key: cord-0876076-gh9cifjr authors: Feng, Fan; Tuchman, Sylvie; Denninger, John W.; Fricchione, Gregory L.; Yeung, Albert title: Qigong for the Prevention, Treatment, and Rehabilitation of COVID-19 Infection in Older Adults date: 2020-05-15 journal: Am J Geriatr Psychiatry DOI: 10.1016/j.jagp.2020.05.012 sha: d86a70957ae5e263b0bc98255561a7cbd88c309e doc_id: 876076 cord_uid: gh9cifjr The elderly are at high risk of contracting respiratory infectious diseases, including COVID-19 infection. The recent pandemic has the potential to cause significant physical and mental damage in older adults. Similarly to other mind-body exercises in Traditional Chinese medicine, Qigong features regulation of breath rhythm and pattern, body movement and posture, and meditation. Given these traits, Qigong has the potential to play a role in the prevention, treatment, and rehabilitation of respiratory infections, such as COVID-19. Potential mechanisms of action include stress reduction, emotion regulation, strengthening of respiratory muscles, reduction of inflammation, and enhanced immune function. Three forms of Qigong; abdominal breathing, Ba Duan Jin and Liu Zi Jue, all of which are gentle, smooth, and simple for the elderly to practice, are recommended in this context. The outbreak of coronavirus disease 2019 , that was first reported by local health facilities in Wuhan Studies for inclusion were identified by querying Pubmed, the China national knowledge infrastructure, the China Science and Technology Journal Database, and Wanfang data. The main mechanisms for the occurrence and development of COVID-19 are immunosuppression and cytokine storm. 4 COVID-19 patients with severe symptoms may develop respiratory impairment and need rehabilitation, including respiratory muscle training, whole-body movement and psychological rehabilitation. 5 We searched in the above databases using terms to address the potential mechanism of Qigong in the prevention, treatment and rehabilitation of COVID-19, including "immune function", "inflammation", "cytokine", "respiratory muscle", "stress" , "mood" and "emotion", combined with terms which address different types of Qigong: "Qigong", "Qi Gong", "Tai-Chi", "Tai Chi", "Taichi", "Taiji", "Yi Jin Jing", "Yijinjing", "Wu Qin Xi", "Wuqinxi", "Liu Zi Jue", "Liuzijue", "Ba Duan Jin", "Baduanjin", as well as "abdominal breathing" and "abdominal respiration". Given that clinical studies on the intervention of Qigong for COVID-19 are limited, we used the terms "respiratory infection" and "respiratory rehabilitation", combined with terms mentioned above to search for clinical evidence about the application of Qigong in the treatment and rehabilitation of respiratory infection. The abstract and the full text of each article were reviewed and included if it identified as clinical research or as a clinical systematic review published in English or Chinese. "Qigong" is composed of two Chinese characters "Qi" and "Gong". "Qi" refers to the energy that motivates human life activities, and "Gong" refers to the regulation of Qi through practice. The concept of Qi in TCM is very broad, and it is involved in nearly all physiological and pathological processes. 6 According to its different functions, Qi can be divided into different types, for example defensive Wei Qi, and the organ Qi that regulates the function of each organ. The channels through which Qi moves in the body are called meridians, which are distributed on the surface of the limbs and trunk and extend to the inside organs. Qigong is a mind-body training skill that can regulate body, breath and mind under the guidance of theory of TCM to guide Qi operation in the meridian, to regulate physical function, and to prevent and treat diseases. 7 Qigong regulates the body through an adjustment of body movement and posture. Qigong's body regulation is aimed at relaxation, so the movements are typically gentle and smooth. Regulation of breath involves changes in respiratory movement, rhythm, and pattern. Breath in Qigong needs to be slow, long, and deep. Sometimes changes in breath pattern are also required, such as abdominal breathing, and breathing with phonation, both of which are typical patterns of Qigong respiration. Abdominal breathing refers to a breathing pattern with obvious abdomen movement, and breathing with phonation is a combination of breath and the production of speech sounds. Regulation of mind includes focusing attention and visualization. Most operations of mind regulation are similar to meditation, therefore Qigong is also considered a meditative movement. 