Huangqi1, Liang Fengxia1

(1 Hubei University of Chinese Medicine, Institute of Acupuncture & Moxibustion / Hubei Provincial Collaborative Innovation Center of Preventive Treatment by Acupuncture & Moxibustion)

Abstract: Background: Qigong is a kind of traditional Chinese exercise combining breathing,movement, and meditation in order to keep fit for the purpose of preventing disease and prolonging life. Methods: Within this short article some topics like clinical efficacy and mechanism of health-care Qigong, the impact on the respiratory function and on the cardiovascular function, the influence on the immune system, the impact on the emotional aspects and brain function research on Qigong will be discussed briefly. Results: Light imagination during meditation showed a 22.2% increase of the mean blood flow velocity in the posterior cerebral artery and a mean reduction of blood flow velocity of 23.1% in the middle cerebral artery in a male Qigong master. Conclusions: In summary, the clinical efficacy of Qigong cannot be denied. Health-care Qigong exercise may prevent diseases however more scientific studies with high quality are also needed.

Keywords： Qigong; Preventive Medicine; Clinical Efficacy; Respiratory Function; Cardiovascular Function;

Qigong in health care and clinical efficacy

Qigong is a kind of traditional Chinese exercise that combines breathing, exercise, and meditation to stay physically fit to prevent or reduce disease and prolong life. It can be roughly divided into four categories[1]. One part includes, for example, medical Qigong, Qigong in Confucianism, Qigong in Taoism and active Qigong. Depending on the position you can distinguish standing Qigong, sitting Qigong, lying Qigong, and so-called active Qigong. A classification can also be made in dynamic and static Qigong. The well-known different kinds of Tai Chi (Tai Ji Quan) belong to dynamic Qigong. In addition, there are many other distinguishing possibilities depending on the characteristics, content and function. The basic principles of the Qigong are very well described in textbooks and accessible to western literature [2,3].

In ancient China, Qigong was often referred to only for expiration and inspiration to guide the so-called Qi and to initiate the Qi flow through physical and breathing exercises, but also to promote educational activities through meditation. In the 1980s, the development of Qigong therapy began to unfold, and research on its nature, underlying mechanism, clinical efficacy, and classical literature has made great progress. Political developments before 2001, however, led to a sinking enthusiasm in the field of Qigong research[4]. To help people in China to get a better understanding of Qigong therapy, the Chinese government has launched a series of health Qigong measures for self-rehabilitation and self-realization since 2002[4]. Qigong sports become a necessary part of physical education in some universities in China, and students of acupuncture & moxibustion and massage specialty take professional course to learn systematic training methods of Qigong to help in massage exercise.

Muscle-bone strengthening exercise (Yi Jin Jing), the game of the five animals (Wu Qin Xi), the six healing lutes (Liu Zi Jue) and the eight brocade exercises (Ba Duan Jin) are currently the main health care exercises in the area of Qigong in China[5], which is derived from Health Qigong Management Center of China National Sports General Administration in 2004. With the development of preventive medicine, Qigong has gradually developed into a research hotspot in Chinese medicine, as it is indicated to regenerate the body adequately, to prevent disease, to alleviate symptoms, and sometimes even to cure diseases. This article summarizes the function of Qigong in various diseases, with a view to disclosing its underlying mechanism.

The effects on the respiratory function

Health-promoting Qigong as physical activities has long-term positive effects on the function of the respiratory system and the cardiovascular system. This is especially true for older patients.

Investigations in China have confirmed that the muscle strength, especially those of the lower limb, as well as the lung capacity after a 75-day Qigong therapy were significantly strengthened[6]. Increasing clinical evidences have shown that Qigong can alleviate common symptoms of chronic obstructive pulmonary disease, such as dyspnoea, abnormal sputum, or chronic cough, and can increase pulmonary capacity by increasing the strength of the respiratory muscles, thereby improving the quality of life of patients[7-9]. Besides, Qigong,for example the sitting eight brocade exercises, requires slow action and focusing on the adjustment of breathing[10].Breathing control training can relax muscles of the chest and shoulder by utilizing the diaphragm to breathe, which is an effective breathing mode with less energy consumption, subsequently leading to alleviation of  the symptoms of dyspnoea[10].

