|Year : 2019 | Volume
| Issue : 2 | Page : 73-77
Effectiveness of Tai chi and Qigong on motor and cognitive functions in Parkinson’s disease: A preliminary study
Jayasree Lakshmi1, Keshav Janakiprasad Kumar1, Pramod K Pal2
1 Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Web Publication||13-Aug-2019|
Dr. Keshav Janakiprasad Kumar
Department of Clinical Psychology, 3rd Floor, Dr. M. V. Govindaswamy Block, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru 560029, Karnataka
Source of Support: None, Conflict of Interest: None
BACKGROUND: There is an emerging role of various non-pharmacological strategies in the management of motor and non-motor symptoms of Parkinson’s disease (PD). OBJECTIVE: The aim of the study was to examine the effectiveness of Tai chi and Qigong on cognitive and motor functions, emotions, and quality of life in patients with PD. SUBJECTS AND METHODS: Seven subjects with mean age of 50.2 years, education of 11.71 years, and duration of PD of 6.03 years underwent four-week training of Qigong and Tai chi. They received one session per week under supervision and daily two 45-min practice sessions at home following instructions from the manual. Participants were assessed before and after intervention on neuropsychological tests, Unified Parkinson’s Disease Rating Scale (motor section), Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D), Epworth Sleepiness Scale (ESS), and Parkinson’s Disease Questionnaire (PDQ-39). RESULTS: There was a significant improvement in executive functions, verbal memory, and reduced scores on clinical scales (UPDRS III, HAM-A, PDQ-39). CONCLUSION: Combined practice of Tai chi and Qigong improves motor and non-motor symptoms of PD. However, well-designed randomized controlled trials and longitudinal studies are required to understand its full potential.
Keywords: Cognitive functions, motor functions, Qigong, quality of life, Tai chi
|How to cite this article:|
Lakshmi J, Kumar KJ, Pal PK. Effectiveness of Tai chi and Qigong on motor and cognitive functions in Parkinson’s disease: A preliminary study. Ann Mov Disord 2019;2:73-7
|How to cite this URL:|
Lakshmi J, Kumar KJ, Pal PK. Effectiveness of Tai chi and Qigong on motor and cognitive functions in Parkinson’s disease: A preliminary study. Ann Mov Disord [serial online] 2019 [cited 2022 Aug 12];2:73-7. Available from: https://www.aomd.in/text.asp?2019/2/2/73/264358
Parkinson’s disease (PD) is characterized by both motor symptoms and cognitive deficits. It is estimated that about 30%–40% of patients with PD develop dementia. Cognitive impairments are noted in both PDs. The deficits are primarily in executive functions including visuospatial working memory,, planning, verbal fluency and attention, visuo-perceptual deficits, speed of processing, learning, and memory. They adversely affect the overall functioning even in the early stages of the diseases. Management of motor symptoms associated with PD includes pharmacological intervention and functional neurosurgery, especially deep brain stimulation. Cholinesterase inhibitors have been used to improve for cognitive functions in 30%–40% of PD.
There is an increased interest in using Tai chi and Qigong as an alternative form of treatment to improve mental health, psychological well-being, and stress and sleep in several neurological conditions including PD., Tai chi and Qigong are meditative, mind, and body exercise used in China over centuries for health benefits. Both Tai chi and Qigong use a combination of deep breathing and relaxed, controlled, gentle movements. They are known to improve muscle strength, flexibility, and balance. Both the methods have been used as a therapeutic intervention in a number of medical conditions such as hypertension, heart disease, multiple sclerosis, and dementia. It is hypothesized that Tai chi might work on the neurotransmitters in the motor cortex and basal ganglia and improve symptoms by bypassing the dysfunctional circuitry in PD. Integrated mind and body programs similar to Tai chi have demonstrated structural changes. A recent study by Tang and Posner using diffusion tensor imaging demonstrated white matter neuroplasticity in the anterior cingulate cortex with short-term integrative body mind training. A number of studies demonstrated improvement in cognitive functions including trail making test, clock drawing, digit span, and semantic fluency with continued practice of Tai chi in older adults. On the contrary, some studies failed to document any change in cognitive functions after Tai chi training.,, The beneficial effects of Tai chi include improvement in quality of life, reduced depression, and increased psychological well-being. The aim of this study was to test the efficacy of four-week Tai chi training program on neuropsychological functions, motor symptoms, anxiety and depression, and quality of life in early-onset PD.
| Subjects and Methods|| |
The subjects consisted of seven patients recruited from the Outpatient Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India, diagnosed as PD by a Movement Disorder specialist. The study was approved by the departmental protocol review committee and written informed consent was obtained from all the patients. The mean age was 50.2 ± 9.2 years, mean education was 11.7 ± 6.04 years, and the mean duration of PD was 6.03 ± 2.4 years. The patients underwent Qigong and Tai chi training for one month. The patients were assessed before and after Tai chi training.
