Complementary Therapies in Medicine (2014) 22, 244—250
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
Effect of qigong training on fatigue in haemodialysis patients: A non-randomized controlled trial Chin-Yen Wu a, Hui-Mei Han a, Mmi-Chiung Huang a, Yu-Ming Chen b, Wen-Pin Yu a, Li-Chueh Weng c,∗ a
Nursing Department, Chang Gung Medical Foundation Linkou Branch, No. 5, Fuxing Street, Guishan Township, Taoyuan County 333, Taiwan b Medical Department, Chang Gung Medical Foundation Linkou Branch, No. 5, Fuxing Street, Guishan Township, Taoyuan County 333, Taiwan c School of Nursing, Chang Gung University, 259, Wen-Hwa 1st Road, Kwei-Shan, Taoyuan 33302, Taiwan Available online 10 January 2014
KEYWORDS End-stage renal disease; Fatigue; Haemodialysis; Qigong
Summary Background: Fatigue is a debilitating symptom in haemodialysis patients. Qigong presents a potentially safe modality of treatment for chronic fatigue patients but has not yet been evaluated in haemodialysis patients. Objective: The aim of this study is to investigate whether qigong exercise affects fatigue in haemodialysis patients. Design: A 6-month non-randomized control trial with six measurement periods was conducted. The qigong group was taught to practice qigong three times per week for six months. The control group received usual routine care. Main outcome measure Fatigue, as measured by the ‘‘Haemodialysis Patients Fatigue Scale’’. Results: A total of 172 patients participated in this study, with 71 patients in the qigong group and 101 patients in the control group. The results indicated that all patients experienced mild to moderate fatigue. There was no difference between the qigong and control groups in fatigue at baseline. However, fatigue was lower in the qigong group than in the control group at 8 weeks (43.5 vs. 53.9), 12 weeks (44.7 vs. 53.6), 16 weeks (43.2 vs. 50.8), 20 weeks (42 vs. 50.2), and 24 weeks (41.4 vs. 48.4). The results, based on the generalized estimating equation method, showed that fatigue was significantly lower in the qigong group than in the control group (odds ratio = 0.004, p = 0.005).
∗
Corresponding author. Tel.: +886 3 2118800 3205; fax: +886 3 2118800 5326. E-mail addresses: [email protected] (C.-Y. Wu), [email protected] (H.-M. Han), [email protected] (M.-C. Huang), [email protected] (Y.-M. Chen), [email protected] (W.-P. Yu), [email protected] (L.-C. Weng). 0965-2299/$ — see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctim.2014.01.004
Effect of qigong training on fatigue in haemodialysis patients
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Conclusion: Fatigue in the qigong group showed a continuous decrease, which was maintained until the end of data collection at 24 weeks. Thus, qigong presents a potentially effective and safe method to reduce fatigue in haemodialysis patients. © 2014 Elsevier Ltd. All rights reserved.
Introduction End-stage renal disease (ESRD) is a common chronic illness that has been increasing in incidence and prevalence around the world, including in Taiwan.1 Patients with ESRD are commonly treated with haemodialysis (HD). This treatment removes metabolites, including uremic toxins, and water through diffusion, convention, and ultrafiltration.2 Dialysis partially replaces kidney function, but patients endure many distressful symptoms.1,2 A common debilitating symptom in ESRD patients on maintenance HD is fatigue.3 Fatigue has been defined as a subjective feeling of tiredness, an unpleasant experience that is difficult with which to live.4,5 A high prevalence of fatigue, ranging from mild to severe, has been reported in HD patients.6,7 Fatigue in patients on HD has been associated with many physiological factors, including accumulation of metabolic waste, metabolic disturbance, abnormal energy consumption, and loss of appetite.6—8 Moreover, dialysis patients’ fatigue can worsen due to physical inactivity (sedentary behaviour) and emotional distress.7,9 Poor management of fatigue may limit physical activities, affect daily living, impair the quality of life, increase the risk of cardiovascular events, and negatively influence survival.3,5,10,11 Thus, fatigue is understood as a common, severe problem and needs management in ESRD patients on maintenance HD. Traditional Chinese medicine is based on the theory that discomfort, pain, and sickness are a result of a blockage or stagnation of energy flow through channels in the human body.12,13 In traditional Chinese medicine, fatigue is considered to reflect disharmony and depletion in the supply of energy, or ‘‘Qi’’, in the body. Qigong is one of the traditional complementary interventions used to strengthen Qi through self-practice.12,14 If performed regularly, qigong, which consists of a mindfulness technique, steady deep breathing, slow body movement, and relaxing one’s posture, affects the muscular system and leads to increased muscle strength and a sense of relaxation. It also may improve psychological functioning and diminish emotional stress and, thereby, beneficially affect fatigue.12,15 Previous studies have found that qigong represents a potentially safe method of treatment for chronic fatigue syndrome and cancer-related fatigue. In one study, in which 18 Caucasian, British females participated in qigong exercises, the results indicated a significant reduction in the symptoms of chronic fatigue.12 A randomized trial was used to assess the effect of a four-month qigong intervention programme among patients with chronic fatigue syndrome. The results indicated that fatigue symptoms and mental functioning were significantly improved in chronic fatigue patients who received qigong training, as compared to the controls.16 One trial included 162 cancer patients who participated in qigong training for 10 weeks. The results showed that the qigong training significantly improved their quality of life and reduced their fatigue.13 However, there are few
studies that have investigated the effect of qigong on fatigue in HD patients. Several studies have tested the effect of complementary therapy, such as acupuncture, yoga-based exercise, and acupressure, on the fatigue of HD patients.17—19 It is relatively simple for patients to practice qigong training as compared to other methods such as acupuncture and yoga-based exercise. The effect of qigong exercise on fatigue as well as the long-term effect in ESRD patients, however, has not yet been evaluated. If research provides evidence that qigong training will reduce the fatigue of HD patients, then it can be incorporated into the clinical care plan to improve patients’ well-being. Thus, the aim of this study is to investigate the effects of qigong exercise on fatigue in ESRD patients on HD. We hypothesized that patients who engage in qigong exercise would experience a reduction in fatigue and that the effect would be maintained for a six-month period.
Materials and methods Design A non-randomized control 6 month trial with six measurement periods (baseline, 8 weeks, 12 weeks, 16 weeks, 20 weeks, and 24 weeks after intervention) was conducted. The patients underwent HD three times per week on a MondayWednesday-Friday schedule or a Tuesday-Thursday-Saturday schedule at an HD centre that had an open design. This meant that random assignment of participants was difficult to achieve because patients in the experimental and control groups could come to the centre at the same time. To avoid contamination, we used a coin toss to assign the patients on the Monday-Wednesday-Friday schedule to the qigong group. The experimental group did qigong exercises 10 min per day, three times per week on their HD day at the centre and self-practiced twice per day on non-HD days at home. Patients were asked to record the times of qigong selfpractice in a diary. Patients in the control group received usual routine care. The qigong exercises were conducted for six months. A total of six months was chosen because, according to previous research, qigong, yoga, or tai chi participants may need more than three months to achieve the effects of the practice. In addition, the aim of this study was to evaluate the long-term effect of qigong training on fatigue.
