Abstract
Background
Frailty predicts increased cancer recurrence and mortality among older cancer survivors. Qigong has been shown to improve physical and mental well-being, as well as inflammation, which are closely linked with frailty in the cancer population.
Objective
This study aims to evaluate the effect of qigong on frailty among older cancer survivors.
Design
An assessor-blind multi-centre randomised controlled trial.
Methods
Post-treatment cancer survivors aged 65+ screened as pre-frail or frail based on the Fried frailty phenotype were recruited and randomised to an intervention (16-week qigong Baduanjin) or an active control group (16-week light flexibility exercise). The primary outcome was the reversal of frailty status. The secondary outcomes included physical frailty severity, multidimensional frailty severity, physical performance, psychological well-being and quality of life. Analysis was based on the intention-to-treat principle.
Results
Two hundred twenty-six older cancer survivors were randomised, 113 to the qigong group and 113 to the light flexibility exercise group. At 16 weeks, the difference in the rates of frailty reversal in the qigong group (28.7%) and the light flexibility exercise group (22.5%) was insignificant (adjusted odds ratio = 1.39, 95% CI, 0.65 to 2.95). While both groups had significant improvement in physical frailty severity, physical performance, psychological well-being and quality of life, only the qigong group had significant improvement in multidimensional frailty severity. The group × time interaction was not significant.
Conclusion
Qigong was not superior to an active control in its effect on improving frailty in older cancer survivors. Researchers should include routine care as control and examine the underlying mechanisms driving the change in frailty.
Keywords: randomised controlled trial, frailty, older adults, qigong, physical activity, cancer
Key Points
Qigong was not superior to an active control in its effect on improving frailty in older cancer survivors.
Further research should include routine care as control to distinguish intervention effects.
More research on the underlying mechanisms driving the change in frailty in cancer survivors is warranted.
Background
Cancer disproportionately affects older adults, with half the cases diagnosed in individuals aged over 65. Frailty, characterised by increased vulnerability to adverse health outcomes and poor global health, is an important health indicator in geriatric oncology [1]. It predicts increased cancer recurrence and mortality [2, 3]. A review reported that frailty affects 42% and prefrailty affects 43% of older cancer patients [3].
Frailty has been found to be reversible in general older adults by appropriate interventions, the most evident intervention being exercise [4]. To date, there is a lack of evidence-based strategies specifically targeting frailty reversal in older cancer survivors. Research found that majority of older cancer survivors prefer low intensity exercise to vigorous exertion [5]. Qigong, a low-to-moderate intensity exercise, is rooted in Traditional Chinese Medicine. It aims to achieve a harmonious flow of qi (energy) through rhythmic movements, breath regulation and mindful meditation. Popular among older adults, it has the potential to reverse frailty in older cancer survivors given that: (1) systematic reviews have consistently demonstrated that qigong has physiological benefits in general populations, including reducing blood pressure, increasing strength and improving physical and cardiovascular fitness [6–8], which are outcomes closely associated with frailty; (2) systemic inflammation may serve as a major physiopathological contributor of cancer-related frailty [9] and qigong has been found to benefit immune system functioning and inflammatory processes [10].
One randomised controlled trial (RCT) demonstrated qigong significantly reduced frailty scores in older adults with cognitive impairment [11]. However, the effect on frailty status, an important prognostic indicator among older cancer survivors [1–3], was not analysed. Another RCT targeting general older adults found that 36.5% of participants in the qigong group reversed their frailty status (vs. 43.6% in the control group) [12]. The findings of qigong’s effect on frailty are mixed. To our knowledge, no RCT has been designed and conducted to examine modalities to improve frailty in older cancer survivors, which may have distinctive frailty aetiologies and respond differently to frailty management strategies. This study aimed to evaluate the effects of qigong on frailty, physical performance, psychological well-being and health-related quality of life (HRQoL) among older cancer survivors, compared to an active control group.
