.8) 3 (4.5)
Ex-smoker (%) 55 (78.6) 47 (68.1) 46 (68.7)
Current smoker (%) 12 (17.1) 16 (23.2) 15 (22.4)
Stage of COPD: .57
Mild (%) 7 (10) 13 (19) 12 (18)
Moderate (%) 31 (44) 26 (38) 29 (43)
Severe (%) 32 (46) 30 (43) 26 (39)
Co-existing diseases: 9 (13) 10 (15) 6 (9) .60
Heart disease (%) 28 (40) 36 (52) 28 (42) .33
HT (%) 7 (10) 6 (9) 7 (10) .94
DM (%)
Exercise, mean hours 16.8 (16.3) 13.4 (9.6) 17.5 (12.6) .15
Per week (SD)
FVC, litre, mean (SD) 1.97 (.62) 1.84 (.52) 1.82 (.58) .24
FEV1 , litre, mean (SD) .89 (.38) .91 (.39) .89 (.39) .94
6MWD, mean meter (SD) 298 (68.53) 285 (79.11) 290 (72.97) .56
Dyspnoea, mean (SD) 1.06 (1.10) .62 (.98) .81 (1.04) .05
Fatigue, mean (SD) .99 (1.14) .88 (1.25) .70 (1.06) .35
SaO2 , mean (SD) 96 (3.16) 95 (2.4) 95 (2.41) .75
Exacerbation rate, mean (SD) .86 (1.39) .30 (.79) .21 (.75) <.01*
No. of admission, mean (SD) .13 (.38) .17 (.59) .07 (.50) .51
Extra usage of inhaler, mean (SD) 2.80 (5.99) 3.01 (7.87) 2.00 (4.86) .62
FVC, forced volume capacity; FEV1 , forced expiratory volume in 1 s; 6MWD, 6-min walking distance; SaO2 , oxygen saturation.
* p < .05.

nicant differences were noted in other baseline data among
the three study groups.
Results of RANCOVA demonstrated signicant interac-
tion effects between time and group in FVC (p = .002,
2 = .06), FEV1 (p < .001, 2 = .02), 6MWT (p < .001, 2 = .06),
and exacerbation rate (p = .006, 2 = .06) with the TCQ
group showing greatest improvements across the three
study endpoints. The exercise group did not reveal any
signicant improvement, while the control group demon-
strated a decline in lung functions (Table 2). The changes
of the signicant results of the study groups at the 6-week
and 3-month study endpoints from baseline are shown in
Figs. 25.
Post hoc pairwise comparisons with Bonferroni adjust-
ment indicated signicant difference between the TCQ
group and the control group in FVC (p = .01). The exer-
cise group showed no difference from the TCQ group and
the control group. On the 6MWT, TCQ revealed signi-
cant differences from both the exercise group (p = .03) and
the control group (p = .03). On the other hand, no differ-
ences were noted between the exercise and control groups
(Table 3).
No signicant differences were detected in Borg scale
with respect to dyspnoea level (p = .542), fatigue level
(p = .517), and SaO2 (p = .096). No differences were found
in the hospital admission rate (p = .148), and extra usage of
Tai Chi Qigong improves physiological functions: A RCT 7

Assessed for eligibility (n= 449)

Excluded (n= 243)

Enrollment
Not meeting inclusion criteria (n= 81)
Refused to participate (n= 147)
Randomized (n=206)
Other reasons:
- Needed to work, no time (n=7)
- Lived in Mainland China (n=5)
- Engaged in other study (n=3)

Allocation

Allocated to TCQ (n= 70) (ITT) Allocated to breathing and Allocated to Control (n=67)
exercise (n= 69)
Received allocated intervention
All subjects were taught All subjects were instructed to
(n= 68)
breathing and walking exercise continue usual activities
Did not receive allocated
(n= 69) (n=67)
intervention (n=2)
Reasons:
- hospital admission (n=1)
- joint pain (n=1)

Follow-Up

Lost to follow-up (n=10) Lost to follow-up (n=19) Lost to follow-up (n=19)