8 Qigong originated in the primeval time of China as a means of self-care. According to the first historical record in China "Shang Shu", 4000 years ago, ancient Chinese people found that stretching and dancing could release pain. This is the rudiment of Qigong. Almost all religions and philosophical schools, such as Taoism, Buddhism, Traditional Chinese medicine, and martial arts, have elements of Qigong practice methods, with different appellations. In the 1950s, experts and scholars reached a consensus and coined this methodology "Qigong", and the first Qigong institute was established in China in 1954. Many studies on Qigong have been carried out through modern research methods, including the observation of physiological and psychological changes during or after Qigong practice, along with clinical trials of treating various diseases with Qigong. Qigong is particularly appropriate for older people due to its gentle and smooth movements, and there are wide applications of Qigong in geriatric medicine, 9 including in the treatment of musculoskeletal disorders, pain relief, and muscle strengthening. As a mind-body skill, Qigong has been found to impact internal and psychosomatic diseases, such as asthma, hypertension, peptic ulcers and diabetes. Qigong is also used as a meditative movement for treating geriatric mental conditions including mood disorders and cognitive impairment. 10, 11 According to different operations, Qigong techniques can be divided into two groups: Dynamic Qigong is more successful than passive Qigong with regards to physical regulation, therefore it can be more effective in treating musculoskeletal and psychosomatic disease. Practitioners who have difficulty focusing their attention can concentrate on movements and actions in dynamic Qigong, which is an easier skill to master. Passive Qigong pays more attention to mind regulation. Attention training is an important and common technique of mind regulation that asks practitioners to focus attention on an object or on the present, which is similar to mindfulness meditation. According to theory of TCM, through extensive practice of focusing attention, practitioners can enter a state of tranquility. Passive Qigong has few requirements for physical strength, as it can be practiced in any posture without movement. In addition, for those with impaired body movement ability, passive Qigong is a better choice than dynamic Qigong. A study on mindfulness, conducted by Lacaille et al. 12 , indicated that prolonged mindfulness practice was associated with an increase in mindful responding, which was in turn associated with increased positive affect and with less perceived stress and negative affect. Thus, those who engage in extensive practice of passive Qigong may be likely to experience better psychological outcomes. Respiratory infectious diseases belong to the category of external pathogens diseases in TCM. Its pathogenesis is that external pathogens invade the human body and produce tension in the balance between "good and evil". The "evil" refers to exogenous pathogens, which can be considered similar to the pathogen of infection. "Good" refers to the defensive function of the human body. When exogenous pathogens invade the human body, defensive Wei Qi fights against them. It can be considered that Wei Qi represents immune function from the perspective of modern medicine. The relationship between Wei Qi and exogenous pathogens determines whether the disease will develop and the prognosis of the disease. If Wei Qi is strong enough to defend against the exogenous pathogen, the disease would not occur, or would be easier to heal, and the prognosis would be good. Because of a decline in organ function and an increase in chronic medical conditions, older people are considered to be in a state of weakness or insufficient energy, conceptualized as Qi and blood deficiency in TCM. Wei Qi is thought of as being scarce in the elderly. Therefore, according to theories of TCM, when encountering infectious diseases such as COVID-19, the elderly are more likely to be affected, and infections are more likely develop into severe diseases with poor prognoses. Given that Qigong regulates the function of Qi in the human body, in which Wei Qi is included, it may prevent respiratory infection or promote recovery from respiratory infection in the elderly. Outbreaks and illness are a source of stress, and stress reactions or emotional problems can occur in hospital inpatients, people in isolation, and those in the general population. Benson et al. 13 observed physiological changes during meditation, and found that meditation can counteract stress response. Benson coined the physiological change elicited by meditation a "relaxation response". As a meditative movement, Qigong has been studied as a tool for stress management. Ryu et al. 14 observed changes in stress hormones during Qigong practice, and found that beta-endorphins increased in the middle of training while levels of adreno-cortico-tropic-hormone declined mid and post-practice suggesting decreased stress levels. It has been suggested that Qigong regulates emotion through enhancing nonreactivity to aversive thoughts and impulses by focusing attention, regulating the hypothalamus-pituitary-adrenal axis reactivity and the balance of the autonomic nervous system, and through changing the function of the brain, limbic system, and expression of genes linked to inflammatory responses and stress-related pathways. 