Effects on cardiovascular function

Numerous Chinese researchers also studied the effects of Qigong on the cardiovascular system. Wang considered  "Qi"  as a form of vibration energy derived from rhythmic body movements[11]. This energy is used to promote resonance with the heartbeats, which is a major factor in improving the health condition[11]. It is reported that both the systolic blood pressure and the diastolic blood pressure in a group that performed regular exercise significantly decreased compared to a control group without movement[12,13]. Similar positive results are also found in heart rate, stress, cardiac output, lipids and heart function[14]. These may be related to the excitability of the sympathetic nerve. Studies showed that the rise of α1 wave and the decline of βwave of electroencephalogram(EEG) under Qigong exercises contributed to the inhibition in the cerebral cortex, thereby reducing excitability of the sympathetic nerve and rising the vagus nerve excitability[15]. Results from systematic review based on RCT studies concluded that health Qigong Ba Duan Jin was hopeful to benefit the patients with coronary heart diseases, reducing the number of angina episodes and shortening the duration of angina pectoris, with the improvement of the anxiety and depression situation. More researches of large-scale, multi-center with high-quality are needed to prove the effectiveness of Ba Duan Jin for CHD[16].

The influence on the immune system

Strict adherence to given Qigong exercises is also seen in China as a method of improving the immune system of the body. Wu Qin Xi (the game of the five animals), a kind of health Qigong, plays an important role in the positive development of the activity of NK cells and the immune system through posture, breathing and meditation[17]. There are scientific evidences showing that immunoglobulin and Th1 /Th2 /Treg cells were enhanced by Qigong exercises[18-20].It is well known that Treg cell is a subgroup of T cells with immune negative regulation, which can inhibit the activation and proliferation of other immune effector cells and play an important role in immune system[21]. Due to this characteristic, Cao and his colleagues selected the representative Th1 / Th2 / Treg cell-associated cytokines for the research and demonstrated that moderate exercise improved the body's immune function, whereas excessive exercise could lead to immunosuppressant effects[20]. Differently, Lee investigated the effect of Qigong on intracellular signalling and demonstrated that the endogenous growth hormone(GH) was released during and immediately after Qigong training, which could mediate the priming of O2- production by neutrophils PMNs via tyrosine kinase[22]. This implies the molecular mechanism in immune system by Qigong exercises. 

The impact on emotional aspects

Emotion is the experience of attitude to objective things that have a great impact on people's lives, work and health. According to epidemiological studies, over three per cent of the elderly worldwide suffer from severe depression and/or emotional disorders[23], especially when they are in chronic conditions[24]. It could be noted that those people who regularly perform Qigong exercises are less affected by emotional fluctuation than others who never do such exercises[25,26]. There is also a reduction of anxiety by Qigong, which is particularly helpful in the early stages of the depression[27]. These results may be linked to the Qigong principle of the concentration of attention, the coordination of breathing with movement, the orientation of the right body posture. The decreasing of the activity and volitional control lead to the low mentation, thereby inducing depression in the elderly and the people in chronic conditions[28].Besides, Qigong relieves the  tension and stress, and guides the body to release the cumulative bio-energy  in the static state[29].

Brain function research and Qigong

In previous scientific studies [30,31] we investigated changes in cerebral blood flow velocity, near-infrared spectroscopic parameters, electroencephalogram, and stimulation-induced 40 Hz oscillations during Qigong in well-trained individuals. With special probe support constructions, effects after light stimulation and light imaging on the flow velocity of the blood in the posterior cerebral artery (PCA) and the middle cerebral artery (MCA) were objectivised and quantified [32]. In this context, Niehaus et al. [33] presented normal values of visually evoked blood flow alterations in 30 healthy volunteers. During 60 seconds of light stimulation, the mean blood flow velocity in the PCA increased by 13.8% without significant side differences. In a study of 15 healthy volunteers, our research team found that the mean blood flow velocity during light stimulation was increased by 15% in the PCA and by 4.3% in the MCA [34]. Using a special eye acupuncture scheme, the mean blood flow velocity in the PCA increased by 12.5%, while the velocity in the MCA decreased by 4.5% [34]. In the meditation study (Figure 2), light imagination showed a 22.2% increase in the PCA and a mean reduction of blood flow velocity of 23.1% in the MCA in a male subject (Qigong Master). A second study showed a similar trend, but with minor changes (PCA: + 8.8%, MCA: - 4.8%) [30,31]. During Qigong ,EEG alpha activity occurred predominantly in the anterior half  of the brain and occurred silently in the posterior half [31].Besides, the frequency of EEG alpha rhythm of Qigong state  was slower than in the resting state[31]. Changes in brain activity during meditation were already described by Wallace  in 1970[35]. Studies indicated that experienced Qigong masters of transcendental meditation as well as novices showed increased alpha coherence compared to resting state with eyes closed [36] . Qigong state is considered as a special state of excitation according to a task networks in action, but not a state of consciousness between wakefulness and sleep[36,37].