Methods
Study design
This study was a two-arm, assessor-blinded RCT conducted from 19 February 2021 to 31 July 2024. Eligible participants were assigned to the qigong group or light flexibility exercise group (1:1) by randomisation. The rationale for using an active control was to control the non-specific effects of group sessions. The study was approved by the ethics committee of the study sites.
Participants and setting
Eligible participants were aged 65 or above, had a confirmed diagnosis of Stages I–III non-metastatic cancer, were classified as pre-frail or frail based on the Fried frailty phenotype [13] and had completed primary treatment with curative intent 6 months to 5 years prior to baseline with no recurrence or additional cancers. Exclusion criteria included regular qigong/mind–body practice and medical conditions affecting mobility. Participants were recruited from the Department of Clinical Oncology in two major regional hospitals in Hong Kong and community cancer survivor support groups. Patients identified in designated post-treatment clinics were given a brochure about the study. Interested participants were then screened for eligibility.
Patient/public involvement
Patients in the pilot study provided feedback on the acceptability and feasibility of both study arms, reviewed the participant-facing materials (e.g. information sheet and consent form) and advised on recruitment and retention strategies [14]. These shaped the main trial design and influenced participant engagement in the main trial.
Sample size calculation
Based on our pilot study, the proportion of reversal of frailty status in the qigong group was estimated to be approximately double that of the control group (~40% vs. 20%) [14]. Assuming a type I error rate of 5% and allowing for a 20% attrition, a sample size of 113 older cancer survivors per group (total n = 226) was required to provide 80% power at a 5% significance level.
Randomisation and masking
Participants were randomly assigned to the qigong or control groups using block randomisation with a random block size of four or six. An independent statistician generated the randomisation list using a computer and sealed the group assignment in sequential sealed opaque envelopes. The qigong master and exercise trainer were blinded to the study aims, and the research assistant responsible for data collection and entry were blinded to the group allocation.
Treatment conditions
The qigong group received a 16-week Baduanjin qigong intervention led by a certified qigong master. Baduanjin is a popular form of qigong which involves eight easy-to-learn movements [15]. During Weeks 1–8, 1-h supervised Baduanjin training sessions were held twice weekly to develop participants’ skills through demonstration, practice and feedback. During Weeks 9–16, 1-h practice sessions were held once weekly to reinforce practice and give remedial classes. All sessions were conducted in small groups of five to six participants. Participants had to self-practice Baduanjin for 30 min twice weekly in Weeks 1–8 and three times weekly in Weeks 9–16 (i.e. an average of 75 min per week throughout the intervention period).
The control group received supervised light flexibility exercise sessions of identical duration and frequency but without any abdominal breathing and meditation techniques. The sessions were led by certified exercise trainers and involved seated and standing stretches targeting the upper and lower body. The self-practice instructions were the same as those of the qigong group.
Intervention fidelity
Spot checks of classes were performed monthly by the principal investigator to ensure the intervention was implemented as intended. For both groups, participants were asked to record their self-practice time and duration in logbooks for the research assistant to check during class every week. Also, a self-practice package was provided for both groups in the form of a booklet and videos to promote home practice. For the qigong group, in Week 8, participants were rated by the master with a pre-designed competency checklist in terms of accuracy of movement, limb coordination and appropriate breath control (score range for each domain = 0–40; maximum total score = 120; passing score = 72) (Appendix 1).
Outcome measures
Measurements (excluding the background questionnaire and Credibility/Expectancy Questionnaire) were obtained in both arms at three time points: baseline, post-training (8 weeks after baseline) and post-intervention (16 weeks after baseline).
Primary outcome
Reversal of frailty status (primary outcome) was defined as transitioning to a lower frailty category from baseline (i.e. frail to pre-frail/robust and pre-frail to robust). The Fried frailty phenotype [16], the most utilised frailty definition in clinical and experimental research [17] and applied in the local setting [18, 19], was used to assess frailty status. The five domains include slowness, weakness, unintentional weight loss, exhaustion and low activity. Participants with 0 criteria were considered as robust, 1–2 as pre-frail and ≥3 as frail. For exploratory purposes, the reversal of frailty domains was also examined, and the sum of criteria was examined as a continuous variable (i.e. frailty score) to evaluate physical frailty severity [20].
