Baduanjin Exercise Improves Cognitive Function in Older... : The Journal of Nervous and Mental Disease (original) (raw)

To acquire or use knowledge, the human brain must first absorb, process, and transform external information into internal mental activity; memory, language, spatial awareness, executive function, calculation, and comprehension assessments are all cognition elements involved in this process (Martin et al., 2011). Cognitive impairment is the deficiency of one or more of these cognitive functions, which affects an individual's daily or social abilities; significant impairment is diagnosed as dementia (Gallou-Guyot et al., 2020). Mild cognitive impairment (MCI) lies between normal aging memory loss and dementia (or neurocognitive disorder); its characteristics include a decrease in concentration, memory, thinking speed, and language expression (Jia et al., 2022). If not managed appropriately, MCI can accelerate the deterioration rate and lead to signs of dementia in older adults. According to the World Health Organization's 2021 Global Status update on the public health response to dementia, 55 million 65-year-olds have dementia worldwide (World Health Organization, 2021). This number is expected to rise to 78 million by 2030 and 139 million by 2050 (World Health Organization, 2021).

Currently, there are two types of intervention for cognitive impairment: pharmacological and nonpharmacological. Often, pharmacological approaches are only partially accepted or approved by clinicians, patients, and family members owing to cost and adverse side effects. Nonpharmacological approaches hold the potential to stabilize or restore; however, it can enhance cognitive function through physical activity and social engagement (Reeve et al., 2023). Studies have shown that individuals over 60 with cognitive impairment can improve their typical cognitive function with 30 to 50 minutes of aerobic exercise (Ahn and Kim, 2023). However, many older adults have limited tolerance for high-intensity cardio exercise (e.g., sprinting, resistance sports), and moderate-intensity aerobic exercise (e.g., yoga, walking) beyond their physical capacity rarely holds their attention (Tarumi et al., 2022). Baduanjin exercise (BE) is one of the traditional forms of fitness known as qigong in China. It consists of eight movements. During practice, it is necessary to coordinate the body, breathing, and mind, characterized by soothing and rhythmic movement to promote muscle activation and whole-body exercise. Recent studies have shown that BE can improve the cognition of older adults with MCI (Ma et al., 2022). For this reason, in recent years, older adults have increasingly incorporated BE into their daily exercise routine (Wang et al., 2021a, 2021b; Xia et al., 2019). Consequently, a systematic review and meta-analysis are required to determine the effects of BE on the cognitive abilities of older adults with MCI and provide reliable data for therapeutic practice.

METHODS

Search Strategy

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were employed to conduct this study. The literature search was performed on Chinese databases, including China National Knowledge Internet (CNKI), Wanfang, China Science and Technology Journal Database (VIP), Chinese Medical Journal, and China Biomedical (SinoMed). English databases search was also performed, including PubMed, Web of Science (WoS), Embase, and the Cochrane Library; the search was conducted from database inception through to February 2024. The English search terms were as follows: “Qigong,” “Qi Gong,” “Ch'l Kung,” “Baduanjin,” “Chinese traditional cultivation method,” “cognition,” “cognitions,” “cognitive function,” “cognitive functions,” “function, cognitive,” “functions, cognitive,” “older adults,” “older people,” and “Mild cognitive impairment.”

Eligibility Criteria

The inclusion criteria were as follows: 1) randomized controlled medical trials, 2) participants with MCI aged ≥60 years, and 3) the experimental group performed BE, whereas the control group did no exercise intervention.

The exclusion criteria were as follows: 1) exercise interventions other than BE or combined with BE; 2) conference proceedings, experimental protocols, or duplicate published studies; 3) data that were incomplete or unable to be extracted; and 4) studies including participants aged <60 years.