Setting and participants ESRD patients who were undergoing maintenance HD three times per week at the outpatient dialysis units of a medical centre in northern Taiwan were recruited for the study. The inclusion criteria was a diagnosis of ESRD, having received regular HD treatment for at least 6 months, aged 18 years or
246
C.-Y. Wu et al. Accessed for eligibility (N = 182) Excluded (n = 10) No interest
Entry in trial (N = 172)
Coin toss used to decide the qigong group
Qigong intervention (n = 71)
Control usual care (n = 101)
Dropped out (n = 4)
Dropped out (n = 2)
Transferred to another hospital = 3
Hospitalized = 1 Died = 1
Died = 1
Figure 1
Consort diagram of the flow of patients in this study.
older, and conscious, alert, and oriented without a recent hospitalization or surgical intervention. A total of 182 patients met the inclusion criteria, and 172 agreed to participate in the study (10 patients had no interest in participating). There were 71 patients in the qigong group and 101 patients in the control group. Six patients were dropped from the study, of whom 4 were in the qigong group (3 transferred to another hospital, 1 died) and 2 were in the control group (1 was hospitalized, 1 died). The cause of death was related to disease progress. We also used the data obtained from this study to compute the achieved statistical power. The results showed that the statistical power of this study was 0.89 (the effect size was 0.496, 5% for a type-I error (˛), 2-sided). The flow of participants is shown in Fig. 1.
Intervention protocol Patients assigned to the intervention group received a qigong training booklet that provided an introduction to qigong, precautions, and procedures as well as a blank diary. The qigong training was held in the room or in a lounge located in the HD centre. A certified qigong master, who had trained in qigong for approximately 20 years, led the classes. First, the qigong master taught participants individually and ensured that each could do the procedure correctly. He then led the group practice for 10 min per day, three times per week on the HD day for 24 weeks (6 months). Participants also were encouraged to undertake home practice for at least 10 min twice per day. Thus, every participant in the qigong group was expected to practice qigong for at least 110 min per week. The qigong exercise in this trial is a simple method that involves ‘‘qi catching and filling’’. It consists of a mindfulness technique and relaxing postures and focuses on
rhythmic breathing with slowly moving one’s hand to one’s head. The instructions are as follows: 1. Gently close your eyes and try to relax and make your mind free from any distractions; relax your body and mind by calming your brain and coming to a natural state. 2. With your legs open to about shoulder width, point your toes forward and parallel to the floor, hang your hands down naturally, with your fingers naturally open, and place your palms toward your legs at a distance of about 10 to 15 cm. 3. With your head at the midline of your body, keep your head (Baihui DU20) upward. 4. Slow your breathing into a coordinated rhythm. With your palms facing up, inhale slowly and slowly lift your hands to your head. Once your hands are lifted to the top of your head, please imagine that you are holding a ball with energy (qi) between your palms. 5. Please imagine that you hold the energy ball steady, and then prime the energy (qi) through the top of your head (Baihui DU20) to your whole body. 6. Keep the relaxed posture and repeat steps 1 to 5 at least nine times. 7. The entire procedure should assure slow movement and gentle, slow, deep, and long breathing. Participants assigned to the control group received usual care and completed all measures in the same timeframe as did the intervention group. Usual care comprised appropriate medical and nursing intervention, without the qigong training.
Main outcome measures Fatigue was measured by the Haemodialysis Patients Fatigue Scale.20 To represent the construct of fatigue, this scale consists of five factors: decrease in energy and motivation, decrease in functional capacity, decrease in mental and cognitive function, decrease in daily activities, and depressive symptoms. This scale has been used with HD patients.20 The Cronbach’s ˛ for internal consistency reliability was 0.91 for the entire scale and 0.72—0.85 for the five subscales. The overall scale consists of 26 items that use a 4-point Likert-type scale that ranges from1 seldom or does not happen to4 happens almost every day. The range of scores is 26—104. A higher score indicates a higher level of fatigue. To assess home practice, participants in the qigong group were asked to keep a diary, which the research assistant collected at each data collection point. Participants were encouraged to report any adverse effects such as dizziness or sweating to the research assistant; however, none was reported. We also collected patient characteristics, including basic demographic data, gender, age, marital status, educational achievement, and regular exercise habits. In addition, we collected the duration from initial HD until the start of the study (in months) and serum haemoglobulin level at baseline.
Ethical considerations The research was conducted in accordance with the Code of Medical Ethics of the World Medical Association (Declaration of Helsinki) for experiments. Ethical approval was obtained from the institutional review board of the study site (approval number 100-2390 C). All participants were informed of the purpose and procedures of the study. Participants were assured of their right to refuse to participate or to withdraw from the study at any stage. If participants agreed to participate, then their written consent was obtained. A trained research assistant collected the data through participant interviews.
Statistical analysis The SPSS, Version 17.0 (SPSS, Inc., Chicago, IL, USA), software package was used for all statistical analyses. In analyses of primary outcomes, the intention-to-treat principle was used. Descriptive statistics (frequencies, means, and standard deviations) were used to describe and summarize baseline data. Chi-square tests and independent sample t-tests were used to investigate differences between the control and qigong groups. A generalized estimate equation model (GEE model) was used to examine the main effect of group and time on fatigue.
Results Participants’ characteristics Between November 2010 and October 2011, 182 patients met the inclusion criteria; among them, 10 patients were not interested in participating in the study. Therefore, a total of 172 patients were included in this study. The baseline characteristics of the participants are presented in Table 1. The mean patient age was 57.8 ± 11.3 years (range = 26—92 years). The patients comprised 54.7% women and 45.3% men. Most patients had an elementary (38.4%) or high school education (39.5%). Most were married (91.9%) and unemployed (63.4%). More than half engaged in regular exercise every week (55.2%). The mean duration of receiving HD was 79.9 months (range = 6—373 months). The mean haemoglobin level at baseline was 10.5 ± 1.1 gm/dl (range = 4.19—14 gm dl). The original cause for HD was as follows: kidney parenchymal disease (n = 32, 18.6%), DMrelated nephropathy (n = 64, 37.2%), hypertension-related nephropathy (n = 14, 8.1%), immune-related (n = 4, 2.3%), glomerulonephritis (n = 40, 23.3%), and unknown (n = 18, 10.5%). All patients were dialyzed using hollow fibre dialyzers that contained either Sinton® solution or Taita® solution combined with Bibag® powder (Fresenius Medical Care, Waltham, MA, USA) or Bicart® powder (Gambro Taiwan Ltd. Taipei, Taiwan), and all used bicarbonate-based dialysate. There were no significant differences in regard to age or months of HD between the control and qigong groups; the only significant difference was gender. Chi-square tests showed there were fewer male patients in the qigong group than in the control group (22 vs. 56, p = 0.003). The comparison of patients’ characteristics is also shown in Table 1.