Discussion

In the scientific database Pubmed (www.pubmed.gov), there are currently more than 100 published reviews on the Qigong (February 2017), most of which have been published in the last ten years. In addition to the above-mentioned indications, Qigong may be helpful in the treatment of diseases of hematologic system, musculoskeletal system and other systems [38,39]. With the globalization of economic and cultural health care, Qigong has gradually been extended to an international level and partially accepted by the international community. Hempel et al. [40], for example, summarized findings on Tai Chi, published in international journals. In addition, Qigong has also received international medical attention in the health care sector for various other medical conditions. These include balance and postural control[41], osteoarthritis[42], rheumatoid arthritis[43], osteoporosis[44], psycho physiological disorders[45], depression[46], immune system modulation[47], cardiovascular disorders and hypertension[48,49].

In China scientific research on the mechanism of action of Qigong can be traced back to the fifties and sixties of the 20th century. Results of a number of studies have provided evidence for the inclusion of Qigong exercises in the prevention of diseases and the improvement of the quality of life. Advantages of improved respiratory regulation and thus of the lung function are to be mentioned first. Desired increases in blood flow, an improvement in the blood pressure situation and an adjustment of the heart rate by regular Qigong exercises must also be mentioned here. Further Chinese studies show that the change in the number of white blood cells under different circumstances when practicing Qigong changes measurably[50]. Other blood parameters, such as glucose tolerance, also provide positive modulation after Qigong exercises[50]. Functional changes in the cerebrum and sub cortical alterations are measurable[51]. In recent years, research on the mechanism of Qigong has also been made by advancing into the molecular and genetic level. Some studies from China have provided evidence that Qigong exercises can regulate the signal pathways in cells and affect hormone levels, thereby developing a positive effect on the whole body[52,53].

A meta-analysis on Qigong in patients with chronic diseases (including diabetes, coronary heart disease and hypertension) showed that the most prominent positive effects of Qigong can be achieved in the immune system, cardiopulmonary function, and depression[54]. The underlying mechanisms can be related to a number of psycho-physiological effects, including improvement of the immune response, adaptation of the function of the sympathetic and parasympathetic nervous system, acceleration of metabolism and blood flow, and enhancement of the respiratory function[54].

Effects of Qigong and Tai Chi on brain function were also investigated in Europe using the most modern neuromonitoring methods [30,31,55]. Results from multidirectional transcranial Doppler sonography, electroencephalogram, stimulation-induced 40 Hz oscillations, near-infrared spectroscopy and heart rate variability have been published in previously [30,31,55]. Modern neuromonitoring seems to be able to elucidate some of the ancient myths of Chinese meditation technique.

Moreover, randomised controlled trials about Qigong in the treatment or rehabilitation are now being carried out in China [56,57]. Qigong could be regarded as an adjunct measure in clinical practice, while the results are needed to provide more objective clinical outcome measures with long-term follow-up.

Conclusions

In summary, the clinical efficacy of Qigong cannot be neglected. Qigong's health-enhancing effect can be derived from many aspects according to mechanism research. The "three-regulation principle" (the breathing, the movement and the spirit) has a positive effect on body and spirit. In addition, Qigong can prevent onset of diseases and the development of diseases. This health care is clearly consistent with traditional Chinese medicine.

References 

[1] Wei N. Summary of Qigong Classification.Journal of Fujian Institute of Physical Education(Fujian Tiyu Xueyuan Xuebao).1992; (2):70-72,76

[2]Elleberger O. Qigong für Therapeuten: Vom Umgang mit positiven und negativen Energien. Munich: Elsevier Urban & Fischer; 2005.

[3]Wenzel G. Qigong. Quelle der Lebenskraft. Bad Sauerbrunn: Edition Tau; 2000.

[4]Zhao D, Ge LB, Feng XX. Analysis of Qigong Literature in 1989 – 2009. Journal of Traditional Chinese Medicine(Zhongyi WenXian Zazhi). 2011; (5):14-18

[5]Chen XQ, Wang F, Lu JT. Research Review of Chinese Health Qigong. Wushu Science(Boji ·Wushu Kexue).2012;9(6):102-103.