Outcomes

Data on the following outcome variables were extracted: 1) the Montreal Cognitive Assessment (MoCA), created by Nasreddine et al., a rapid cognitive screening instrument measuring cognitive abilities, including analytic thought, numeracy, and orientation (Kang et al., 2018); 2) the Mini-Mental State Exam (MMSE), another cognitive screening instrument that measures similar cognitive functions as MoCA, though it requires more time to complete; the MMSE is the preferred screening tool and is adapted from the simple mental state examination revised by Zhang Mingyuan; 3) the Wechsler Memory Scale (WMS), a simple scale consisting of seven subtests: word-pair learning, orientation, mental control ability, logical memory, logic skills, quantity span, and common sense (Kent, 2017); 4) the Trail Making Test (TMT), developed by Partington et al. in 1938 (Llinàs-Reglà et al., 2017), examining spatial perception, hand-eye coordination, and attention skills; 5) the Edmonton Frailty Scale (EFS), created by Rolfson et al. in 2000 (Navarro-Flores et al., 2020), evaluating various cognitive deficiencies, including balance/motor abilities, mood, nutritional status, health, cognition, and quality of life, using 17 points, with higher ranks indicating more significant debilitation.

Data Extraction and Quality Assessment

Two researchers reviewed and extracted the literature to determine inclusion in the study. The data extracted comprised the author, year, age range of the participants, type and frequency of the intervention, and outcome measures. The Cochrane Handbook 5.1.0 recommended that guidelines were used to evaluate the quality of the included studies, including low quality (high bias), medium quality (unclear bias), and high quality (low bias) (Cochrane, 2023).

Statistical Analysis

The MoCA, MMSE, WMS, and TMT outcomes were subject to meta-analysis utilizing Review Manager (Rev Man) 5.4 software. A weighted mean difference was used for outcome markers measured through a separate tool, whereas standardized mean difference (SMD) was used for outcome markers measured with the same tools; 95% confidence intervals (CIs) were calculated for both measures. When heterogeneity was present between studies (p < 0.1 and _I_2 ≥ 50%), a random-effects model was used; when heterogeneity was not found (_p_ > 0.1 and _I_2 < 50%), a fixed-effects model was applied. Sensitivity and subgroup analyses were performed to explore the sources of heterogeneity.

RESULTS

Literature Search Results

The literature review retrieved a total of 770 Chinese and English articles; 77 articles were accessed from Pub Med, 56 from WoS, 57 from Cochrane, 57 from CNKI, 13 from Chinese Medical Journal, 18 from SinoMed, 412 from Wanfang, and 9 from VIP. Zotero, a management software, was employed to remove 222 duplicate entries. Following full-text screening of the potentially eligible literature, those 203 that did not meet the criteria for inclusion were excluded. After reading the title and abstract, 331 articles were excluded, including those that could not be included in the study, such as conferences and abstracts. Finally, 14 studies were included in this review, 3 in English and 11 in Chinese. A flowchart of the literature review process is shown in Figure 1.

FIGURE 1:

Literature screening Flowchart. RCT, randomized controlled trial.

Basic Characteristics of the Included Studies

Of the 14 included articles, two were doctoral theses, four were master theses, and eight were peer-reviewed studies; these were all published between 2015 and 2023. With 498 participants in the experimental group and 496 in the control group, 994 adults aged ≥60 years were evaluated. The control group primarily received health education, and one study maintained the original lifestyle without any intervention; the experimental group performed the exercise intervention. The intervention period was 24 weeks, with one study lasting 48 weeks. The experimental group exercised 3–7 times weekly for 17–60 minutes each time. Table 1 shows the main features of the studies that were used.

TABLE 1 - Fundamental Study Features

Note: ①MOCA, ②MMSE, ③WMS, ④ TMT, and ⑤EFS.

C, control group; T, experimental group.

Quality Evaluation of Included Studies

The Cochrane Handbook guidelines served as the principal source to determine the quality of the 14 included studies. The random sequence generation was assessed as “high risk” in one study; allocation concealment was reported in eight articles, with blinding of participants and personnel recorded in six trials. Of the 14 studies, blinding of outcome assessment was not deemed to pose a bias risk, as such, the studies identified in this group were assigned a medium risk of bias. Likewise, six studies contained “complete” data. Among the other bias indicators, 14 studies did not find bias, so they were rated as low-risk (Figs. 2 and 3).