247 mean score of fatigue
Effect of qigong training on fatigue in haemodialysis patients 60 50 40 30 Qigong
20
Control
10 0 baseline
T1
T2
T3
T4
T5
Figure 2 Mean scores of fatigue for the control and qigong groups from baseline to T5.
We further examined gender differences in fatigue level of both groups at different data collection times. For all patients, the results of independent sample t-tests showed that there was no significant difference between female and male patients at the different time periods, except at T4 (20 weeks), when the fatigue level was lower in female patients than in male patients (44.2 vs. 50.2, t = −2.44, p = 0.02). In addition, there was no significant difference in fatigue level between female and male patients, either in the control or the qigong group, at the time of data collection (Table 2).
Fatigue between the qigong and control groups Table 2 shows the levels of fatigue and the number of patients who completed the data collection. There were 172 patients at baseline, 166 (96.5%) at T1, 161 (93.6%) at T2, 151 (87.8%) at T3, 142 (82.6%) at T4, and 138 (80.2%) at T5. Of these, 71 patients (100%) were in the qigong group complete at baseline, 66 (92.9%) at T1, 62 (87.3%) at T2, 59 (83.1%) at T3, 54 (76.1%) at T4, and 51 (71.8%) at T5. The mean fatigue for all study patients was 54.1 (SD = 15.3) at baseline. From T1 to T5, all study patients’ fatigue levels were 49.7, 50.2, 47.8, 47.1, and 45.8, respectively. This indicated that patients experienced mild to moderate fatigue. The results of independent sample t-tests showed there were no differences between the qigong and control groups in fatigue at baseline (54.6 vs. 53.8, p = 0.75). Fatigue was significantly less in the qigong group than in the control group at T1 (43.5 vs. 53.9), T2 (44.7 vs. 53.6), T3 (43.2 vs. 50.8), T4 (42 vs. 50.2), and T5 (41.4 vs. 48.4). Data are shown in Table 3 and Fig. 2. We used the GEE model to examine the difference in fatigue between groups during the six time periods. GEE methods are widely used in the analysis of longitudinal data, especially when there are missing data. An unstructured working correlation matrix was used to analyze the main effect of group and time on fatigue. The results showed that group had a significant effect on fatigue (Wald chisquare = 7.54, p = 0.005). Fatigue was significantly lower in the qigong group than in the control group (B = −5.51, odds ratio = 0.004, p = 0.005). Fatigue also showed significant decreases at the five data collection points (time effect, Wald chi-square = 42.48, p < 0.001). The odds ratios were 0.001 (8 weeks), 0.002 (12 weeks), 0.003 (16 weeks), 0.022 (20 weeks), and 0.012 (24 weeks), respectively. The results are shown in Table 4.
248 Table 1
C.-Y. Wu et al. Homeogeneity test of characteristics between the two groups (N = 172).
Variable
Gender Male Female Education No Elementary High College Marital status Married Single Exercise Regular Irregular Employed No Yes
2
p
22 (31) 49 (69)
9.10
0.003**
12 (11.9) 38 (37.6) 40 (39.6) 11 (10.9)
8 (11.3) 28 (39.4) 28 (39.4) 7 (9.9)
0.09
0.99
158 (91.9) 14 (8.1)
93 (92.1) 8 (7.9)
65 (91.5) 6 (8.5)
0.02
0.90
95 (55.2) 77 (44.8)
40 (39.6) 61 (60.4)
37 (52.1) 34 (47.9)
2.16
0.14
109 (63.4) 63 (36.6)
65 (64.4) 36 (35.6)
44 (62.0) 27 (38.0)
0.03
0.87
All (N = 172)
Control (n = 101)
Qigong (n = 71)
n (%)
n (%)
n (%)
78 (45.3) 94 (54.7)
56 (55.4) 45 (44.6)
20 (11.6) 66 (38.4) 68 (39.5) 18 (10.5)
Variable
Age (26—92 yrs) HD months (6—373 mos.) HB at baseline (4.19—14 gm/dl)
All (N = 172)
Control (n = 101)
Qigong (n = 71)
M ± SD
M ± SD
M ± SD
57.8 ± 11.3 79.9 ± 69.4 10.5 ± 1.1
58.3 ± 11.5 76.9 ± 65.0 10.6 ± 0.98
57.1 ± 10.9 84.3 ± 75.4 10.5 ± 1.3
2
p
0.67 −0.69 0.64
0.51 0.49 0.52
Note: HD, haemodialysis; HB, haemoglobin; M, mean; SD, standard deviation. ** p < 0.01.
Table 2 Time
Baseline T1 T2 T3 T4 T5
Gender difference in fatigue between the two groups (N = 172). All (N = 172)
Control (n = 101)
Qigong (n = 71)
Male
Female
Male
Female
Male
Female
M ± SD
M ± SD
M ± SD
M ± SD
M ± SD
M ± SD
52.6 51.6 51.3 49.1 50.2 46.3
± ± ± ± ± ±
15.7 17.0 16.8 14.3 14.3 12.7
55.3 48.2 49.2 46.7 44.2 45.3
± ± ± ± ± ±
14.9 14.9 16.6 15.8 14.9a 16.1
52.3 54.1 53.8 50.8 51.2 47.3
± ± ± ± ± ±
15.8 16.5 17.2 14.3 13.1 12.7
55.8 53.5 53.3 50.9 48.8 49.7
± ± ± ± ± ±
15.4 16.4 16.8 13.9 15.3 16.1
53.7 44.5 44.2 44.4 47.4 43.4
± ± ± ± ± ±
15.7 16.7 13.9 13.3 17.3 12.4
54.9 43.2 44.9 42.7 39.3 40.4
± ± ± ± ± ±
14.7 13.9 15.4 16.8 12.7 14.8
Note: T1 = 8 weeks; T2 = 12 weeks; T3 = 16 weeks; T4 = 20 weeks; T5 = 24 weeks; M, mean; SD, standard deviation. a t = −2.44, p = 0.02.
Table 3
Comparison of fatigue between the two groups (N = 172).
Time
Total/qigong
All (N = 172) Mean ± SD
Baseline T1 T2 T3 T4 T5
172/71 166/66 161/62 151/59 142/54 138/51
54.1 49.7 50.2 47.8 47.1 45.8
± ± ± ± ± ±
15.3 16.5 16.7 15.2 14.8 14.5
Control (n = 101) Mean ± SD 53.8 53.9 53.6 50.8 50.2 48.4
± ± ± ± ± ±
15.6 16.4 16.9 14.1 14.1 14.2
Qigong (n = 71) Mean ± SD 54.6 43.5 44.7 43.2 42.0 41.4
± ± ± ± ± ±
15.0 14.7 14.8 15.8 14.8 14.0
Note: T1 = 8 weeks; T2 = 12 weeks; T3 = 16 weeks; T4 = 20 weeks; T5 = 24 weeks; SD, standard deviation. ** p < 0.01.
t
p
−0.32 4.12 3.38 3.11 3.29 2.79
0.75 0.000** 0.001** 0.002** 0.001** 0.006**
Effect of qigong training on fatigue in haemodialysis patients Table 4
249
Group effects on fatigue by GEE analysis (N = 172).