Secondary outcomes
Multidimensional frailty severity was measured using the Edmonton Frail Scale. The questionnaire consists of 11 items and covers nine domains e.g. cognition, social support and nutrition. Higher total scores represent more severe frailty [21].
Physical performance was measured using the Short Physical Performance Battery, which involved three functional tasks: gait speed, chair stand and balance tests. Higher scores indicate better performance [22]. Minimal clinically meaningful change was 0.3–0.8 points [23].
Psychological well-being was measured using the Short-Form Geriatric Depression Scale. It consists of 15 items, where higher mean scores represent more severe depression [24].
HRQoL was measured using the global health status subscale of the European Organisation for Research and Treatment of Cancer Core Quality of Life questionnaire. Higher scores represent better HRQoL [25].
A background questionnaire was used to collect demographic characteristics and disease information. The Credibility/Expectancy Questionnaire (6 items) was collected after the first training session to examine participants’ beliefs about the treatment [26].
Statistical analysis
All analyses were conducted using SPSS (Version 28.0) based on the intention-to-treat principle. Differences in background characteristics and adherence between the intervention and control groups were assessed using Chi-square or two independent samples t-tests. For dichotomous outcome variables (i.e. a reversal in frailty status and frailty domains), missing data were replaced using multiple imputation methods (with five imputations and an automatic imputation method selection). Logistic regression was conducted to report the adjusted odds ratio (AOR) of frailty status reversal with 95% confidence intervals (CIs) for each follow-up time point. For continuous outcome variables (scores of frailty, Edmonton Frail Scale, Short Physical Performance Battery Scale, European Organisation for Research and Treatment of Cancer Core Quality of Life questionnaire), the changes were analysed using a linear mixed model (i.e. a statistical method that handles missing outcomes by covariance structure) [27]. Group, time, group × time interaction and potential covariates were set as fixed factors and the intercept as a random factor. Potential covariates (i.e. age, gender, comorbidity, cancer type, cancer stage, treatment received, time since last treatment, baseline frailty status and expectancy toward treatment condition) were adjusted. A 5% level of significance was used.
Results
Of the 1356 approached patients, 339 (25%) were ineligible and 791 (58.3%) were eligible but refused to participate. Consequently, 226 (16.7%) cancer survivors were randomised (Fig. 1). A total of 18 participants (8.0%) dropped out (8 in the qigong group and 10 in the control group) mostly due to deteriorated health and loss of interest. No adverse events arose from the study. Table 1 shows participant characteristics. No statistically significant differences in demographic characteristics, baseline frailty and expectancy toward the treatment condition were found across the two groups.
Figure 1.
Study flow chart.
Table 1.