Sociodemographic data sheet was used to document age, education, marital status, and duration of disease.
The severity of motor signs of PD was assessed by the motor subscale Unified Parkinson’s Disease Rating Scale Part III (UPDRS III), subject’s level of daytime sleepiness or average sleep propensity in daily life was assessed by Epworth Sleepiness Scale (ESS), levels of depression were assessed on Hamilton Rating Scale for Depression (HAM-D), and levels of anxiety symptoms were assessed on Hamilton Anxiety Rating Scale (HAM-A). Health status of the patients was measured using Parkinson’s Disease Questionnaire-39 (PDQ-39). PDQ-39 consists of 39 questions addressing eight domains: mobility, activity of daily living (ADL), emotional well-being, stigma, social support, cognition, communication, and bodily discomfort. The questions refer to how often patients have experienced difficulties due to having PD during the preceding month. Cognitive functions were assessed using Mini-Mental State Examination (MMSE) and a battery of neuropsychological tests. All the tests were performed in drug “on” phase.
Executive function tests included Digit Span to assess span of attention, Spatial Span (WMS-III) to test visuospatial sequence of locations in working memory, Animal Names Test to test the ability to generate words belonging to a particular semantic category, and Tower of Hanoi Test (TOH) to test planning ability.
Tests of memory
The test of memory included non-graph motor test such as Face test used to test visual memory and recognition, and Word Lists (WMS-III) used to assess verbal learning and memory.
Patients were trained by the first author who had received training in Qigong and Tai chi before the study. Qigong and Tai chi moves used for training patients were demonstrated by an experienced professional Tai chi master. A video was made and a manual was developed using the expertise of the trainer. In addition, the second author who has been practicing Tai chi and Qigong for 16 years monitored the training program on a weekly basis. Tai chi and Qigong were combined and taught to patients with PD to make them shift from more simple and stationary movements of Qigong to more fluid movements of Tai chi. The training program consisted of both Qigong (eight silk brocades) and Tai chi including Tai chi walking, raising the hands, single whip, and cloud hands, from short yang (37 form) developed by master Cheng Man-Ch’ing’s for four weeks with four sessions of hospital-based and home-based training. Each hospital-based session lasted for 1.5–2h. Videos and manuals containing step-by-step instruction of the demonstration were given to the patients to follow during their practice at home twice every day. Each session lasted for about 45min.
Comparisons between the baseline and the post-Tai chi training performance on neuropsychological tests, such as HAM-D, HAM-A, UPDRS III, and PDQ-39, were made using the Wilcoxon signed rank test. The results are presented as means and standard deviation (SD). A value of P < 0.05 was considered as statistically significant.
| Results|| |
Results indicate significant differences on cognitive [Table 1] and motor functions, quality of life, and emotions [Table 2] after four-week training of Tai chi and Qigong.
There were significant differences between pre- and post-Tai chi training on the performances in the cognitive domains. There were improvements on the tests of planning as evident from TOH 3-disc time (P = 0.018), time taken on 5-disc (P = 0.018), number of moves on 5-disc problem on TOH (P = 0.04), and verbal learning and memory evident on WMS word list, immediate recall (P = 0.016), total recall (P = 0.018), and delayed recall (P = 0.038) test.