Variable Intercept Group Qigong Control Time Baseline T1 T2 T3 T4 T5
Wald 2 7.54
42.48
p
B
SE
Exp(B)
95% C.I.
p
56.16
1.43
−5.51 —
1.95
0.004
0.008—0.186
0.005**
1.22 1.18 1.27 1.11 1.04
0.001 0.002 0.003 0.022 0.012
0.001—0.007 0.001—0.020 0.001—0.030 0.003—0.200 0.001—0.090
0.000** 0.000** 0.000** 0.001** 0.000**
0.005**
0.000** — −7.35 −6.46 −5.95 −3.79 −4.45
Note: T1 = 8 weeks; T2 = 12 weeks; T3 = 16 weeks; T4 = 20 weeks; T5 = 24 weeks. ** p < 0.01.
Discussion Our study provides evidence for the effect of qigong on fatigue in ESRD patients on maintenance HD. In this study, patients in the qigong intervention group experienced significantly less fatigue than did those in the usual care control group. Our finding is consistent with results from previous studies that showed that qigong had a positive effect on fatigue in other patient groups.12,15,16 Moreover, our study revealed that the effect of qigong training on fatigue can be maintained for a long period (six months). There was no difference in fatigue between the two groups at baseline. This confirmed that the fatigue level was the same between the groups prior to the intervention. After the intervention, fatigue in the qigong group decreased and continued to decrease until the end of data collection at 24 weeks. This indicates that the qigong training had both a short-term effect as well as a long-term benefit on the fatigue of HD patients. The mechanism of qigong that may be responsible includes balancing breathing (qi) and energy, which may decrease emotional stress and perception of fatigue.14,21,22 Qigong also may result in an increase in oxygen and a decrease in carbon dioxide concentrations in the blood, which may help remove metabolic waste from the tissues.23 Increased physical activity may be another mechanism. Previous research has found that the sedentary lifestyle of HD patients is associated with fatigue.7 Qigong training consists of slow body movements that are tolerable and do not require much energy use, which may strengthen muscle power and improve daily physical functioning.12 Therefore, it is worthwhile to incorporate qigong exercise into the routine HD care plan. Fatigue in the control group also showed a decrease over the six months of data collection, which may have been due to the procedures of the study. To avoid contamination, we selected the patients on the Monday-Wednesday-Friday schedule to be in the experimental group. Nevertheless, there may have been some type of connection among participants. Additionally, participants may have given a desirable response when research staff approached them at data collection, even if they did not receive qigong training. The fatigue scale used in this study did not provide a cut point or reference score to indicate the significance of
clinical benefits. However, the difference in mean scores between baseline and 24 weeks of fatigue in the qigong group was 13.2 but only 5.4 in the control group. As noted, the post hoc statistical power for this study was adequate. Based on the results, we assume that the reduction in reported fatigue is clinically as well as statistically significant. More research may be necessary to confirm this notion. In this study, the completion rate of the qigong group was relatively low (76%) but comparable to a previous study that followed patients for 20 weeks (77%).16 Nevertheless, this study has several potential limitations. Due to the nature of the intervention, it was not possible to make use of a blinding protocol. To reduce the likelihood that patients would provide a desirable response, a third research assistant collected the pre- and post-intervention questionnaire. Participation in this study was voluntary, which may have created a potential selective bias, with those patients interested in qigong participating and those with no interest in qigong declining. More prospective and randomized trial will be needed to confirm these findings.
Conclusion This study investigated the long-term benefits of qigong, specifically, whether it is worthwhile in terms of improving optimal comprehensive care. As stated in the introduction, fatigue is a complex, common problem that needs comprehensively management by health care professionals. Qigong is one of the complementary therapies that can be of benefit to patients with fatigue by strengthening muscle power, improving psychological function, and diminishing emotional stress. Our results showed that 6 months of qigong training can reduce fatigue significantly and that qigong exercise can be integrated into the current clinical care plan to optimize the improvement of HD patient’s fatigue. The qigong procedure used in this study was easy to learn and had a significant effect on the reduction of fatigue. No adverse effects of qigong, such as uncomfortable breathing, sweating, or dizziness, were reported by the HD patients in this study. In addition, no patient in the qigong group left the
250 study due to adverse effects. In this study, the occurrence of adverse effects did not weaken the benefits of qigong training on fatigue. In fact, such effects were easy to overcome by pausing qigong training and taking a short rest. Thus, we can conclude that qigong is a safe and effective method for reducing fatigue in ESRD patients on maintenance HD. The mechanisms of qigong that have a positive effect on fatigue, however, warrant additional research.
Conflicts of interest All authors declare that there is no conflict of interest.
Acknowledgements This study was funded by the Chang Gung Medical Foundation-Linkuo Medical Centre in Taiwan. We also heartily thank Dr. Hsin Yun Liu for her expert contribution to the statistical analyses used in this study.