Baseline characteristics
| Background characteristics | Overall, number (%) | Group, number (%) | P-value | |
|---|---|---|---|---|
| Qigong group (n = 113) | Light flexibility exercise group (n = 113) | |||
| Age, mean (SD), years | 71.0 (4.4) | 70.8 (3.8) | 71.2 (4.9) | .526 |
| Female | 165 (73%) | 80 (70.8%) | 85 (75.2%) | .454 |
| Marital status | NA | NA | NA | .099 |
| Single/divorced | 84 (37.2%) | 36 (31.9%) | 48 (42.5%) | NA |
| Married/cohabiting | 142 (62.8%) | 77 (68.1%) | 65 (57.5%) | NA |
| Education | NA | NA | NA | .892 |
| Primary or below | 89 (39.4%) | 44 (38.9%) | 45 (39.8%) | NA |
| Secondary or above | 137 (60.6%) | 69 (61.1%) | 68 (60.2%) | NA |
| Regularly exercise | 158 (69.9%) | 77 (68.1%) | 81 (71.7%) | .562 |
| Type of cancer | NA | NA | NA | .287 |
| Breast | 112 (49.6%) | 60 (53.1%) | 52 (46.0%) | NA |
| Othera | 114 (50.4%) | 53 (46.9%) | 61 (54.0%) | NA |
| Received chemotherapy | 83 (36.7%) | 38 (33.6%) | 45 (39.8%) | .334 |
| Baseline Frailty status | NA | NA | NA | .604 |
| Pre-frail | 210 (92.9%) | 104 (92.0%) | 106 (93.8%) | NA |
| Frail | 16 (7.1%) | 9 (8.0%) | 7 (6.2%) | NA |
| Time since treatment completion, mean (SD), months | 29.74 (20.73) | 30.50 (23.56) | 28.99 (17.53) | .587 |
| Time since cancer diagnosis, mean (SD), months | 37.05 (21.93) | 37.70 (23.87) | 36.40 (19.88) | .657 |
| Credibility/Expectancy scores (out of 6), mean (SD) | 5.03 (0.81) | 5.02 (0.86) | 5.04 (0.76) | .801 |
aOther cancers include colorectum, lung, prostate, liver, stomach, thyroid, laryngeal, cervical, lymphoma, oesophageal, bladder and kidney.
The mean attendance for the qigong and light exercise classes was 19.21 (SD 4.81) and 18.85 (SD 5.65) out of 24 classes, respectively (Table 2). The mean competency score for the qigong group was 91.85 (SD 16.21) out of 120, with 84.9% of participants scoring over 72. The qigong group reported significantly more self-practice than the control group (109.23, SD 85.42 vs. 82.00, SD 91.44 min/week, P = 0.034).
Table 2.
Intervention fidelity parameters
| Fidelity measures | Overall, number (%) | Group, number (%) | P-value | |
|---|---|---|---|---|
| Qigong group (n = 105) | Light flexibility exercise group (n = 103) | |||
| Self-practicea, mean (SD), min/week | 96.25 (89.16) | 109.23 (85.42) | 82.00 (91.44) | .034 |
| Attendance (out of 24), mean (SD) | 19.91 (3.84) | 19.99 (3.61) | 19.83 (4.08) | .760 |
| Qigong competency scoreb (out of 120), mean (SD) | NA | 91.85 (16.21) | NA | NA |
| Number of participants with qigong competency score ≥ 72b | NA | 90 (84.9%) | NA | NA |
aFor both groups, participants were recommended to self-practice for 30 min twice weekly in Weeks 1–8, and three times weekly in Weeks 9–16 (i.e. on average 75 min/week).
bThe total number of participants was 106 because the assessment took place at 8 weeks.
Table 3 shows the reversal of frailty status in each group. At 8 weeks, the difference in the rate of reversal of frailty status in the qigong group 22.8% (95% CI, 20.82% to 24.82%) and light exercise group 21.4% (95% CI, 19.60% to 22.72%) was statistically insignificant (AOR 0.99, 95% CI, 0.41 to 2.41). At 16 weeks, the difference in the proportion of reversal of frailty status in the qigong group 28.7% (95% CI, 26.97% to 30.35%) and control group 22.5% (95% CI, 20.59% to 24.33%) was also statistically insignificant (AOR 1.39, 95% CI, 0.65 to 2.95). The reversal of frailty domains is displayed in Table 2. The rates of reversal of frailty domains of fatigue, weight loss, slowness, weakness and physical activity in the two groups did not show a statistically significant difference between the two groups at both time points.
Table 3.