There was a significant improvement of the motor score of UPDRS III (P = 0.042) following training with Tai chi and Qigong. Similarly, seven of the eight domains of health status in patients with PD as measured on PDQ-39 improved significantly after the training. The seven domains of PDQ-39 included cognition (P = 0.0041), communication (P = 0.016), mobility (P = 0.042), emotional well-being (P = 0.0043), on stigma (P = 0.043), ADL (P = 0.016), bodily discomfort (P = 0.066), and summary index (PDQ-39 SI [P = 0.018]) improved after the training. There was no change in the social support domain as measured on PDQ-39. Anxiety (as measured on HAM-A) reduced after training (P = 0.02). The effect size for each variable calculated using Cohen’s d (d = 0.2–0.49 indicating small, 0.05–0.79 medium, and ≥0.8 large effect size) is depicted in [Table 1] and [Table 2]. There were no significant differences on HAM-D, MMSE, and ESS.
| Discussion|| |
Tai chi and Qigong have been increasingly recognized as an alternative mode of intervention to decrease stress and improve psychological functions in several clinical conditions.,, It has been considered as an integrated mind and body program as it requires the synergy of both the mind and body. Its efficacy has been particularly demonstrated in improving mobility and balance in PD. However, there are very few studies, which have explored the benefits on neuropsychological functions comprehensively including executive function, learning and memory, emotions such as anxiety and depression, quality of life, mobility, activity of daily living, cognitive and motor symptoms using UPDRS III in patients with PD. The aim of the study was to test the efficacy of four-week Tai and Qigong training program on neuropsychological functions, motor symptoms, anxiety and depression, and quality of life in patients with PD.
Our study showed that patients with PD improved on neuropsychological functions including planning ability on TOH. The improvement was evident on the number of moves on 5-disc problem as well as time taken on both three and five discs of TOH. TOH is known to be sensitive to procedural memory and requires the integrity of the functions of basal ganglia. The reduction in time taken and the number of moves on 3- and 5-disc problem on TOH suggests that Tai chi might have the potential to improve executive functions as well as the fronto-subcortical structures mediating these functions. The improvement in executive functions in our study is consistent with the previous studies., Our results revealed additional improvement on verbal learning and memory on word list (WMS-III––immediate recall, total recall, and delayed recall). The improvement on encoding as well as recall has not been previously demonstrated after Tai chi and Qigong training in PD. Memory function is not a unitary process. Rather, it requires multiple cognitive processes and is mediated by diverse structures including the frontal, temporal, and diencephalic memory circuitry. Improvements in memory imply that practice of Tai chi and Qigong requires both encoding and retrieval of moves and possibly improve memory as a whole. Repeated practice of Tai chi and Qigong over a period might improve the functioning of the memory circuits in addition to the circuits mediating executive functions. A recent study by Tang et al. demonstrated white matter changes in several brain regions with integrated mind body training program. Tai chi is also considered to be a mind and body integration program as it requires a synergy between the mind and body., Furthermore, the results indicate improvement on motor function as indicated by UPDRS III motor score, anxiety (HAM-A), and seven domains of health status as indicated by PDQ-39 including mobility, ADL, emotional well-being, stigma, cognition, communication, bodily discomfort, and the SI. These findings are consistent with some of the previous studies, although other studies contradict these findings. The improvement of anxiety and depression and quality of life with practice of Tai chi has been documented in several studies. On the contrary, there was no significant difference on depression score of HAM-D. A recent review on the effectiveness of Tai chi for PD indicates that the results are inconclusive.
This study suggests that a combination of Tai chi and Qigong training program might be a useful alternative method of intervention to improve neuropsychological function, quality of life, anxiety, and motor symptoms in PD.
The study has several limitations in terms of small sample size, lack of control group, and lack of long-term follow-up. However, the results from our study are encouraging and highlight the need for further studies using Tai chi and Qigong as alternative forms of intervention to improve cognitive, motor, and emotional functions in PD.
We would like to acknowledge the valuable contribution Sensei KV Subramanian towards the development of Tai Chi and Qigong training programme for individuals with Parkinson’s disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Horstink M, Tolosa E, Bonuccelli U, Deuschl G, Friedman A, Kanovsky P, et al
.; European Federation of Neurological Societies; Movement Disorder Society-European Section. Review of the therapeutic management of Parkinson’s disease. Report of a joint task force of the European Federation of Neurological Societies (EFNS) and the Movement Disorder Society-European Section (MDS-ES). Part II: Late (complicated) Parkinson’s disease. Eur J Neurol 2006;13:1186-202.
Morris ME Movement disorders in people with Parkinson disease: A model for physical therapy. Phys Ther 2000;80:578-97.
Yu RL, Wu RM, Tai CH, Lin CH, Cheng TW, Hua MS Neuropsychological profile in patients with early stage of Parkinson’s disease in Taiwan. Parkinsonism Relat Disord 2012;18:1067-72.
