East meets West: making the case for traditional Chinese exercises in the management of heart disease

Approaches in the secondary prevention of heart disease have witnessed a steady evolution in the past decades from educational leaflets to standardized face-to-face therapies to harnessing technology to deliver individualized telehealth-based rehabilitative initiatives.1 Yet, heart disease remains the leading cause of mortality globally.2 Given the chronicity and morbidity that accompanies heart diseases, and in light of an aging population, this is an especially important concern for healthcare systems worldwide.2 There is a growing interest in exploring alternative approaches to supplement existing preventive strategies in a way that is effective and sustainable to meet the holistic needs of patients with heart disease.3,4 This is mirrored in the inclusion of Traditional Chinese medicine (TCM) in the 11th revision of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD).5 Traditional Chinese exercises (TCEs) has been practiced in China for over 2000 years and focuses on promoting physical health and mental well-being through the restoration and balance of qi.6 Qi is defined as the ‘the circulating life force whose existence and properties are the basis of much Chinese philosophy and medicine’.7 Common TCEs like Tai Chi, Qigong and Baduanjin share similar exercises philosophies of low- to moderate-intensity movements performed in combination with muscle stretching and relaxation, coordinated breathing, and a meditative state of mind.6 However, owing to the nature of its practice and roots in TCM, reception to TCEs has been previously met with scepticism and contention.8,9 While mainstream Western medicine seeks to draw conclusions from large samples based on statistical methods to explain and generalize well-tested disease states and treatment choices, this perspective is too simplistic in TCM where factors determining health are viewed as specific to an individual and priority is given to holistically understanding and managing the individual as a whole.8,9 In this editorial, we discuss the recent efforts made to legitimize and validate the efficacy of TCEs in heart disease management and the opportunities that exist to integrate these two practice perspectives for improved outcomes for patients and healthcare systems. Several papers investigating the effectiveness of TCEs in heart disease management have been published in the European Journal of Cardiovascular Nursing. One such TCE is Tai Chi—where movements are graceful and meditative in nature to generate internal energy, integrate the mind and body, mindfully control breathing, and relieve tension to result in calmness and serenity.10 Tai Chi has five classic styles (i.e. Chen, Wŭ, Wú, Yang, and Sun) each emphasizing its own unique characteristic movement, and various forms reflecting the number of movements (e.g. 8-, 16-, 24-form, etc.).10,11 In a systematic review and meta-analysis, Liu et al.12 found that patients with coronary heart disease receiving Tai Chi-based cardiac rehabilitation showed significant improvement in their aerobic endurance compared with both active (stretching and walking exercises) and non-active control interventions, and had significantly better quality of life (QoL), and significantly lower depression and anxiety levels compared with non-active control groups. Compared with Phase III cardiac rehabilitation only, Taylor-Piliae et al.13 observed that participants attending group-based Tai Chi as an adjunct to cardiac rehabilitation reported better perceived physical health. Recently, in a randomized controlled trial undertaken by Liu et al.,14 participants with coronary heart disease receiving a 6-week group- plus 6-week home-based Tai Chi programme achieved significant improvements in lower-body agility, strength and dynamic balance, aerobic endurance, exercise self-efficacy and diastolic blood pressure over a 24-week study period compared with those receiving an attention control (non-exercise community activities). Baduanjin—also known as Eight-Section Brocades—is another TCE involving eight low-intensity individual movements performed slowly and in a relaxing manner.15 Chen et al.16 found that patients with heart failure receiving a 12-week Baduanjin exercise programme reported significant improvements in their fatigue and QoL compared with participants receiving usual care. In another randomized controlled trial among chronic heart failure patients, Ma et al.17 found significant improvements in muscle strength and physical functioning, exercise capacity, exercise self-efficacy, and QoL in those that received a home-based Baduanjin plus elastic band exercise programme and community care follow-up compared with those receiving the community care follow-up only. There is evidence that TCEs can serve as a promising exercise option to improve aerobic endurance and psychological well-being in patients undergoing cardiac rehabilitation. Additionally, given that both Tai Chi and Baduanjin do not require special exercise attire, equipment, or gym facility and can be safely performed at home,18 it presents an affordable and accessible complementary option for clinically stable coronary heart disease and chronic heart failure patients. The facets of TCEs align with the shift towards home-based rehabilitation delivery models amid a changing patient population of work and care commitments and rehabilitation preferences that are not suited for traditional centre-based rehabilitation.3,19 Traditional Chinese exercises would be an especially attractive option in low-resource communities.6 The current question is whether TCEs can be integrated to compliment current Western healthcare delivery models to establish a unified approach to heart disease management and rehabilitation. Evidence-based research remains the best approach to increase acceptance of TCEs.6 It is essential for TCEs to demonstrate efficacy through high-quality reporting and evidence if its potential benefits are to be confidently harnessed by modern Western medicine.6,8 Yet, current evidence lacks consensus on the gold standard for Tai Chi and Baduanjin interventions with regards to the specific style and form, frequency, duration, intensity, and learning and practice methods.12,15 In addition, evidence-based knowledge on the potential mechanisms through which TCEs yield its benefits is only just emerging in the literature.6 These hinder attempts to replicate TCEs in clinical settings and is an area where much research focus is needed. Standardization in the design of TCE interventions and an understanding of the physiological mechanism of TCE’s beneficial effects are necessary before TCEs can be explored as a cost-effective treatment option and considered an integral component in rehabilitation initiatives. Ultimately, as with evidence-based medicine and practice, there is an opportunity for efforts in heart disease management and rehabilitation to evolve in reflecting and incorporating complementary alternatives from our Eastern counterparts that are based on best-available clinical evidence. No new data were generated or analysed in support of this research.