Transition in overall frailty status and frailty domains
| Frailty parametersa | Time points | Group, % (95% CI) | Adjusted odds ratio (qigong—control) (95% CI) | |
|---|---|---|---|---|
| Qigong group (n = 113) | Light flexibility exercise group (n = 113) | |||
| Improvement in overall frailty status | 8 weeks | 22.8 (20.82 to 24.82) | 21.4 (19.60 to 22.72) | 0.99 (0.41 to 2.41) |
| 16 weeks | 28.7 (26.97 to 30.35) | 22.5 (20.59 to 24.33) | 1.39 (0.65 to 2.95) | |
| Improvement in fatigue | 8 weeks | 12.6 (11.65 to 13.52) | 12.0 (11.43 to 12.65) | 0.92 (0.35 to 2.42) |
| 16 weeks | 12.2 (11.29 to 13.15) | 12.6 (11.12 to 14.04) | 0.91 (0.35 to 2.39) | |
| Improvement in weight loss | 8 weeks | 8.0 (7.23 to 8.73) | 8.7 (7.47 to 9.81) | 0.93 (0.29 to 3.04) |
| 16 weeks | 9.4 (8.34 to 10.34) | 9.6 (8.13 to 10.95) | 0.97 (0.33 to 2.82) | |
| Improvement in slowness | 8 weeks | 11.3 (10.38 to 12.26) | 6.9 (6.42 to 7.42) | 2.24 (0.59 to 8.50) |
| 16 weeks | 9.0 (8.11 to 9.89) | 7.8 (7.32 to 8.32) | 1.25 (0.38 to 4.15) | |
| Improvement in weakness | 8 weeks | 14.7 (13.05 to 16.31) | 15.6 (14.54 to 16.54) | 0.95 (0.40 to 2.28) |
| 16 weeks | 20.4 (18.65 to 22.07) | 14.7 (13.76 to 15.64) | 1.72 (0.77 to 3.84) | |
| Improvement in low activity | 8 weeks | 5.7 (5.05 to 6.27) | 9.2 (8.55 to 9.77) | 0.54 (0.16 to 1.78) |
| 16 weeks | 5.3 (4.51 to 6.09) | 8.1 (6.96 to 9.28) | 0.56 (0.15 to 2.15) | |
Adjusted for age, gender, comorbidity, cancer type, cancer stage, treatment received, time since last treatment, baseline frailty status and expectancy toward treatment condition.
aBy Fried frailty phenotype.
Table 4 summarises the change in the continuous outcomes from baseline at 8- and 16-week follow-ups for the two groups. For all continuous outcomes, there was a significant main effect of time (P < .001). Within-group comparisons revealed that the qigong group had significant improvements from baseline on physical frailty severity, multidimensional frailty severity, psychological well-being, physical performance and HRQoL at 8 and 16 weeks (all P < .001), while the control group demonstrated significant improvements in physical frailty severity and physical performance at both time points (all P < .001) and psychological well-being (P = .003) and HRQoL (P = .014) at 16 weeks. Of note, the improvement in physical performance in both groups exceeded clinically meaningful threshold at both time points. Compared to the control group, the qigong group showed greater improvement in multidimensional frailty severity (P = .043) and physical performance (P = .030) at 8 weeks. Despite these post-hoc differences, none of the group × time interactions were significant, indicating no significant between-group difference in change over time.
Table 4.
