Traditional Chinese Rehabilitation Exercise (TCRE) for Myofascial Pain—A Superficial Synthesis with Missed Opportunities [Letter]

Dear editor

We write to critique the recent article “Traditional Chinese Rehabilitation Exercise (TCRE) for Myofascial Pain: Current Evidence and Further Challenges” by Liu et al.¹ While the authors commendably synthesize existing evidence on Baduanjin, Wuqinxi, and Yijinjing, the perspective suffers from critical oversights that undermine its scientific rigor and translational value. Below, we outline four major shortcomings.

The authors highlight positive outcomes of TCRE in myofascial pain but inadequately address the methodological flaws of cited studies. For instance, the referenced RCTs often suffer from small sample sizes, short follow-up periods, and inconsistent outcome measures, mirroring broader issues in TCRE research. The review uncritically cites meta-analyses without acknowledging heterogeneity among studies, such as variations in intervention protocols and control group designs. The latest systematic review² in 2025 emphasize substantial high heterogeneity and methodological biases across studies examining TCRE, raising significant concerns about the generalizability and reliability of findings. While the meta-analysis demonstrates statistically significant improvements in pain scores among patients practicing Baduanjin, these findings must be interpreted with caution due to substantial methodological heterogeneity across included studies.

The article hypothesizes that TCRE alleviates pain through “fascial remodeling” and “neuromodulation”, yet it fails to engage with mechanistic studies validating these claims. In 2024, a study investigating the effects of Baduanjin on axial myofascial biomechanical properties in patients with ankylosing spondylitis (AS) has demonstrated significant improvements.³ Specifically, Baduanjin practice enhances myofascial biomechanical function, alleviates mechanical stress, mitigates microdamage and inflammatory responses at tendon-bone attachment points, and modulates downstream cellular signaling pathways – potentially inhibiting pathological osteogenesis. In contrast, Liu’s theoretical framework notably omits recommendations for comparable pharmacological or biomechanical analyses of TCRE. This absence of mechanistic investigation leaves TCRE’s purported therapeutic mechanisms at the level of anecdotal observation, thereby impeding its systematic incorporation into evidence-based rehabilitation protocols.

The perspective promotes TCRE as a “low-cost, non-invasive” therapy but overlooks critical barriers to standardization. Baduanjin and Wuqinxi protocols vary widely across studies in movement execution, breathing techniques, and instructor expertise, raising concerns about reproducibility. Additionally, while the authors mention TCRE’s “favorable safety profile”, they omit discussions on adverse events, such as joint strain in elderly populations or improper technique exacerbating pain—a notable gap given the inclusion of older adults in trials.

The proposed future research—focusing on aging and robotics—reads as a superficial checklist rather than a transformative vision. While the authors note the potential of exoskeletons, they fail to articulate how TCRE’s principles (eg, “mind-body coordination”) could inform robot-assisted rehabilitation algorithms. Contrastingly, recent protocols for knee osteoarthritis TCM trials emphasize blinded designs and objective biomarkers, which this perspective neglects to prioritize. Furthermore, the discussion on long-COVID syndrome is speculative, lacking references to registered trials or mechanistic hypotheses connecting TCRE to post-viral myofascial recovery. More evidence⁴ should be added to enrich these contents.⁵ While Liu et al provide a timely overview of TCRE, the perspective’s uncritical synthesis and missed opportunities for depth render it more a catalog of studies than a critical guide for future research.

Funding Statement

This work was supported by Education Department reform project of Zhejiang province, Zhejiang Chinese Medicine University Postgraduate Scientific Research Fund Project (project number: Y202351281). The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Disclosure

The authors declare no conflicts of interest in this communication.