There are several limitations of this review. First, data were not pooled from all of the trials. For example, only 3 trials contributed to the calculation of the difference previously mentioned in FEV1/FVC ratio between QG/TC and no exercise. Second, the internal validity of the results was affected by the limitations in the methodology of these trials. Third, all trials were conducted in China or Hong Kong and involved only Chinese subjects. This limits generalizing the results to populations in other cultures. Interestingly, a recent study reported improved outcomes for COPD patients from Europe using TC as an exercise training modality.34
Despite the above limitations, these 12 RCTs offered some positive evidence supporting QG/TC having slightly increased benefits compared with conventional exercise. Instead of suggesting it as a replacement for conventional exercise, QG/TC can be considered as an alternative and/or a supplementary format for physical activity, especially for the frail COPD patients. Qigong and TC has the advantage that when patients live in small environments, are homebound, and/or have concerns about the additional cost of using portable oxygen for outdoor exercise, QG/TC can be practiced at home. For exercise to be integrated into the lifestyle of patients, exercise modalities should be fun, meaningful, and affordable. Increased choices definitely mean more flexibility to suit different needs and preferences of individual patients. In addition, in areas where conventional PRP may not readily available to patients,35 QG/TC can be considered as the primary form of exercise, because the effect size between QG/TC and no exercise was favorable for the patients using QG/TC. Qigong and TC group exercise program being led by a peer and audiovisual training materials are readily available and provide valuable instructions. Qigong and TC can be used as a preliminary exercise program before patients begin a formal, supervised PRP. Two of the 4 standardized QG protocols, Liuzijue and Baduanjin, would be appropriate for a preliminary exercise program. Both of these protocols have adequate training materials that are published in Chinese, as well as English.
According to the PEDro scale, there were obvious methodological limitations to the studies included in this review and analysis that threatened internal validity. In future research trials involving QG/TC, investigators are encouraged to address issues such as allocation concealment, blinding, use of intention-to-treat analysis, and improving and reporting compliance to training protocols. Blinding of patients and therapists is difficult to achieve, but investigators can consider blinding the statisticians when data are analyzed. Moreover, investigators should also consider implementing multicenter trials of a larger scale and adoption of a common quality of life scale as an outcome measure. In addition, the analysis should be supplemented with one for subjects who can use a QG/TC protocol.36
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