Change in secondary outcomes
| Time points | Qigong group (n = 113) | Light flexibility exercise group (n = 113) | Qigong group change from baseline | Light flexibility exercise group change from baseline | Between-group difference in change (qigong-light flexibility exercise) | Time P-value | Group P-value | Group × time interaction P-value | |||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean (95% CI) | Mean (95% CI) | Mean (95% CI) | P-value | Mean (95% CI) | P-value | Mean (95% CI) | P-value | NA | NA | NA | |
| Physical frailty severity (Fried frailty score) | |||||||||||
| Baseline | 2.08 (1.78, 2.38) | 2.00 (1.71, 2.29) | NA | NA | NA | NA | NA | NA | <.001 | .591 | .823 |
| 8 weeks | 1.68 (1.38, 1.99) | 1.67 (1.37, 1.98) | −0.39 (−0.60, −0.19) | <.001 | −0.33 (−0.53, −0.13) | <.001 | −0.07 (−0.30, 0.17) | 0.580 | NA | NA | NA |
| 16 weeks | 1.63 (1.32, 1.93) | 1.62 (1.31, 1.92) | −0.45 (−0.65, −0.25) | <.001 | −0.39 (−0.58, −0.19) | <.001 | −0.07 (−0.29, 0.16) | 0.565 | NA | NA | NA |
| Multidimensional frailty severity (EFS Score) | |||||||||||
| Baseline | 6.50 (5.39, 7.60) | 5.71 (4.64, 6.79) | NA | NA | NA | NA | NA | NA | <.001 | .052 | .111 |
| 8 weeks | 5.60 (4.51, 6.69) | 5.41 (4.34, 6.48) | −0.90 (−1.41, −0.40) | <.001 | −0.30 (−0.81, 0.20) | .455 | −0.60 (−1.18, −0.02) | 0.043 | NA | NA | NA |
| 16 weeks | 5.69 (4.61, 6.78) | 5.43 (4.36, 6.50) | −0.81 (−1.32, −0.30) | <.001 | −0.28 (−0.79, 0.23) | .561 | −0.53 (−1.12, 0.06) | 0.080 | NA | NA | NA |
| Depressive symptoms (GDS Score) | |||||||||||
| Baseline | 0.42 (0.33, 0.51) | 0.40 (0.31, 0.49) | NA | NA | NA | NA | NA | NA | <.001 | .741 | .122 |
| 8 weeks | 0.36 (0.27, 0.44) | 0.37 (0.29, 0.46) | −0.07 (−0.10, −0.03) | <.001 | −0.03 (−0.07, 0.01) | .180 | −0.04 (−0.08, 0.01) | 0.114 | NA | NA | NA |
| 16 weeks | 0.36 (0.27, 0.44) | 0.34 (0.26, 0.43) | −0.06 (−0.10, −0.02) | <.001 | −0.06 (−0.10, −0.02) | .003 | −0.01 (−0.05, 0.04) | 0.783 | NA | NA | NA |
| Physical performance (SPPB Score) | |||||||||||
| Baseline | 9.17 (8.38, 9.96) | 9.05 (8.28, 9.82) | NA | NA | NA | NA | NA | NA | <.001 | .400 | .076 |
| 8 weeks | 9.64 (8.86, 10.42) | 9.91 (9.15, 10.67) | 0.47 (0.16, 0.78) | <.001 | 0.86 (0.55, 1.17) | <.001 | −0.39 (−0.75, −0.04) | 0.030 | NA | NA | NA |
| 16 weeks | 9.94 (9.16, 10.72) | 10.17 (9.41, 10.94) | 0.77 (0.45, 1.10) | <.001 | 1.13 (0.80, 1.45) | <.001 | −0.35 (−0.73, 0.02) | 0.063 | NA | NA | NA |
| HRQoL (EORTC Score) | |||||||||||
| Baseline | 53.11 (45.01, 61.21) | 53.73 (45.84, 61.62) | NA | NA | NA | NA | NA | NA | <.001 | .381 | .144 |
| 8 weeks | 59.61 (51.41, 67.80) | 55.82 (47.78, 63.87) | 6.50 (2.63, 10.37) | <.001 | 2.10 (−1.77, 5.97) | .577 | 4.40 (−0.07, 8.87) | 0.054 | NA | NA | NA |
| 16 weeks | 59.06 (50.97, 67.15) | 58.00 (50.06, 65.94) | 5.95 (2.35, 9.55) | <.001 | 4.28 (0.67, 7.88) | .014 | 1.67 (−2.49, 5.83) | 0.428 | NA | NA | NA |
Note. EFS: Edmonton Frail Scale; GDS: Geriatric Depression Scale; SPPB: Short Physical Performance Battery; HRQoL: health-related quality of life; EORTC Score: European Organisation for Research and Treatment of Cancer Core Quality of Life questionnaire.
Adjusted for age, gender, comorbidity, cancer type, cancer stage, treatment received, time since last treatment, baseline frailty status and expectancy toward treatment condition.