Emre M, Aarsland D, Brown R, Burn DJ, Duyckaerts C, Mizuno Y, et al
. Clinical diagnostic criteria for dementia associated with Parkinson’s disease. Mov Disord 2007;22:1689-707; quiz 1837.
Owen AM Cognitive dysfunction in Parkinson’s disease: The role of frontostriatal circuitry. Neuroscientist 2004;10:525-37.
Zhang JG, Ishikawa-Takata K, Yamazaki H, Morita T, Ohta T The effects of Tai chi Chuan on physiological function and fear of falling in the less robust elderly: An intervention study for preventing falls. Arch Gerontol Geriatr 2006;42:107-16.
Abbot R, Llavretsky H Tai Chi and Qigong for the treatment and prevention of mental disorders. Psychiatr Clin North Am 2013;36:109-19.
Wayne PM, Kiel DP, Krebs DE, Davis RB, Savetsky-German J, Connelly M, et al
. The effects of Tai chi on bone mineral density in postmenopausal women: A systematic review. Arch Phys Med Rehabil 2007;88:673-80.
Tang YY, Lu Q, Fan M, Yang Y, Posner MI Mechanisms of white matter changes induced by meditation. Proc Natl Acad Sci USA 2012;109:10570-4.
Matthews MM, Williams HG Can Tai chi enhance cognitive vitality? A preliminary study of cognitive executive control in older adults after a Tai chi intervention. J S C Med Assoc 2008;104:255-7.
Taylor-Piliae RE, Newell KA, Cherin R, Lee MJ, King AC, Haskell WL Effects of Tai chi and western exercise on physical and cognitive functioning in healthy community-dwelling older adults. J Aging Phys Act 2010;18:261-79.
Burgener SC, Yang Y, Gilbert R, Marsh-Yant S The effects of a multimodal intervention on outcomes of persons with early-stage dementia. Am J Alzheimers Dis Other Demen 2008;23:382-94.
Deschamps A, Onifade C, Decamps A, Bourdel-Marchasson I Health-related quality of life in frail institutionalized elderly: Effects of a cognition-action intervention and Tai chi. J Aging Phys Act 2009;17:236-48.
Nowalk MP, Prendergast JM, Bayles CM, D’Amico FJ, Colvin GC A randomized trial of exercise programs among older individuals living in two long-term care facilities: The FallsFREE Program. J Am Geriatr Soc 2001;49:859-65.
Fahn S, Elton RL UPDRS III Development Committee. Unified Parkinson’s Disease Rating Scale. In: Fahn S, Marsden CD, Calne DB, Goldstein M, editors. Recent Developments in Parkinson’s Disease. Florham Park, NJ: Macmillan; 1987. pp. 153-63.
Johns MW A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991;14:540-5.
Peto V, Jenkinson C, Fitzpatrick R, Greenhall R The development and validation of a short measure of functioning and well being for individuals with Parkinson’s disease. Qual Life Res 1995;4:241-8.
Wechsler D Wechsler Adult Intelligence Scale. 3rd ed. San Antonio, TX: Psychological Corporation; 1997.
Welsh MC, Huizinga M Tower of Hanoi disk-transfer task: Influences of strategy knowledge and learning on performance. Learn Individ Differ 2005;15:283-98.
Man-Ch’ing C Cheng Tzu’s Thirteen Treatises on Tai Chi Ch’uan. Berkeley, CA: Blue Snake Publication; 1985.
Hamilton M The assessment of anxiety states by rating. British Journal of Medical Psychology 1959;32:50-55.
Folstein MF, Folstein SE, McHugh PR. Mini-mental state: Apractical method of grading the cognitive state of patients for the clinician. J of Psychiatr Research 1975;12:189-98.
Guan H, Koceja DM Effects of long-term Tai chi practice on balance and H-reflex characteristics. Am J Chin Med 2011;39:251-60.
Saint-Cyr JA, Taylor AE, Lang AE Procedural learning and neostriatal dysfunction in man. Brain 1988;111:941-59.
Ranganath C, Minzenberg MJ, Ragland JD The cognitive neuroscience of memory function and dysfunction in schizophrenia. Biol Psychiatry 2008;64:18-25.
Lee MS, Lam P, Ernst E Effectiveness of Tai chi for Parkinson’s disease: A critical review. Parkinsonism Relat Disord 2008;14:589-94.
[Table 1], [Table 2]