FIGURE 2:

Evaluated risk and quality.

FIGURE 3:

Evaluated risk and quality.

Intervention Effect

Global Cognition

The MoCA instrument was employed in 14 studies (Li, 2016; Li, 2017; Lin, 2016; Lin, 2017; Lin et al., 2023; Liu et al., 2018; Sun et al., 2021; Wan et al., 2022; Wang, 2019; Xia, 2017; Xia, 2020; Ye, 2019; Zheng et al., 2021; Zhu et al., 2015) to gauge the effect of BE in older adults with MCI. With moderate heterogeneity among the studies (p = 0.03, _I_2 = 47%), the fixed-effects model was chosen and demonstrated that BE significantly increased older adults' baseline cognitive abilities (SMD = 2.56; 95% CI, 2.17, 2.96; p < 0.001) (Fig. 4). In three studies (Lin, 2016; Lin, 2017; Wang, 2019), MMSE was reported as an outcome measure for 248 participants: 124 in the experimental group and 124 in the control group. With significant heterogeneity across the studies (p = 0.05, _I_2 = 67%), a random-effects model was employed and revealed that BE significantly enhanced universal cognitive function in older adults with MCI (SMD = 2.54; 95% CI, 1.22, 3.86; p < 0.001) (Fig. 5).

FIGURE 4:

Global cognitive function forest map (MoCA).

FIGURE 5:

Global cognitive function forest map (MMSE).

Memory

Four articles (Li, 2017; Wan et al., 2022; Ye, 2019; Zheng et al., 2021) comprising 226 participants (114 in the experimental group and 112 in the control group) investigated the effects of BE on MCI as measured by the WMS. No heterogeneity was uncovered (p = 0.79, _I_2 = 0%), and the fixed-effects model showed a significant reduction in the rate of memory loss in the experimental group compared with the control group (SMD = 12.46; 95% CI, 8.36, 16.57; p < 0.001) (Fig. 6).

FIGURE 6:

Forest map of memory intervention.

Executive Function

Three of the 14 included studies (Li, 2017; Sun et al., 2021; Xia, 2020) investigated the effect of BE on executive function in older adults with MCI, as evaluated by the EFS instrument. The experimental and control groups contained 125 and 124 individuals, respectively. There was no heterogeneity between studies (p = 0.44, _I_2 = 0%), and the fixed-effects model showed that BE improved executive function in older adults with MCI (SMD = −7.08; 95% CI, −11.21, −2.94; p = 0.0008) (Fig. 7).

FIGURE 7:

Forest map of executive function.

Physical Frailty

Three of the 14 included studies (Lin et al., 2023; Wan et al., 2022; Xia, 2020) reported that BE diminished physical frailty in older adults with MCI, with 128 participants in the experimental group and 126 in the control group. No heterogeneity was found among the trials (p = 0.9, _I_2 = 0%), and the fixed-effect model supported a substantial reduction in physical frailty after BE intervention in older adults with MCI (SMD = −0.97; 95% CI, −1.30, −0.64; p < 0.001) (Fig. 8).

FIGURE 8:

Forest map of physical frailty.

Sensitivity Analysis

Significant heterogeneity was detected among studies for the MoCA (_I_2 = 47%) and MMSE (_I_2 = 67%) outcomes; thus, sensitivity analyses were performed by individually excluding each study. The heterogeneity in the MoCA outcomes was resolved by excluding Liu et al. (2018) (_I_2 = 0%), and the difference was statistically significant (SMD = 2.92; 95% CI, 2.48, 3.36; p < 0.001). Therefore, the results of Liu et al. (2018) may be sources of heterogeneity in the MoCA analysis (Fig. 9). Using the same methods for the MMSE data, excluding Wang (2019) resulted in no heterogeneity (_I_2 = 0%), and the difference was statistically significant (SMD = 3.19; 95% CI, 2.12, 4.27; p < 0.001). Consequently, the results of Wang (2019) may be sources of heterogeneity in the MMSE analysis (Fig. 9).