Discussion
To our knowledge, this is the first interventional RCT seeking to improve frailty of older cancer survivors. Our findings do not support the significant benefit of qigong on frailty compared to an active control (i.e. light flexibility exercise). For secondary outcomes, both qigong and control groups showed significant improvement in physical frailty severity, physical performance, psychological well-being and quality of life, while significant improvement in multidimensional frailty severity was found only in the qigong group. Nevertheless, no significant between-group difference in change over time was observed.
Our study found 28.7% and 22.5% of qigong and light flexibility exercise group participants reversed their frailty status, respectively, whereas a longitudinal study in older cancer survivors did not identify any ameliorative curve when characterising frailty trajectories [28]. In terms of frailty scores (i.e. physical frailty severity), the qigong and light flexibility exercise group had a reduction of 0.45 and 0.39 points, respectively. This suggests that both qigong and light flexibility exercises potentially exhibited small positive influences on frailty. During the study design, qigong was speculated to improve cancer-related frailty based on its well-established benefits of promoting holistic well-being, reducing inflammation [10] and improving fatigue, grip strength, activity levels and gait speed [8, 9, 29], which are physical phenotypes of frailty. Light flexibility exercise, a gentle exercise modality for improving range of motion [30], was selected as an active control condition to control for non-specific factors related to group sessions. The positive change in both groups in our study may be attributed to physical activity in general, and the clinical meaningfulness of such change in cancer survivors is not clear. Future interventional research should further explore the underlying mechanisms driving the change in frailty, investigate the clinical meaningfulness of frailty measures in cancer survivors and adopt a routine care control group to distinguish the intervention effect.
In addition to physical phenotype, our study examined the change in multidimensional frailty severity. Notably, a significant reduction in multidimensional frailty severity was observed only in the qigong group but not in the control group. Although the between-group difference in change did not reach statistical significance, the findings provide insights on the uniqueness of qigong practice. The multidimensional model of frailty is a relatively novel approach to frailty, characterised by the loss of harmonic interaction among multiple domains, including psychological [31]. Some of the unique characteristics of qigong compared to light flexibility exercise include its meditation and breathing regulation components and ability to replenish qi, which may have contributed to its effect on multidimensional frailty severity. Given the increasing emphasis on considering multidimensions of frailty beyond physical criteria, future RCTs may consider adopting co-primary outcomes including both physical phenotype and multidimensional frailty severity to provide a holistic understanding of the intervention effect. An RCT in older adults with cognitive frailty showed a significant effect of a 24-week qigong intervention vs usual care for improving multidimensional frailty severity [11]. Within-group change comparisons showed that the qigong group had a reduction of 1.94 points on the Edmonton Frailty Scale score (i.e. the same instrument as the one used in our study) [11], which appears to be double the reduction in our study (i.e. 0.81 points). Our seemingly smaller effect size may be explained by the shorter intervention period (i.e. 16 weeks) and the longer time frailty may take to change.
Two network meta-analyses consistently found that physical activity was the most effective type of intervention for managing frailty among general older adults, relative to other interventions such as nutrition supplementation, physical activity combined with nutrition supplementation and comprehensive geriatric assessment [4, 32]. Among different forms of physical activity, resistance training and mind–body exercise ranked the most effective modalities [4]. A recent meta-analysis demonstrated that in older cancer survivors, exercise combined with dietary advice might be a more effective approach in improving physical functioning [33]. To examine an optimal strategy for managing frailty in older cancer survivors, future trials could explore the efficacy of combination of qigong exercise with dietary support. As light flexibility exercise has been mostly examined for its effect on range of motion in the literature [30], its potential for improving frailty should also be explored in further research. Providing older cancer survivors with various physical activity options may enhance their overall activity level, which may benefit frailty to the largest extent.