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C.-Y. Wu et al. [9]. McCann K, Boore JR. Fatigue in persons with renal failure who require maintenance hemodialysis. J Adv Nurs 2000;32:1132—42. [10].Bossola M, Vulpio C, Tazza L. Fatigue in chronic dialysis patients. Semin Dialysis 2011;24:550—5. [11].Delgado C, Johansen KL. Barriers to exercise participation among dialysis patients. Nephrol Dial Transpl 2012;27:1152—7. [12].Craske NJ, Turner W, Zammit-maempe J, Lee MS. Qigong ameliorates symptoms of chronic fatigue: a pilot uncontrolled study. Evid-Based Complement Alternat Med 2009;6:265—70. [13].Oh B, Butow P, Mullan B, Clarke S, Beale P, Pavlakis N, et al. Impact of medical qigong on quality of life, fatigue, mood and inflammation in cancer patients: a randomized controlled trial. Ann Oncol 2010;21:608—14. [14].Wang F, Man JK, Lee EK, Wu T, Benson H, Fricchione GL, et al. The effects of qigong on anxiety, depression, and psychological well-being: a systematic review and meta-analysis. Evid-Based Complement Alternat Med 2013:152738. [15].Oh B, Butow PN, Mullan BA, Clarke SJ, Beale PJ, Pavlakis N, et al. Effect of medical qigong on cognitive function, quality of life, and biomarker of inflammation in cancer patients: a randomized controlled trial. Support Care Cancer 2012;20:1235—42. [16].Ho RT, Chan JS, Wang CW, Lau BW, So KF, Yuen LP, et al. A randomized controlled trial of qigong exercise on fatigue symptom, functioning, and telomerae activity in persons with chronic fatigue or chronic fatigue syndrome. Ann Behav Med 2012;44:160—70. [17].Tsay SL, Cho Yc, Chen ML. Acupressure and transcutaneous electrical acupoint stimulation in improving fatigue, sleep quality and depression in hemodialysis patients. Am J Chinese Med 2004;32:407—16. [18].Yurtkuran M, Alp A, Yurtkuran M, Dilek K. A modified yogabased exercise program in hemodialysis patients: a randomized controlled study. Complement Ther Med 2007;15:164—71. [19].Kim KH, Kim TH, Kang JW, Sul JU, Lee MS, Kim JI, et al. Acupuncture for symptom management in hemodialysis patients: a prospective, observational pilot study. J Altern Complement Med 2011;17:741—8. [20].Lin CC, Lee YH, Hung CC, Lee BO. Development of a novel fatigue scale for hemodialysis patients. Formos J Med 2006;10:422—8. [21].Jahnke R, Larkey L, Rogers C, Etnier J, Lin F. A comprehensive review of health benefits of qigong and Tai Chi. Am J Health Promot 2010;24:1—25. [22].Oh B, Choi SM, Inamori A, Rosenthal D, Yeung A. Effects of qigong on depression: a systemic review. Evid-Based Complement Alternat Med 2013:134737. [23].Lee MS, Ryu H, Song J, Moon SR. Effects of Qi-training (qigong) on forearm blood gas concentration. Int J Neurosci 2004;114:1503—10.
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Effect of qigong training on fatigue in haemodialysis patients: A non-randomized controlled trial Chin-Yen Wu a, Hui-Mei Han a, Mmi-Chiung Huang a, Yu-Ming Chen b, Wen-Pin Yu a, Li-Chueh Weng c,∗ a
Nursing Department, Chang Gung Medical Foundation Linkou Branch, No. 5, Fuxing Street, Guishan Township, Taoyuan County 333, Taiwan b Medical Department, Chang Gung Medical Foundation Linkou Branch, No. 5, Fuxing Street, Guishan Township, Taoyuan County 333, Taiwan c School of Nursing, Chang Gung University, 259, Wen-Hwa 1st Road, Kwei-Shan, Taoyuan 33302, Taiwan Available online 10 January 2014
KEYWORDS End-stage renal disease; Fatigue; Haemodialysis; Qigong
Summary Background: Fatigue is a debilitating symptom in haemodialysis patients. Qigong presents a potentially safe modality of treatment for chronic fatigue patients but has not yet been evaluated in haemodialysis patients. Objective: The aim of this study is to investigate whether qigong exercise affects fatigue in haemodialysis patients. Design: A 6-month non-randomized control trial with six measurement periods was conducted. The qigong group was taught to practice qigong three times per week for six months. The control group received usual routine care. Main outcome measure Fatigue, as measured by the ‘‘Haemodialysis Patients Fatigue Scale’’. Results: A total of 172 patients participated in this study, with 71 patients in the qigong group and 101 patients in the control group. The results indicated that all patients experienced mild to moderate fatigue. There was no difference between the qigong and control groups in fatigue at baseline. However, fatigue was lower in the qigong group than in the control group at 8 weeks (43.5 vs. 53.9), 12 weeks (44.7 vs. 53.6), 16 weeks (43.2 vs. 50.8), 20 weeks (42 vs. 50.2), and 24 weeks (41.4 vs. 48.4). The results, based on the generalized estimating equation method, showed that fatigue was significantly lower in the qigong group than in the control group (odds ratio = 0.004, p = 0.005).
∗
Corresponding author. Tel.: +886 3 2118800 3205; fax: +886 3 2118800 5326. E-mail addresses: [email protected] (C.-Y. Wu), [email protected] (H.-M. Han), [email protected] (M.-C. Huang), [email protected] (Y.-M. Chen), [email protected] (W.-P. Yu), [email protected] (L.-C. Weng). 0965-2299/$ — see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctim.2014.01.004
Effect of qigong training on fatigue in haemodialysis patients
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Conclusion: Fatigue in the qigong group showed a continuous decrease, which was maintained until the end of data collection at 24 weeks. Thus, qigong presents a potentially effective and safe method to reduce fatigue in haemodialysis patients. © 2014 Elsevier Ltd. All rights reserved.
Introduction End-stage renal disease (ESRD) is a common chronic illness that has been increasing in incidence and prevalence around the world, including in Taiwan.1 Patients with ESRD are commonly treated with haemodialysis (HD). This treatment removes metabolites, including uremic toxins, and water through diffusion, convention, and ultrafiltration.2 Dialysis partially replaces kidney function, but patients endure many distressful symptoms.1,2 A common debilitating symptom in ESRD patients on maintenance HD is fatigue.3 Fatigue has been defined as a subjective feeling of tiredness, an unpleasant experience that is difficult with which to live.4,5 A high prevalence of fatigue, ranging from mild to severe, has been reported in HD patients.6,7 Fatigue in patients on HD has been associated with many physiological factors, including accumulation of metabolic waste, metabolic disturbance, abnormal energy consumption, and loss of appetite.6—8 Moreover, dialysis patients’ fatigue can worsen due to physical inactivity (sedentary behaviour) and emotional distress.7,9 Poor management of fatigue may limit physical activities, affect daily living, impair the quality of life, increase the risk of cardiovascular events, and negatively influence survival.3,5,10,11 Thus, fatigue is understood as a common, severe problem and needs management in ESRD patients on maintenance HD. Traditional Chinese medicine is based on the theory that discomfort, pain, and sickness are a result of a blockage or stagnation of energy flow through channels in the human body.12,13 In traditional Chinese medicine, fatigue is considered to reflect disharmony and depletion in the supply of energy, or ‘‘Qi’’, in the body. Qigong is one of the traditional complementary interventions used to strengthen Qi through self-practice.12,14 If performed regularly, qigong, which consists of a mindfulness technique, steady deep breathing, slow body movement, and relaxing one’s posture, affects the muscular system and leads to increased muscle strength and a sense of relaxation. It also may improve psychological functioning and diminish emotional stress and, thereby, beneficially affect fatigue.12,15 Previous studies have found that qigong represents a potentially safe method of treatment for chronic fatigue syndrome and cancer-related fatigue. In one study, in which 18 Caucasian, British females participated in qigong exercises, the results indicated a significant reduction in the symptoms of chronic fatigue.12 A randomized trial was used to assess the effect of a four-month qigong intervention programme among patients with chronic fatigue syndrome. The results indicated that fatigue symptoms and mental functioning were significantly improved in chronic fatigue patients who received qigong training, as compared to the controls.16 One trial included 162 cancer patients who participated in qigong training for 10 weeks. The results showed that the qigong training significantly improved their quality of life and reduced their fatigue.13 However, there are few
studies that have investigated the effect of qigong on fatigue in HD patients. Several studies have tested the effect of complementary therapy, such as acupuncture, yoga-based exercise, and acupressure, on the fatigue of HD patients.17—19 It is relatively simple for patients to practice qigong training as compared to other methods such as acupuncture and yoga-based exercise. The effect of qigong exercise on fatigue as well as the long-term effect in ESRD patients, however, has not yet been evaluated. If research provides evidence that qigong training will reduce the fatigue of HD patients, then it can be incorporated into the clinical care plan to improve patients’ well-being. Thus, the aim of this study is to investigate the effects of qigong exercise on fatigue in ESRD patients on HD. We hypothesized that patients who engage in qigong exercise would experience a reduction in fatigue and that the effect would be maintained for a six-month period.