Reasons
- hospital admission (n=3)
- no interest (n=2)
- increased SOB (n=2)
- joint pain (n=2)
- died (n=1)
Reasons Reasons:
- no interest (n=10) - no interest (n=11)
- hospital admission (n=3) - Hospital admission (n=3)
- joint pain (n=2) - Default, lost contact
- increased SOB (n=2) (n=3)
- venue too far from home (n=1) - Increased SOB (n=2)
- died (n=1)

Analysis

Analyzed (n=70) (ITT) Analyzed (n=69) (ITT) Analyzed (n=67) (ITT)

Withdrawn (n=10)(14.3%) Withdrawn (n=19)(27.5%) Withdrawn (n=19)(28.3%)
PP subjects (n=60) PP subjects (n=50) PP subjects (n=48)

Figure 1 The consort owchart: to track participants through randomized controlled trial.

short acting beta2 agonist inhaler (p = .931) among the three
groups (Table 2).
Tai chi Qigong program
The compliance rate of daily practice of TCQ was 74%,
while compliance of daily breathing and walking exercise
was 69%. The TCQ skill performance of subjects was evalu-
ated by the TCQ instructor at the end of the program using
a 3-point Likert scale (3 indicated TCQ skills were well mas-
tered and 1 indicated not yet mastered). The overall mean
was 2.42, suggesting that subjects were able to master TCQ
forms in three months. The TCQ program attendance rate
was high at 83%. The reason for absence was mainly due to
clashing schedules with the medical appointments. For the
program evaluation, a 5-point Likert scale questionnaire was
used (5 indicated most and 1 indicated least satisfaction).
It measured the satisfactory level of subjects who partic-
ipated in the TCQ class. The overall mean score was 4.57
out of 5, demonstrating the high satisfaction of the subjects
in the TCQ program. Additionally, 92% of subjects stated
they would continue practicing TCQ after the program com-
pleted.
Discussion
This study has been conducted in a primary care setting, and
the results are applicable to the COPD clients in the commu-
nity. The study aimed to evaluate the effectiveness of a TCQ
program in enhancing physiological health of COPD clients.
The TCQ group was compared with the exercise group and
the control group over a 3-month period. TCQ did contribute
 8
Table 2 Comparison of outcome variables at baseline, 6th week and 3rd month.

TCQ (n = 70) Exercise (n = 69) Control (n = 67)

Change from last Measurement Change from last Measurement Change from last Measurement RANCOVA

M (SD) M (%) M (SD) M (%) M (SD) M (%) p-Value 2

FVC, litre .002* .06

Baseline 1.97 (.62) 1.84 (.52) 1.82 (.58)
6-Week 2.08 (.65) .11 (5.58) 1.87 (.59) .03 (1.63) 1.73 (.56) .09 (4.95)
3-Month 2.10 (.62) .02 (.96) 1.92 (.63) .05 (2.67) 1.74 (.58) .01 (.58)
FEV1 , litre <.001* .02
Baseline .89 (.38) .91 (.39) .89 (.39)
6-Week .96 (.40) .07 (7.87) .92 (.39) .01 (1.10) .85 (.36) .04 (4.49)
3-Month .96 (.39) 0 (0) .92 (.38) 0 (0) .85 (.35) 0 (0)
6MWD, meters
Baseline 297.91 (68.53) 284.64 (79.11) 289.75 (72.97) <.001* .06
6-Week 316.37 (60.15) 18.46 (6.20) 291.33 (84.82) 6.69 (2.35) 283.55 (82.25) 6.20 (2.14)
3-Month 330.74 (61.86) 14.37 (4.54) 290.04 (80.09) 1.29 (.44) 294.57 (78.05) 11.02 (3.89)
BORG SCALE
Dyspnoea .542
Baseline 1.98 (1.21) 1.38 (1.74) 1.51 (1.43)
6-Week 1.84 (1.38) .14 (7.07) 1.74 (1.37) .36 (26.09) 2.02 (1.50) .51 (33.77)
3-Month 1.86 (1.25) .02 (1.09) 1.70 (1.38) .04 (2.30) 2.06 (1.53) .04 (1.98)
Fatigue .517
Baseline 1.49 (1.46) 1.38 (1.42) 1.31 (1.44)
6-Week 1.72 (1.35) .23 (15.44) 1.38 (1.36) 0 (0) 1.78 (1.61) .47 (35.88)
3-Month 1.56 (1.39) .16 (9.30) 1.42 (1.32) .04 (2.90) 1.66 (1.37) .12 (6.74)
SaO2 , % .096
Baseline 94.60 (5.52) 94.33 (4.80) 94.72 (3.49)
6-Week 94.11 (3.95) .49 (.52) 93.77 (5.54) .56 (.59) 94.75 (2.98) .03 (.03)
3-Month 94.03 (5.46) .08 (.09) 94.25 (5.07) .48 (.51) 94.33 (3.31) .42 (.44)
FVC, forced volume capacity; FEV1 , forced expiratory volume in 1 s; 6MWD, 6-min walking distance; SaO2 , oxygen saturation. RANCOVA, repeated measures of analysis of covariate.