[6] Zeng YG, Zhou XQ, Wang AL,Yang BL, Wang ST.Research on the Impacts of Fitness Qigong·BaDuanJin on Figure and Physical Function among the Middle-aged and Aged People. Journal of Beijing Sport University(Beijing Tiyu Daxue Xuebao).2005;28(9):1207-1209.

[7]Xiao CM, Zhuang YC. Efficacy of Liuzijue Qigong in Individuals with Chronic Obstructive Pulmonary Disease in Remission. J Am Geriatr Soc.2015;63(7):1420-1425.

[8]Zhu Z,Zhang SQ. Effect of lung Rehabilitation by Health Qigong on Respiratory Function and Quality of Life in Stable Patients with Chronic Obstructive Pulmonary Disease. Jilin Journal of Traditional Chinese Medicine(Jilin Zhongyiyao).2012;32(8):803-804. 

[9]Chan AW, Lee A, Suen LK, et al. Effectiveness of a Tai chi Qigong program in promoting health-related quality of life andperceived social support in chronic obstructive pulmonary disease clients.Qual Life Res. 2010;19(5):653-664.

[10]Xu YH, Wang JH, Li HF, et al. Efficacy of integrative respiratory rehabilitation training in exercise ability and quality of life of patients with chronic obstructive pulmonary disease in stable phase: a randomized controlled trail. J Chin Integr Med.2010;8(5):432-437. 

[11]Wang WG.The Musical Movements of“Qi”. Taipei: Locus Publishing Company,2002.

[12]Chen D. Effect of Health Qigong Mawangdui Guiding on Blood Pressure of Individuals with Essential Hypertension. J Am Geriatr Soc. 2016;64(7):1513-1515.

[13]Wang LJ. Effect of TaiChi on the Cardiovascular Function of the Elderly.Chin Med Herald(Zhongguo Yiyao Daobao). 2009;6(6): 155-156.

[14] Li ZW,Zhou LJ. Intervention Effect of Wu Qin Xi of Health Qigong on Patients with Abnormal lipid. Journal of Guangzhou Sport University(Guangzhou Tiyu Xueyuan Xuebao). 2009,29(4):97-99.

[15] Liu WJ. Influences of Eight-week-practice Health Qigong Baduanjin on Human EEG and HRV.

Beijing Sport University(Beijing Tiyu Daxue).2012.

[16] SUN HL, WANG SR, WANG YH. Systematic Review of Ba Duan Jin Application in Rehabilitation of Coronary Heart Disease [J]. Journal of Changchun University of Traditional Chinese Medicine(Changchun Zhongyiyao Daxue Xuebao). 2016,32(2): 326-329. 

[17] Yu DH, Wu JM. Effects of the Wu Qin Xi of Health Qigong on Elderly NK cells. Journal of Shanghai University of Sport(Shanghai Tiyu Xueyuan Xuebao). 2008,(1): 57-58.

[18] Taylor JJ, Mohrs M, Pearce EJ. Regular T cell response develop in parallel to Th response and control the magnitude and phenotype of the Th effector population. J Immunol 2006,176(10): 5839-5847.

[19]Xi BS, Wang B. Effects of Mewangdui Guiding on Cardiovascular Function and Immunoglobulin in Aged Women. Chinese Journal of Gerontology(Zhongguo Laonianxue Zazhi). 2015,35(13):3662-3664.

[20]Cao Y. Effects of Health Qigong- BaDuanJin Exercise on Hba1c and Immune Function in II Diabetes Population. Journal of Guangzhou Sport University(Guangzhou Tiyu Xueyuan Xuebao). 2015,35(6):97-99.

[21] Khazaie K, von Bochmer H. The impact of CD4 + CD25 Treg on tumor specific CD8 + T cell cytotoxicity and cancer. Semin Cancer Biol,2006,16(2):124-136.

[22]Lee MS,Kim MK,Ryu H. Qi-training (Qigong) enhanced immune functions: what is the underlying mechanism?.The International Journal of Neuroscience, 2005,115(8):1099-1104.

[23] Serby M, Yu M. Overview: Depression in the elderly. Mount Sinai Journal of Medicine. 2003,70(1):38-44.

[24].Noel PH, Williams JW Jr, Unutzer J, et al. Depression and comorbid illness in elderly primary care patients: Impact on multiple domains of health status and well-being. Annals of Family Medicine, 2004,2(6):555–562.