Materials and methods Design A non-randomized control 6 month trial with six measurement periods (baseline, 8 weeks, 12 weeks, 16 weeks, 20 weeks, and 24 weeks after intervention) was conducted. The patients underwent HD three times per week on a MondayWednesday-Friday schedule or a Tuesday-Thursday-Saturday schedule at an HD centre that had an open design. This meant that random assignment of participants was difficult to achieve because patients in the experimental and control groups could come to the centre at the same time. To avoid contamination, we used a coin toss to assign the patients on the Monday-Wednesday-Friday schedule to the qigong group. The experimental group did qigong exercises 10 min per day, three times per week on their HD day at the centre and self-practiced twice per day on non-HD days at home. Patients were asked to record the times of qigong selfpractice in a diary. Patients in the control group received usual routine care. The qigong exercises were conducted for six months. A total of six months was chosen because, according to previous research, qigong, yoga, or tai chi participants may need more than three months to achieve the effects of the practice. In addition, the aim of this study was to evaluate the long-term effect of qigong training on fatigue.
Setting and participants ESRD patients who were undergoing maintenance HD three times per week at the outpatient dialysis units of a medical centre in northern Taiwan were recruited for the study. The inclusion criteria was a diagnosis of ESRD, having received regular HD treatment for at least 6 months, aged 18 years or
246
C.-Y. Wu et al. Accessed for eligibility (N = 182) Excluded (n = 10) No interest
Entry in trial (N = 172)
Coin toss used to decide the qigong group
Qigong intervention (n = 71)
Control usual care (n = 101)
Dropped out (n = 4)
Dropped out (n = 2)
Transferred to another hospital = 3
Hospitalized = 1 Died = 1
Died = 1
Figure 1
Consort diagram of the flow of patients in this study.
older, and conscious, alert, and oriented without a recent hospitalization or surgical intervention. A total of 182 patients met the inclusion criteria, and 172 agreed to participate in the study (10 patients had no interest in participating). There were 71 patients in the qigong group and 101 patients in the control group. Six patients were dropped from the study, of whom 4 were in the qigong group (3 transferred to another hospital, 1 died) and 2 were in the control group (1 was hospitalized, 1 died). The cause of death was related to disease progress. We also used the data obtained from this study to compute the achieved statistical power. The results showed that the statistical power of this study was 0.89 (the effect size was 0.496, 5% for a type-I error (˛), 2-sided). The flow of participants is shown in Fig. 1.
Intervention protocol Patients assigned to the intervention group received a qigong training booklet that provided an introduction to qigong, precautions, and procedures as well as a blank diary. The qigong training was held in the room or in a lounge located in the HD centre. A certified qigong master, who had trained in qigong for approximately 20 years, led the classes. First, the qigong master taught participants individually and ensured that each could do the procedure correctly. He then led the group practice for 10 min per day, three times per week on the HD day for 24 weeks (6 months). Participants also were encouraged to undertake home practice for at least 10 min twice per day. Thus, every participant in the qigong group was expected to practice qigong for at least 110 min per week. The qigong exercise in this trial is a simple method that involves ‘‘qi catching and filling’’. It consists of a mindfulness technique and relaxing postures and focuses on
rhythmic breathing with slowly moving one’s hand to one’s head. The instructions are as follows: 1. Gently close your eyes and try to relax and make your mind free from any distractions; relax your body and mind by calming your brain and coming to a natural state. 2. With your legs open to about shoulder width, point your toes forward and parallel to the floor, hang your hands down naturally, with your fingers naturally open, and place your palms toward your legs at a distance of about 10 to 15 cm. 3. With your head at the midline of your body, keep your head (Baihui DU20) upward. 4. Slow your breathing into a coordinated rhythm. With your palms facing up, inhale slowly and slowly lift your hands to your head. Once your hands are lifted to the top of your head, please imagine that you are holding a ball with energy (qi) between your palms. 5. Please imagine that you hold the energy ball steady, and then prime the energy (qi) through the top of your head (Baihui DU20) to your whole body. 6. Keep the relaxed posture and repeat steps 1 to 5 at least nine times. 7. The entire procedure should assure slow movement and gentle, slow, deep, and long breathing. Participants assigned to the control group received usual care and completed all measures in the same timeframe as did the intervention group. Usual care comprised appropriate medical and nursing intervention, without the qigong training.
Main outcome measures Fatigue was measured by the Haemodialysis Patients Fatigue Scale.20 To represent the construct of fatigue, this scale consists of five factors: decrease in energy and motivation, decrease in functional capacity, decrease in mental and cognitive function, decrease in daily activities, and depressive symptoms. This scale has been used with HD patients.20 The Cronbach’s ˛ for internal consistency reliability was 0.91 for the entire scale and 0.72—0.85 for the five subscales. The overall scale consists of 26 items that use a 4-point Likert-type scale that ranges from1 seldom or does not happen to4 happens almost every day. The range of scores is 26—104. A higher score indicates a higher level of fatigue. To assess home practice, participants in the qigong group were asked to keep a diary, which the research assistant collected at each data collection point. Participants were encouraged to report any adverse effects such as dizziness or sweating to the research assistant; however, none was reported. We also collected patient characteristics, including basic demographic data, gender, age, marital status, educational achievement, and regular exercise habits. In addition, we collected the duration from initial HD until the start of the study (in months) and serum haemoglobulin level at baseline.
Ethical considerations The research was conducted in accordance with the Code of Medical Ethics of the World Medical Association (Declaration of Helsinki) for experiments. Ethical approval was obtained from the institutional review board of the study site (approval number 100-2390 C). All participants were informed of the purpose and procedures of the study. Participants were assured of their right to refuse to participate or to withdraw from the study at any stage. If participants agreed to participate, then their written consent was obtained. A trained research assistant collected the data through participant interviews.
Statistical analysis The SPSS, Version 17.0 (SPSS, Inc., Chicago, IL, USA), software package was used for all statistical analyses. In analyses of primary outcomes, the intention-to-treat principle was used. Descriptive statistics (frequencies, means, and standard deviations) were used to describe and summarize baseline data. Chi-square tests and independent sample t-tests were used to investigate differences between the control and qigong groups. A generalized estimate equation model (GEE model) was used to examine the main effect of group and time on fatigue.