A.W.K. Chan et al.

* p < .0.5.
Tai Chi Qigong improves physiological functions: A RCT 9

Figure 2 Changes in the forced vital capacity (FVC, litre) from

baseline. T2 T1, changes at 6th week study endpoint from Figure 3 Changes in the forced expiratory volume in 1 s (FEV1 ,
baseline; T3 T1, changes at 3rd month study endpoint from litre) of the study groups. T2 T1, changes at 6th week study
baseline. endpoint from baseline; T3 T1, changes at 3rd month study
endpoint from baseline.
noticeable improvement in health outcomes with respect to
lung functions and activity tolerance.
Due to reduced physical abilities, people with COPD may
not be able to carry out exercises at high-intensity levels.
Despite the fact that much of the evidence pertaining to the
physiological benet of exercise is based on conventional
physical exercise, such as walking, jogging, swimming and
cycling, the role of other complementary and alternative
modes of exercise also deserves attention.31 TCQ has been
selected in this study because it has a number of potential
advantages for health promotion among people with chronic
illnesses. Studies have shown that practicing TCQ in a sup-
portive atmosphere can foster feelings of self-efcacy.32
Through continuous practice, the subjects gradually devel-
oped mastery, which may have the effect of increasing their
condence in disease management and treatment compli-
ance. In addition, through the TCQ program, subjects could
increase their abilities to be more independent in terms of Figure 4 Changes in the 6-min walk distance (meters) of the
self-care and decrease their feelings of physical dysfunc- study groups. T2 T1, changes at 6th week study endpoint from
tion due to the disease. TCQ was also well tolerated and baseline; T3 T1, changes at 3rd month study endpoint from
enjoyed by the subjects. This might be the reason for the baseline.
higher compliance rate and less attrition due to no interest
to continue in the TCQ group (n = 2) than in the exercise
(n = 10) and the control groups (n = 11).
Regarding the exercise group, breathing and walking
exercise was adopted as an active control intervention.
Although no signicant improvement was shown in physi-
ological health status, subjects in this group were able to
maintain their lung functions and exercise endurance at
a comparatively stable level with no signicant decline in
FEV1 and FVC, as well as any negative changes in 6MWT. In
view of the progressive decline of lung functions in the con-
trol group from the gures reported above, regular exercise
could certainly help to maintain functional capacity, slow
down disease progression, and postpone disability in COPD
clients. Therefore, clients should be advised to perform reg-
ular exercises, and TCQ should be highly recommended.
In dealing with missing data, the ITT approach was Figure 5 Changes in the number of exacerbations of the
adopted. One of the most popular methods in random- study groups. T2 T1, changes at 6th week study endpoint from
ized study is the last observation carried forward (LOCF) baseline; T3 T1, changes at 3rd month study endpoint from
analysis.33 This strategy assumes that the last observation of baseline.
10 A.W.K. Chan et al.

