Traditional Chinese exercise in a contextually adapted cardiac rehabilitation program for chronic heart failure

Background: Exercise-based cardiac rehabilitation (EBCR) is a therapy which benefits patients with chronic heart failure (CHF). The delivery of EBCR should adopt an evidencebased approach, as well as be culturally appropriate and sensitive to individual needs and preferences. The Baduanjin Eight-Silken-Movements wIth Self-Efficacy building for Heart Failure (BESMILE-HF) program is a contextually adapted cardiac rehabilitation program. It uses a traditional Chinese exercise, Baduanjin, to solve the unmet demand of EBCR programs due to their scarcity and unaffordability in China.

Aim: The overall aim was to provide knowledge, experience, and evidence on how to effectively deliver a contextually adapted EBCR program for patients with CHF in China or other similar settings where EBCR services are scarce.

Methods: To evaluate the current evidence on traditional Chinese exercises (TCEs) regarding their rehabilitation effects on exercise capacity and quality of life (QoL) for CHF patients, we conducted a systematic review and meta-analysis of 33 randomized controlled trial (RCTs) involving 2,465 patients with CHF (Paper I). Paper II is a descriptive study which evaluates Baduanjin intensity and cardiopulmonary responses during practice. Participants were examined during two separate sessions to measure their maximum exercise capacities, as well as their cardiopulmonary responses during Baduanjin practice. We compared the measurements obtained during Baduanjin with their maximum exercise capacities. Paper III is a pilot RCT evaluating the feasibility of the BESMILE-HF program. We recruited eighteen patients with CHF: 8 in a BESMILE-HF group and 10 in a control group. Participants in both groups received the usual medications, with the intervention group also receiving the BESMILE-HF program for 6 weeks. We explored feasibility using participants’ involvement in the intended intervention. Clinical outcome assessments were conducted at baseline and post-intervention, while adverse events were captured throughout the study period. Paper IV is a qualitative study nested in the pilot RCT to explore the experience of practicing Baduanjin. After the pilot RCT ended, seven participants in the intervention groups agreed to participate in the semi-structured interview. All questions were open-ended, and follow-up questions provided a deeper understanding of areas that appear essential for each individual.

Results: Based on moderate-level evidence, adding TCEs into routine pharmacotherapies was associated with statistically significant improvements in exercise capacity and QoL. When compared to general exercise, we found superior improvements in the TCEs group; these were significant for QoL, but not for exercise capacity. We also found evidence that TCE is safe, and that there is high adherence to TCEs programs (Paper I). In terms of Baduanjin’s intensity, both measures of relative intensity measured in this study, %VO2max and %HRmax, categorize Baduanjin as a moderate-intensity exercise. This makes it suitable for improving CHF patients’ exercise capacity (Paper II). In addition, both the VO2 and the HR responses exhibited a bimodal pattern during the exercise session. Further, the average energy expenditure was estimated as 23.3 kcal for a 9-mintue Baduanjin session. In Paper III, we found that the BESMILE-HF program was well received by patients. As a home-based EBCR program, the intervention group demonstrated good compliance with the required exercises. We also found that one’s initial self-efficacy had a positive effect on the total exercise time. More importantly, intervention can improve participants’ exercise self-efficacy and may have benefit on exercise capacity. Interviews (Paper IV) demonstrated that Baduanjin is perceived as being easy for participants to learn. However, the coordination of the mind, the movements, and the breathing in Baduanjin exercise can only be achieved progressively through repeated practice. They also perceived that regular high-quality Baduanjin practice provides many benefits for both the mental and the physical health. Moreover, the perceived training benefits played a crucial role in adherence to home-based training.

Conclusion: TCEs may represent a promising rehabilitation therapy as an adjunctive to routine pharmacotherapies, or as an alternative to conventional exercise for patients with CHF. Baduanjin’s eight simple postures are not only accessible and learner-friendly, but also suitable for CHF, as it is a moderate-intensity aerobic exercise without excessive cardiopulmonary stress. When practicing Baduanjin, it is essential for the practitioner to coordinate the mind, movements and breathing in Baduanjin exercise, alongside ongoing correct execution. Practicing Baduanjin may promote the overall physical and psychological health of CHF patients. Moreover, integrating Baduanjin into cardiac rehabilitation programs may increase patients’ long-term adherence to exercise by improving exercise self-efficacy. A larger sample size and a longer follow-up period are needed to confirm its benefit on clinical outcomes.

List of scientific papers

I. Chen X, Savarese G, Cai Y, Ma L, Stålsby Lundborg C, Jiang W, Wen Z, Lu W, Marrone G. Taichi and Qigong Practices for Chronic Heart Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Evidence-Based Complementary and Alternative Medicine. 2020 :2034625.
https://doi.org/10.1155/2020/2034625

II. Chen X, Marrone G, Olson TP, Stålsby Lundborg C, Zhu H, Wen Z, Lu W, Jiang W. Intensity Level and Cardiorespiratory Responses to Baduanjin Exercise in Patients with Chronic Heart Failure. ESC Heart Failure, 2020;7(6):3782-91.
https://doi.org/10.1002/ehf2.12959

III. Chen X, Jiang W, Olson TP, Stålsby Lundborg C, Wen Z, Lu W, Marrone G. Feasibility and preliminary effects of the BESMILE-HF Program on Heart Failure Patients: a Pilot Randomized Controlled Trial. [Submitted]

IV. Chen X, Salazar M, Jiang W, Huiying Zhu, Marrone G, Wen Z, Lu W, Stålsby Lundborg C. Traditional Baduanjin Exercise Through the Eyes of Patients with Chronic Heart Failure: A Qualitative Content Analysis Study. [Manuscript]