FIGURE 9:

MoCA bias risk map.

Subgroup Analyses

The MoCA scale, which was diverse in the meta-analysis (_I_2 = 47%), was reported in all 14 studies included in the review (Li, 2016; Li, 2017; Lin, 2016; Lin, 2017; Lin et al., 2023; Liu et al., 2018; Sun et al., 2021; Wan et al., 2022; Wang, 2019; Xia, 2017; Xia, 2020; Ye, 2019; Zheng et al., 2021; Zhu et al., 2015) as a measurement instrument for cognitive function in older adults with MCI. A subanalysis was performed with the BE movement frequency, BE time per day, and publication year as the subgroups.

Exercise Frequency

The study's findings revealed no differences in the total subgroup analysis model (p = 0.02, _I_2 = 81.4%). The overall cognitive function scores of the experimental group with a BE frequency of ≤3 times per week were reported in nine studies (Li, 2016; Li, 2017; Lin et al., 2023; Sun et al., 2021; Wan et al., 2022; Xia, 2017; Xia, 2020; Ye, 2019; Zheng et al., 2021). A noteworthy distinction was found between the two groups (SMD = 2.95; 95% CI, 2.44, 3.47; p < 0.001). Five studies (Lin, 2016; Lin, 2017; Liu et al., 2018; Wang, 2019; Zhu et al., 2015) with a total of 383 subjects (189 in the experimental and 194 in the control groups) assessed total cognitive function scores with a BE frequency >3 times per week. According to the findings, BE significantly improved the cognitive function score in older adults with MCI (SMD = 2.01; 95% CI, 1.39, 2.62; p < 0.001) (Fig. 10).

FIGURE 10:

Frequent exercise improves cognition.

Exercise Duration

The study's findings demonstrated no difference the entire subgroup analysis (p = 0.03, _I_2 = 47%). BE was observed to have a positive effect on the experimental group compared with the control group in four studies, BE for less than 60 minutes a day (Lin, 2017; Sun et al., 2021; Wang, 2019; Zhu et al., 2015) (SMD = 2.92; 95% CI, 2.18, 3.67; p < 0.001). Sixty minutes or more of BE for daily time, according to 10 studies (Li, 2016; Li, 2017; Lin, 2016; Lin et al., 2023; Liu et al., 2018; Wan et al., 2022; Xia, 2017; Xia, 2020; Ye, 2019; Zheng et al., 2021), lead to substantial quantitative improvements in cognition function (SMD = 2.43; 95% CI, 1.96, 2.89; p < 0.001) (Fig. 11).

FIGURE 11:

Daily exercise duration and cognitive.

Publication Year

The study's findings demonstrated no difference the entire subgroup analysis (p = 0.11, _I_2 = 61.6%). Nine studies (Li, 2016; Li, 2017; Lin, 2016; Lin, 2017; Liu et al., 2018; Wang, 2019; Xia, 2017; Ye, 2019; Zhu et al., 2015) published before 2020 showed that the experimental group significantly outperformed the control group in terms of cognitive function (SMD = 2.30; 95% CI, 1.80, 2.81; p < 0.001). A total of five studies (Lin et al., 2023; Sun et al., 2021; Wan et al., 2022; Xia, 2020; Zheng et al., 2021) were released after the year 2020. The findings demonstrated that BE substantially enhanced cognitive performance when compared with the control group (SMD = 2.56; 95% CI, 2.17, 2.96; p < 0.001) (Fig. 12).

FIGURE 12:

Publication year effects cognition.

DISCUSSION

This review included 14 randomized controlled studies and compared the effects of BE and received health education on cognitive performance in older adults with MCI. Consequently, the results discovered that BE improved cognitive function (measured using TWT), reduced the frailty index (EFS), and reduced memory deterioration in older persons with MCI.

