[Systematic Review] Does Tai Chi relieve fatigue? A systematic review and meta-analysis of randomized controlled trials – Full Text

Abstract

Background

Fatigue is not only a familiar symptom in our daily lives, but also a common ailment that affects all of our bodily systems. Several randomized controlled trials (RCTs) have proven Tai Chi to be beneficial for patients suffering from fatigue, however conclusive evidence is still lacking. A systematic review and meta-analysis was performed on all RCTs reporting the effects of Tai Chi for fatigue.

Methods

In the end of April 2016, seven electronic databases were searched for RCTs involving Tai Chi for fatigue. The search terms mainly included Tai Chi, Tai-ji, Taiji, fatigue, tiredness, weary, weak, and the search was conducted without language restrictions. Methodological quality was assessed using the Cochrane Risk of Bias tool. RevMan 5.3 software was used for meta-analysis. Publication bias was estimated with a funnel plot and Egger’s test. We also assessed the quality of evidence with the GRADE system.

Results

Ten trials (n = 689) were included, and there was a high risk of bias in the blinding. Two trials were determined to have had low methodological quality. Tai Chi was found to have improved fatigue more than conventional therapy (standardized mean difference (SMD): -0.45, 95% confidence interval (CI): -0.70, -0.20) overall, and have positive effects in cancer-related fatigue (SMD:-0.38, 95% CI: -0.65, -0.11). Tai Chi was also more effective on vitality (SMD: 0.63, 95% CI: 0.20, 1.07), sleep (SMD: -0.32, 95% CI: -0.61, -0.04) and depression (SMD: -0.58, 95% CI: -1.04, -0.11). However, no significant difference was found in multiple sclerosis-related fatigue (SMD: -0.77, 95% CI: -1.76, 0.22) and age-related fatigue (SMD: -0.77, 95% CI: -1.78, 0.24). No adverse events were reported among the included studies. The quality of evidence was moderate in the GRADE system.

Conclusions

The results suggest that Tai Chi could be an effective alternative and /or complementary approach to existing therapies for people with fatigue. However, the quality of the evidence was only moderate and may have the potential for bias. There is still absence of adverse events data to evaluate the safety of Tai Chi. Further multi-center RCTs with large sample sizes and high methodological quality, especially carefully blinded design, should be conducted in future research.

Background

Although no one can exactly quantify or document fatigue [1], fatigue is a common symptom not only deeply related to most acute and chronic diseases, but also to everyday life. It is not only common, but problematic, for people with conditions such as cancer, multiple sclerosis, and rheumatoid arthritis [2]. The National Comprehensive Cancer Network (NCCN) defined cancer related fatigue as ‘an persistent, unusual, subjective feeling of tiredness correlated with cancer or cancer treatment that obstruct to normal functioning’ [3]. Definition of fatigue was also described as “a subjective feeling of lacking mental and/or physical energy, which was perceived by the caregiver or individuals interfering with usual and desired activities” [4]. Because of its subjective nature, fatigue can only be gauged by self-reported or caregiver-reported questionnaires [5]. Fatigue generally lasts longer than somnolence [6]. Tiredness is a state of temporary decreasing in strength and energy, which may be experienced as a partial of fatigue [7]. Some authors simply divided fatigue into acute and chronic fatigue [2]. Acute fatigue occurs in healthy populations, with a rapid onset and short duration. After a period of rest and exercise, it is generally relieved. Chronic fatigue mainly affects clinically disordered individuals and is onset gradually, persists and develops over time. It usually can’t be alleviated by usual recovery techniques [6]. As a symptom, fatigue is a common complaint among most people, and many ailments are accompanied by fatigue. However, it is often ignored, under-diagnosed, and seen as a natural result of physical deterioration [8].

A previous study had shown that 10.6% of women and 10.2% of men complained of fatigue for ≥ 1 month in the South London general practice attenders [9]. The prevalence rate of chronic fatigue was 10.7% in general Chinese population [10]. Among older adults with myocardial infarction, fatigue is frequently reported to be one of the most serious barriers to physical activity [11]. Fatigue occurs in 50%-83% of patients with multiple sclerosis [12]. Among breast cancer patients 58%-94% undergoing treatment and 56%-95% who are post-chemotherapy experience fatigue [13]. Although the methods, standards, and results of these studies are not always consistent, it is undeniable that fatigue is a common symptom from which many patients suffer.

The mechanisms behind fatigue are unclear [5], however they may be related to a patient’s physical condition. There is no panacea for fatigue other than treating the symptoms [5]. Evidence has shown that exercise including walking, running, jogging, swimming, resistance (strengthening) training, stretching, aerobic exercise can counter fatigue among sufferers of chronic fatigue syndrome [14], multiple sclerosis [15], fibromyalgia [16] and among cancer survivors [17,18]. So we supposes that Tai Chi, a traditional Chinese martial art, may be an effective treatment for patients suffering from fatigue.

Tai Chi has popular in China for several centuries. Many different types of Tai Chi exist, but most consist of movement, meditation and breathing, while concentrating on the mind and maintaining low intensity [1920], and further modulate various aspects of the body including the physical, the psychological, mood and spirit [21]. In the theory of Chinese medicine (CM), Tai Chi can maintain the harmony between qi and the blood, keep yin and yang in balance and also enhance immunity [2223]. These properties are both important in relieving fatigue and maintaining energy. Qi, the energy which promotes the body’s movement, can circulate around the entire body freely if yin and yang are kept in balance [23].

Tai Chi may relieve fatigue via different mechanisms of action. Firstly, through slow movement and weight shifting, Tai Chi may relieve stress, make people more happy [24] and promote relaxation [25]. Secondly, the proven efficacy of Tai Chi to enhance aerobic capacity and immune function [26] and to improve pain [27], depression and psychological well-being [28] may be beneficial to relieve fatigue.

An advantage of Tai Chi is that it is easy to learn, teach, and popularize, and more reports on evidence of its effects should lead to it becoming even more popular. As a low impact exercise, Tai Chi may be ideal for people with fatigue, lack of exercise or who do not have active lifestyles [19]. Several studies have reported that Tai Chi plays a critical role in fighting fatigue [2932]. However, there not been explicit studies to reach a conclusion on Tai Chi’s effects on fatigue. Others have shown no difference between Tai Chi groups and control groups [33,34]. In addition, most of the studies focus on only one ailment [32,35,36]. As far as we know, the majority of the literature on Tai Chi intervention for fatigue is empirical, and uses small sample sizes. Few of the existing studies have explored fatigue as the primary outcome. To date, there have been no systematic reviews nor meta-analyses to evaluate the effects of Tai Chi for fatigue, but single RCTs based on a specific population in a certain place. This systematic review evaluates the effects and safety of Tai Chi for fatigue, and provides an overall understanding of the current situation, as well as problems in this field.

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