Results Participants’ characteristics Between November 2010 and October 2011, 182 patients met the inclusion criteria; among them, 10 patients were not interested in participating in the study. Therefore, a total of 172 patients were included in this study. The baseline characteristics of the participants are presented in Table 1. The mean patient age was 57.8 ± 11.3 years (range = 26—92 years). The patients comprised 54.7% women and 45.3% men. Most patients had an elementary (38.4%) or high school education (39.5%). Most were married (91.9%) and unemployed (63.4%). More than half engaged in regular exercise every week (55.2%). The mean duration of receiving HD was 79.9 months (range = 6—373 months). The mean haemoglobin level at baseline was 10.5 ± 1.1 gm/dl (range = 4.19—14 gm dl). The original cause for HD was as follows: kidney parenchymal disease (n = 32, 18.6%), DMrelated nephropathy (n = 64, 37.2%), hypertension-related nephropathy (n = 14, 8.1%), immune-related (n = 4, 2.3%), glomerulonephritis (n = 40, 23.3%), and unknown (n = 18, 10.5%). All patients were dialyzed using hollow fibre dialyzers that contained either Sinton® solution or Taita® solution combined with Bibag® powder (Fresenius Medical Care, Waltham, MA, USA) or Bicart® powder (Gambro Taiwan Ltd. Taipei, Taiwan), and all used bicarbonate-based dialysate. There were no significant differences in regard to age or months of HD between the control and qigong groups; the only significant difference was gender. Chi-square tests showed there were fewer male patients in the qigong group than in the control group (22 vs. 56, p = 0.003). The comparison of patients’ characteristics is also shown in Table 1.
247 mean score of fatigue
Effect of qigong training on fatigue in haemodialysis patients 60 50 40 30 Qigong
20
Control
10 0 baseline
T1
T2
T3
T4
T5
Figure 2 Mean scores of fatigue for the control and qigong groups from baseline to T5.
We further examined gender differences in fatigue level of both groups at different data collection times. For all patients, the results of independent sample t-tests showed that there was no significant difference between female and male patients at the different time periods, except at T4 (20 weeks), when the fatigue level was lower in female patients than in male patients (44.2 vs. 50.2, t = −2.44, p = 0.02). In addition, there was no significant difference in fatigue level between female and male patients, either in the control or the qigong group, at the time of data collection (Table 2).
Fatigue between the qigong and control groups Table 2 shows the levels of fatigue and the number of patients who completed the data collection. There were 172 patients at baseline, 166 (96.5%) at T1, 161 (93.6%) at T2, 151 (87.8%) at T3, 142 (82.6%) at T4, and 138 (80.2%) at T5. Of these, 71 patients (100%) were in the qigong group complete at baseline, 66 (92.9%) at T1, 62 (87.3%) at T2, 59 (83.1%) at T3, 54 (76.1%) at T4, and 51 (71.8%) at T5. The mean fatigue for all study patients was 54.1 (SD = 15.3) at baseline. From T1 to T5, all study patients’ fatigue levels were 49.7, 50.2, 47.8, 47.1, and 45.8, respectively. This indicated that patients experienced mild to moderate fatigue. The results of independent sample t-tests showed there were no differences between the qigong and control groups in fatigue at baseline (54.6 vs. 53.8, p = 0.75). Fatigue was significantly less in the qigong group than in the control group at T1 (43.5 vs. 53.9), T2 (44.7 vs. 53.6), T3 (43.2 vs. 50.8), T4 (42 vs. 50.2), and T5 (41.4 vs. 48.4). Data are shown in Table 3 and Fig. 2. We used the GEE model to examine the difference in fatigue between groups during the six time periods. GEE methods are widely used in the analysis of longitudinal data, especially when there are missing data. An unstructured working correlation matrix was used to analyze the main effect of group and time on fatigue. The results showed that group had a significant effect on fatigue (Wald chisquare = 7.54, p = 0.005). Fatigue was significantly lower in the qigong group than in the control group (B = −5.51, odds ratio = 0.004, p = 0.005). Fatigue also showed significant decreases at the five data collection points (time effect, Wald chi-square = 42.48, p < 0.001). The odds ratios were 0.001 (8 weeks), 0.002 (12 weeks), 0.003 (16 weeks), 0.022 (20 weeks), and 0.012 (24 weeks), respectively. The results are shown in Table 4.
248 Table 1
C.-Y. Wu et al. Homeogeneity test of characteristics between the two groups (N = 172).
Variable
Gender Male Female Education No Elementary High College Marital status Married Single Exercise Regular Irregular Employed No Yes
2
p
22 (31) 49 (69)
9.10
0.003**
12 (11.9) 38 (37.6) 40 (39.6) 11 (10.9)
8 (11.3) 28 (39.4) 28 (39.4) 7 (9.9)
0.09
0.99
158 (91.9) 14 (8.1)
93 (92.1) 8 (7.9)
65 (91.5) 6 (8.5)
0.02
0.90
95 (55.2) 77 (44.8)
40 (39.6) 61 (60.4)
37 (52.1) 34 (47.9)
2.16
0.14
109 (63.4) 63 (36.6)
65 (64.4) 36 (35.6)
44 (62.0) 27 (38.0)
0.03
0.87
All (N = 172)
Control (n = 101)
Qigong (n = 71)
n (%)
n (%)
n (%)
78 (45.3) 94 (54.7)
56 (55.4) 45 (44.6)
20 (11.6) 66 (38.4) 68 (39.5) 18 (10.5)
Variable
Age (26—92 yrs) HD months (6—373 mos.) HB at baseline (4.19—14 gm/dl)
All (N = 172)
Control (n = 101)
Qigong (n = 71)
M ± SD
M ± SD
M ± SD
57.8 ± 11.3 79.9 ± 69.4 10.5 ± 1.1
58.3 ± 11.5 76.9 ± 65.0 10.6 ± 0.98
57.1 ± 10.9 84.3 ± 75.4 10.5 ± 1.3
2
p
0.67 −0.69 0.64
0.51 0.49 0.52
Note: HD, haemodialysis; HB, haemoglobin; M, mean; SD, standard deviation. ** p < 0.01.