In terms of secondary outcomes, both qigong and light flexibility exercise resulted in significant improvement from baseline in psychological well-being, physical performance and HRQoL, despite the lack of significant change in between-group differences over time. Notably, the improvement in physical performance (i.e. Short Physical Performance Battery scores) in both groups was clinically meaningful. In addition to effectiveness, safety and acceptability are important considerations when adopting interventions in practice, particularly in clinical populations such as cancer patients. The absence of adverse events and low dropout rates in both our study arms support that qigong and light flexibility exercise could serve as safe and acceptable physical activity modalities in older cancer survivors. Notably, the average self-practice time in both the qigong and light flexibility exercise group exceeded our recommendations, and participants in the qigong group had significantly more self-practice than those in the light flexibility exercise group, suggesting high acceptance of both modalities among the cancer population. The potentially greater acceptance of Baduanjin qigong may be attributed to its eight structured movements, which are relatively easy-to-learn and remember.
A major strength of the study is the adoption of both physical and multidimensional frailty measures in outcome measurement, enabling a more comprehensive understanding of intervention effects. In addition, using light flexibility exercise as a control group allowed us to account for placebo and expectancy effects. Participants perceived that the study was to test the effects of two exercise modalities, thereby may have balanced participants’ expectations and minimised biases, as shown by the similar expectancy scores of the two groups at baseline. Nevertheless, the study has a few limitations. First, our sample comprised only the Chinese population and approximately half of the participants suffered from breast cancer. Majority of participants were pre-frail, and the frail older adults with mobility issues were excluded due to safety concern. Hence, the generalisability of the study findings may be limited. Second, the follow-up analysis was limited to post-intervention. A longer-term follow-up examining the sustainability of the intervention effect is recommended. Third, the underlying mechanisms driving the change in frailty were not examined.
Implications
Our study contributes to the current knowledge of frailty management in older cancer survivors. Future research should use both active and inactive conditions as controls. Alternative approaches could be explored to improve frailty in the cancer population (e.g. qigong exercise combined with dietary support). Also, the underlying mechanisms and clinical meaningfulness of frailty change should be examined, and a long-term follow-up time point should be included to study the sustained effects. Despite the lack of evidence regarding the superiority of either qigong or light flexibility exercise, service providers could consider recommending both modalities to older cancer survivors, given their individual significant improvement in psychological well-being, physical performance and QOL. Older cancer survivors could choose a suitable intervention based on their values and preferences.
Conclusions
Qigong was not superior to an active control in its effect on improving frailty in older cancer survivors. Future trials should include routine care as control and examine the underlying mechanisms driving the change in frailty.
Supplementary Material
Acknowledgements
We sincerely thank all participants for their involvement in this study and the qigong masters and exercise trainers who dedicated their time to the interventions. We also extend our gratitude to our research assistants, PhD student Xueyan Chen, and senior research assistant Xuyang Zhang for their collaboration in project management.
Contributor Information
Denise Shuk Ting Cheung, School of Nursing, The University of Hong Kong, Hong Kong.
Wing Lok Chan, Department of Clinical Oncology, The University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong.
Pui Hing Chau, School of Nursing, The University of Hong Kong, Hong Kong.
Inda Sung Soong, Pamela Youde Nethersole Eastern Hospital, Department of Clinical Oncology, Hong Kong.
Wing Fai Yeung, The Hong Kong Polytechnic University, School of Nursing, Hong Kong.
Shing Fung Lee, National University Cancer Institute, Singapore.
Parco M Siu, The University of Hong Kong, School of Public Health, Hong Kong.
Jean Woo, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Faculty of Medicine, Hong Kong.
Doris Sau Fung Yu, The University of Hong Kong Li Ka Shing, Faculty of Medicine, School of Nursing, Hong Kong.
Chia-Chin Lin, University of Hong Kong, School of Nursing, Hong Kong.
Declaration of Conflicts of Interest
None declared.
Declaration of Sources of Funding
This work was supported by Health and Medical Research Fund (Food and Health Bureau), Hong Kong SAR Government (Grant numbers 18192521).
Data Availability Statement
Data from this study will be made available upon reasonable request. For data access, please contact the corresponding author.
Declaration of Trial Registration
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data from this study will be made available upon reasonable request. For data access, please contact the corresponding author.