15 In a meta-analysis on treating chronic obstructive pulmonary disease (COPD) with Qigong, Wu et al. 16 Qigong can reduce both inflammatory factors and inflammatory response. Irwin et al. 22 examined the cytokines in older adults who had participated in a 6-month Tai-Chi program, and found reductions in levels of IL-6 in subjects in the intervention group who previously showed high levels of this inflammatory marker. In another study, Irwin et al. 23 found that in older adults with insomnia, Tai-Chi reduced proinflammatory gene expression and marginally reduced C-reactive protein by the end of the 4-month practice, and reduced monocyte production of proinflammatory cytokines at the end of the program and at the follow-up after 7 and 16 months, when compared to the control group. Additionally, a 12-week program of Tai-Chi has been found to increase levels of the anti-inflammatory cytokine IL-10 in middle-aged adults. 24 Chen et al. 25 found that in COPD patients, 60-day Liu Zi Jue practice lowered the level of IL-4、IL-13 and IL-17, and increased the level of IL-10 when compared to a regular treatment control group. Qigong's enhancement of immune function has manifested in both non-specific immune response and specific immune response. Regarding non-specific immune response, Qigong can increase the amount or activity of immune cells in the body. Yeh et al. 24 found that in middle-aged healthy people, after a 12-week program of Tai Some studies have demonstrated the effectiveness of Qigong in preventing respiratory infectious diseases. Hu et al. 34 selected elderly men as experimental subjects and randomly divided participants into either a Qigong intervention group or a control group who performed jogging. Compared with the control group, the experimental group experienced significantly fewer respiratory tract infections after Qigong exercise for two years, and the difference between the two groups increased with exercise time. Wright et al. 35 found that in swimmers who practiced Qigong at least once per week, cold and flu symptoms showed a significant non-linear association with frequency of Qigong practice, with a strong, inverse relationship between practice frequency and symptom scores. There are few studies on the intervention of Qigong in the acute phase of respiratory infection, but according to limited research results Qigong can be found to shorten the course of infection. In Ties' study, 36 90 female healthy students were separated into three groups; a control group, a three times a week movement group, and a five times a week movement group, after a six-month Tai-Chi training. In the two Tai-Chi groups, the levels of IgA and IgG became higher, as compared with the control group. There was no difference in the frequency of respiratory tract infection in the three groups, however the duration of each onset became shorter in the Tai-Chi group. improved when compared with the control group who received regular treatment. Some simple Qigong can be learned independently through watching Qigong videos. Before learning Qigong, consulting with doctors is necessary for safety reasons. Learners can begin with physical movements of the forms. After practitioners acquire the sequences of both isometric and isotonic segmental movements in upper and lower extremities, they can try to combine breathing techniques and focus their attention on movement, breath and Qi. Considering the physiological characteristics of the elderly, the pathological features of respiratory diseases, and the psychosocial factors in the face of the COVID-19 epidemic, we recommend Ba Duan Jin, Liu Zi Jue, and abdominal breathing. According to the research results mentioned above, these three kinds of Qigong are often used in the prevention and treatment of respiratory infections, for the movement is smooth with low intensity, and easy to learn. In addition, the range of these three Qigong movements is small, and the space requirements are not significant. Thus, they are suitable for home practice during the current epidemic. The type of respiratory pattern of pursed lip breathing performed by expiration to produce six different sounds (xu, he, hu, si, chui, and xi) is similar to the pursed-lips breathing in rehabilitation training for COPD patients 43 . It can modify rapid shallow breathing patterns and retard the expiratory flow rate. Additionally, the different sounds can produce vibrations with different frequencies, which is commonly used in neurorehabilitation 44 and tension relaxation 45 . Research indicates that Liu Zi Jue might help tissue and organs in respiratory recovery through these vibrations. Liu Zi Jue is a good choice for people seeking to recuperate from respiratory dysfunction and sequela of COVID-19 infection. The available biological and psychological evidence suggest Qigong may be potentially useful for the prevention, treatment, and rehabilitation of respiratory infections, including COVID-19. The elderly, in particular, could benefit from Qigong during the ongoing pandemic, for it is easy to practice. Future studies are needed to confirm the effectiveness of Qigong in this context and to provide more evidence on this topic. 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