Table 2 Time
Baseline T1 T2 T3 T4 T5
Gender difference in fatigue between the two groups (N = 172). All (N = 172)
Control (n = 101)
Qigong (n = 71)
Male
Female
Male
Female
Male
Female
M ± SD
M ± SD
M ± SD
M ± SD
M ± SD
M ± SD
52.6 51.6 51.3 49.1 50.2 46.3
± ± ± ± ± ±
15.7 17.0 16.8 14.3 14.3 12.7
55.3 48.2 49.2 46.7 44.2 45.3
± ± ± ± ± ±
14.9 14.9 16.6 15.8 14.9a 16.1
52.3 54.1 53.8 50.8 51.2 47.3
± ± ± ± ± ±
15.8 16.5 17.2 14.3 13.1 12.7
55.8 53.5 53.3 50.9 48.8 49.7
± ± ± ± ± ±
15.4 16.4 16.8 13.9 15.3 16.1
53.7 44.5 44.2 44.4 47.4 43.4
± ± ± ± ± ±
15.7 16.7 13.9 13.3 17.3 12.4
54.9 43.2 44.9 42.7 39.3 40.4
± ± ± ± ± ±
14.7 13.9 15.4 16.8 12.7 14.8
Note: T1 = 8 weeks; T2 = 12 weeks; T3 = 16 weeks; T4 = 20 weeks; T5 = 24 weeks; M, mean; SD, standard deviation. a t = −2.44, p = 0.02.
Table 3
Comparison of fatigue between the two groups (N = 172).
Time
Total/qigong
All (N = 172) Mean ± SD
Baseline T1 T2 T3 T4 T5
172/71 166/66 161/62 151/59 142/54 138/51
54.1 49.7 50.2 47.8 47.1 45.8
± ± ± ± ± ±
15.3 16.5 16.7 15.2 14.8 14.5
Control (n = 101) Mean ± SD 53.8 53.9 53.6 50.8 50.2 48.4
± ± ± ± ± ±
15.6 16.4 16.9 14.1 14.1 14.2
Qigong (n = 71) Mean ± SD 54.6 43.5 44.7 43.2 42.0 41.4
± ± ± ± ± ±
15.0 14.7 14.8 15.8 14.8 14.0
Note: T1 = 8 weeks; T2 = 12 weeks; T3 = 16 weeks; T4 = 20 weeks; T5 = 24 weeks; SD, standard deviation. ** p < 0.01.
t
p
−0.32 4.12 3.38 3.11 3.29 2.79
0.75 0.000** 0.001** 0.002** 0.001** 0.006**
Effect of qigong training on fatigue in haemodialysis patients Table 4
249
Group effects on fatigue by GEE analysis (N = 172).
Variable Intercept Group Qigong Control Time Baseline T1 T2 T3 T4 T5
Wald 2 7.54
42.48
p
B
SE
Exp(B)
95% C.I.
p
56.16
1.43
−5.51 —
1.95
0.004
0.008—0.186
0.005**
1.22 1.18 1.27 1.11 1.04
0.001 0.002 0.003 0.022 0.012
0.001—0.007 0.001—0.020 0.001—0.030 0.003—0.200 0.001—0.090
0.000** 0.000** 0.000** 0.001** 0.000**
0.005**
0.000** — −7.35 −6.46 −5.95 −3.79 −4.45
Note: T1 = 8 weeks; T2 = 12 weeks; T3 = 16 weeks; T4 = 20 weeks; T5 = 24 weeks. ** p < 0.01.
Discussion Our study provides evidence for the effect of qigong on fatigue in ESRD patients on maintenance HD. In this study, patients in the qigong intervention group experienced significantly less fatigue than did those in the usual care control group. Our finding is consistent with results from previous studies that showed that qigong had a positive effect on fatigue in other patient groups.12,15,16 Moreover, our study revealed that the effect of qigong training on fatigue can be maintained for a long period (six months). There was no difference in fatigue between the two groups at baseline. This confirmed that the fatigue level was the same between the groups prior to the intervention. After the intervention, fatigue in the qigong group decreased and continued to decrease until the end of data collection at 24 weeks. This indicates that the qigong training had both a short-term effect as well as a long-term benefit on the fatigue of HD patients. The mechanism of qigong that may be responsible includes balancing breathing (qi) and energy, which may decrease emotional stress and perception of fatigue.14,21,22 Qigong also may result in an increase in oxygen and a decrease in carbon dioxide concentrations in the blood, which may help remove metabolic waste from the tissues.23 Increased physical activity may be another mechanism. Previous research has found that the sedentary lifestyle of HD patients is associated with fatigue.7 Qigong training consists of slow body movements that are tolerable and do not require much energy use, which may strengthen muscle power and improve daily physical functioning.12 Therefore, it is worthwhile to incorporate qigong exercise into the routine HD care plan. Fatigue in the control group also showed a decrease over the six months of data collection, which may have been due to the procedures of the study. To avoid contamination, we selected the patients on the Monday-Wednesday-Friday schedule to be in the experimental group. Nevertheless, there may have been some type of connection among participants. Additionally, participants may have given a desirable response when research staff approached them at data collection, even if they did not receive qigong training. The fatigue scale used in this study did not provide a cut point or reference score to indicate the significance of
clinical benefits. However, the difference in mean scores between baseline and 24 weeks of fatigue in the qigong group was 13.2 but only 5.4 in the control group. As noted, the post hoc statistical power for this study was adequate. Based on the results, we assume that the reduction in reported fatigue is clinically as well as statistically significant. More research may be necessary to confirm this notion. In this study, the completion rate of the qigong group was relatively low (76%) but comparable to a previous study that followed patients for 20 weeks (77%).16 Nevertheless, this study has several potential limitations. Due to the nature of the intervention, it was not possible to make use of a blinding protocol. To reduce the likelihood that patients would provide a desirable response, a third research assistant collected the pre- and post-intervention questionnaire. Participation in this study was voluntary, which may have created a potential selective bias, with those patients interested in qigong participating and those with no interest in qigong declining. More prospective and randomized trial will be needed to confirm these findings.
Conclusion This study investigated the long-term benefits of qigong, specifically, whether it is worthwhile in terms of improving optimal comprehensive care. As stated in the introduction, fatigue is a complex, common problem that needs comprehensively management by health care professionals. Qigong is one of the complementary therapies that can be of benefit to patients with fatigue by strengthening muscle power, improving psychological function, and diminishing emotional stress. Our results showed that 6 months of qigong training can reduce fatigue significantly and that qigong exercise can be integrated into the current clinical care plan to optimize the improvement of HD patient’s fatigue. The qigong procedure used in this study was easy to learn and had a significant effect on the reduction of fatigue. No adverse effects of qigong, such as uncomfortable breathing, sweating, or dizziness, were reported by the HD patients in this study. In addition, no patient in the qigong group left the
250 study due to adverse effects. In this study, the occurrence of adverse effects did not weaken the benefits of qigong training on fatigue. In fact, such effects were easy to overcome by pausing qigong training and taking a short rest. Thus, we can conclude that qigong is a safe and effective method for reducing fatigue in ESRD patients on maintenance HD. The mechanisms of qigong that have a positive effect on fatigue, however, warrant additional research.
Conflicts of interest All authors declare that there is no conflict of interest.
Acknowledgements This study was funded by the Chang Gung Medical Foundation-Linkuo Medical Centre in Taiwan. We also heartily thank Dr. Hsin Yun Liu for her expert contribution to the statistical analyses used in this study.
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