[25]Zhai XY. Investigation on Cultivating Mental Hygiene with Gymnastic Qigong Practice. Journal of Henan Universtry of Chinese Medicine(Henan Zhongyi Xueyuan Xuebao). 2006 ,21(3):47-48.

[26]Zhang CH, Ma HY. The Influence of Four Fitness Qigongs’ Exercise on Emotional Health of Senior Citizens. Chinese Journal of Clinical Psychology(Zhongguo Linchuang Xinlixue Zazhi). 2011,19(3):393,407-409.

[27]Oh B, Butow P, Mullan B, et al. Impact of medical Qigong on quality of life, fatigue, mood and inflammation in cancer patients: a randomized controlled trial. Ann Oncol. 2010 ;21(3):608-614

[28]Tsang HW，Cheung L,Lak DC. Qigong as a psychosocial intervention for depressedelderly with chronic physical illnesses.International Journal of Geriatric Psychiatry, 2002,17(12):1146-1154.

[29] Xia LX. The Psychological Mechanism of Qigong .Science of Social Psychology. 1999 , 15(3): 53-57.

[30]Litscher G, Wenzel G. Hirnfunktionsforschung und Qigong. Schweiz. Zeitschr. GanzheitsMedizin. 2004; 16: 90-94.

[31]Litscher G, Wenzel G, Niederwieser G, Schwarz, G. Effects of Qigong on brain function. Neurol. Res. 2001; 23: 501-505.

[32]Aaslid R. Visually evoked dynamic blood flow response of the human cerebral circulation. Stroke. 1987; 17: 771-775.

[33]Niehaus L, Weber U, Lehmann R. Normwerte visuell evozierter Strömungsgeschwindigkeitsänderungen in der A. cerebri posterior. Klin. Neurophysiol. 2000; 31: 89-93.

[34] Litscher G, Cho ZH (Eds.). Computer-Controlled Acupuncture®. Lengerich Berlin Düsseldorf Leipzig Riga Scottsdale Wien Zagreb: Pabst Science Publishers; 2000.

[35] Wallace RK. Physiological effects of transcendental meditation. Science. 1970; 167: 1751-1754.

[36] Lehmann D, Faber PL , Tei S, et al. Reduced functional connectivity between cortical sources in five meditation traditions detected with lagged coherence using EEG tomography.NeuroImage. 2012;60(2):1574-1586.

[37] Zhang JZ, Zhao J, He QN. EEG Žndings during special psychical state (Qigong state) by means of compressed spectral array and topographic mapping. Comput Biol Med 1988; 18: 455–463

 [38]Jiao RY, Zhong GL, Pan HS.The Influences of Fitness Qigong Baduanjin on Erythrocyte Function of the Elderly. Fujian Sports Science and Technology(Fujian Tiyu Keji). 2013,32(4):25-27.

[39]Li TJ, Li X, Wang SZ. Surface Electromyography of low back pain with Health Qigong YiJinJing in special action. Fujian Journal of TCM(Fujian Zhongyiyao Daxue Xuebao). 2011,42(6):11-12.

[40]Hempel S,Taylor SL,Solloway MR,et al. Evidence Map of Tai Chi[M].Washington (DC): Department of Veterans Affairs (US),2014. 

[41]Wong AM, Lin YC, Chou SW, et al.Coordination exercise and postural stability in elderly people: Effect of tai chi chuan.Archives of Physical Medicine and Rehabilitation,2001,82(5):608-612.

[42]Lee MS, Pittler MH, Ernst E.Tai chi for osteoarthritis: A systematic review. Clinical Rheumatology, 2008,27(2):211-218.  

[43]Lee MS, Pittler MH, Ernst E.Tai chi for rheumatoid arthritis:Systematic review. Rheumatology (Oxford),2007,46(11):1648-1651.

[44]Wayne PM, Kiel DP, Krebs DE, et al.The effects of tai chi on bone mineral density in postmenopausal women: A systematic review. Archives of Physical Medicine and Rehabilitation,2007,88(5):673-680.

[45]Lee LY, Lee DT, Woo J. Effect of tai chi on state self-esteem and health-related quality of life in older Chinese residential care home residents.Journal of Clinical Nursing,2007,16(8):1580-1582.

[46]Tsang HW, Fung KM, Chan AS, et al.Effect of a Qigong exercise programme on elderly with depression.International Journal of Geriatric Psychiatry ,2006,21(9):890-897.

[47]Irwin MR, Olmstead R, Oxman MN. Augmenting immune responses to varicella zoster virus in older adults: A randomized,