Table 3 Pairwise comparisons for FVC and 6MWD among the three groups at 3rd month.

Outcome variable Group Group p-Valuea 95% for differencea

FVC TCQ Exercise .573 .10 to .35

Control .012* .05 to .50
Exercise TCQ .573 .35 to .10
Control .322 .07 to .37
6MWD TCQ Exercise .027* 3.10 to 50.86
Control .031* 2.50 to 50.65
Exercise TCQ .027* 50.86 to 3.10
Control .973 24.22 to 23.41
FVC, forced volume capacity; 6MWD, 6-min walking distance.
a Adjustment for multiple comparisons: Bonferroni.
* The mean difference is signicance at the .05 level.

each dropout subject is an unbiased representation of what
is missing. Although it is argued that the LOCF is conservative
and that it will dilutes the treatment effect,34 this approach
analyzes data collected from all the subjects and takes into
consideration the inuence of attrition35 and compliance36
on study outcomes. Thus, it can be seen as more appropriate
in reecting the usual clinical circumstances.
The limitation of this study is its short duration. A
previous study of a 26-week Tai chi program has shown
improvement in the psychosocial health of elderly clients
in three months and such improvement becomes substan-
tial over a period of six months.31 No signicant changes in
dyspnoea and fatigue scores have been recorded, although
changes may have been apparent if an extension of the study
duration has been implemented. With the majority of the
TCQ subjects expressing their desire to continue practic-
ing TCQ and the high compliance rate of daily self-practice,
future studies should look at a longer period of follow-up
assessment. It would be benecial to assess the long term
adherence of participants and monitor the effectiveness of
TCQ practice in disease progress. In addition, due to the
small number of female subjects enrolled in this study, gen-
der differences on the TCQ effects could not be examined.
More female subjects, if available, should be recruited in
future studies so that gender differences on the therapeutic
effects of TCQ can be evaluated.
at any time and place without close supervision. From the
social perspective, given the ever-rising costs in the health
care system, adopting a low-cost behavioral modality to
enhance health is particularly important.31
Conclusion
This study conrms that the 3-month TCQ program has bene-
cial effects on respiratory functions and activity capacity of
COPD clients. While breathing and walking exercise did not
show signicant improvement in physiological health status,
regular practice could maintain physiological function at a
comparatively stable level and slow down the disease pro-
gression. The insignicant results of Borg scale and hospital
admission rates in our study could be due to the short study
period that may not reect the potential long-term effects
of TCQ on health outcomes. The benets of practicing TCQ
on COPD clients should be further investigated with a longer
follow-up periods in order to detect further improvements
in physiological and psychosocial status. Given that COPD
clients do place a nancial burden on the current health
care system, TCQ should be an affordable and cost-effective
form of exercise to enhance the well-being of COPD clients.
Acknowledgments

This study was funded by:

Implications

This is the rst study using the 13-form TCQ in a pop-
ulation group with COPD. It provides new evidence that
TCQ is benecial for enhancing physiological health among
COPD clients. Our study has also demonstrated that TCQ can
enhance psychosocial health of COPD clients as published
elsewhere.37 TCQ, which is effective, safe and feasible, can
be recommended as an adjunctive intervention to standard
medical treatments. Integrating TCQ into the daily activities
of clients provides a good opportunity for them to actively
and independently participate in their own care.
From the perspective of health professionals, running a
TCQ program does not impose heavy economic load. Only
a TCQ instructor is needed and no special equipment is
required. In addition, TCQ is easily accessible in the com-
munity; once learned, people can perform it conveniently
(1) Health and Health Services Research Fund (HHSRF:
06070201), Research Ofce, Food and Health Bureau,
18/F, Murray Building, Garden Road, Central, Hong Kong.
(2) Lee Hysan Foundation Research Grant and Endowment
Fund Research Grant (CA11125), United College, the
Chinese University of Hong Kong, Shatin, N.T., Hong
Kong.
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