Research has shown that cognitive decline in older adults is associated with damage to the prefrontal cortex, and memory loss in older adults is accompanied by a decline in prefrontal activation and frontal lateralization (Brummelman et al., 2012; Udina et al., 2022). BE can increase the volume of prefrontal gray matter, enhance hippocampal neurogenesis, and improve synaptic neuroplasticity and the effectiveness of neurotrophic factors in the brain, thus preventing the onset of cognitive decline (Liu et al., 2019; Tao et al., 2019). Although performing BE movements, it is necessary to control consciousness; moreover, BE has a gentle massage effect on the abdominal viscera, stimulates the function of the nervous system, and corrects abnormal reactions in the body (Cai et al., 2021). As the human body ages, cerebral arteriosclerosis and atheromatous plaque formation occur, and blood stagnation in the brain leads to a decline in the supply of oxygen or nourishment to the brain, resulting in memory loss and reduced brain function (Bray et al., 2023). By modulating brain activity and structures linked to the norepinephrine and dopamine structures, BE can improve cognitive performance in adults with MCI (Liu et al., 2021). The method by which BE can enhance memory function in older adults with MCI is related to the fact that BE has an incredibly complex movement pattern consisting of eight motions, each requiring the coordination of two separate postures. In this regard, BE is different from simple walking and jogging. Furthermore, each movement must be coordinated with breathing to activate the neural pathways and cortical networks evoked by each movement, including the supplementary motor area, premotor cortex, cingulate gyrus, superior parietal cortex, and inferior parietal cortex (Ye et al., 2022; Zheng et al., 2019; Zheng et al., 2021).

In addition, it is necessary to combine the external movements with intention and breathing (Chen et al., 2020). BE is a medium-intensity aerobic exercise and can be practiced individually or as a group. When performed as a group, BE provides a platform for older people to enhance their social interactions, thus benefiting several health domains (Wang et al., 2021a, 2021b). No adverse effects were reported in any of the 14 studies reviewed, and BE had a safe and predictable effect on cognitive decline in older adults.

Exercise duration and frequency, as well as publication year, were subanalyzed in this study. In older adults with MCI, BE performed thrice weekly for 60 minutes should improve cognitive performance. A further finding of the review was that literature published after 2020 is of better quality than literature published before 2020, likely owing to more standardized experimental procedures, scientific experimental instruments, and careful research. Only 1 of the 14 studies included had an intervention period of 48 weeks, and the other 13 had an intervention period of 24 weeks. Therefore, the current review recommends that older adults with MCI practice BE for 60 minutes three times per week for at least 24 weeks to benefit cognitive function.

This study has some limitations. The studies included were only published with positive results, and there was a lack of gray studies. Eleven of the 14 papers were in Chinese and only three in English. Including fewer papers in English may have led to bias due to incomplete inclusion. In the included studies, it was impossible to blind the participants, although blinding the researchers would have increased the validity of the study results. Eight papers in this study did not report blinding of the participants. This literature does not provide declared blinding of result assessors, which may affect the validity of the findings. Care should be taken to avoid these limitations in future experimental studies. Large sample sizes, rigorous experimental approaches, and high-quality randomized controlled trials are also required to create a more trustworthy foundation for medical practice.

CONCLUSIONS

The results of this study showed that BE can help older adults with MCI improve their overall cognitive abilities. This included vast changes in memory, executive function, and the physical frailty. BE was shown to have a significant positive effect on cognition in older adults with MCI. To this end, older adults with MCI, and older populations as a whole, should be encouraged to perform BE to improve their health.

DISCLOSURE

The authors declare no conflicts of interest.

This study did not involve human or animal subjects, and thus, no ethical approval was required. The study protocol adhered to the guidelines established by the journal.

Author statement: All authors have read and approved the submitted manuscript.

Author contributions: W.L. contributed to the conception and design of the study, data collection, and analysis and interpretation of the data; L.L. contributed to the writing the manuscript or providing critical revision of the manuscript for intellectual content; and T.F. contributed to the statistical expertise, obtaining funding, administrative, technical or material support, and supervision.

Funding: No financial or material support of any kind was received for the work described in this article.

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Keywords:

Aerobic exercise; Baduanjin; cognition; older adults; rehabilitation

Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.