Emotional freedom techniques for anxiety, depression, and quality of life in middle-aged and older adults with chronic obstructive pulmonary disease: A randomized controlled trial in China

Abstract

Objective

To test the effectiveness of Emotional Freedom Techniques (EFT) in reducing anxiety and depression and improving sleep, fatigue, and disease-specific quality of life in middle-aged and older patients with chronic obstructive pulmonary disease (COPD).

Methods

This randomized controlled trial was conducted at a tertiary hospital in Nanjing,China,from December 2024 to July 2025. Ninety COPD inpatients with anxiety (AIR-C ≥ 8) and depression (SDS >53) were randomly allocated to routine care (control, n = 45) or routine care plus a 6-week EFT program (EFT, n = 45). AIR-C, SDS, PSQI, MCFS, and CAT scores were collected at baseline, week 2, and week 6. Repeated-measures ANOVA and independent t-tests were applied with α = 0.05.

Results

Compared with controls, the EFT group showed larger declines at week 6 in anxiety (Δ = 2.40 ± 3.62, P < 0.01) and depression (Δ = 4.49 ± 8.37, P < 0.01) and greater improvements in sleep quality (Δ = 8.66 ± 5.05), fatigue (Δ = 3.55 ± 5.89), and CAT (Δ = 3.91 ± 5.98) (all P < 0.01). Benefits emerged by week 2.

Conclusions

A 6-week EFT program is an effective, safe, and inexpensive adjunct to routine rehabilitation for COPD, producing rapid and sustained improvements in psychological distress and health-related quality of life.

1. Introduction

Chronic Obstructive Pulmonary Disease (COPD) is a major global health burden characterized by persistent airflow limitation and high mortality (Celli et al., 2022). Annual COPD-related deaths are projected to reach 4.4 million by 2040 (World Federation of Chinese Medicine Societies Internal Medicine Professional Committee, 2023). Prevalence increases with age, exceeding 13.7 % in adults over 40 and 27 % in those over 60 (Foreman et al., 2018).

Psychological comorbidities such as anxiety and depression markedly accelerate COPD progression through neuroendocrine and inflammatory mechanisms (Laurin et al., 2012;Hong et al., 2023). A meta-analysis involving 16,922 patients demonstrated strong associations between psychological symptoms and objective physiological markers (Bach et al., 2019), while combined anxiety and depression further increased the risk of acute exacerbation and hospital readmission (Panagioti et al., 2014;Wu et al., 2025). Despite reported prevalence rates of 2–96 % for anxiety and 8–80 % for depression,only one-third of affected patients receive systematic psychological management (Wang et al., 2018; Bauer and Teixeira, 2021). Pharmacologic options pose risks of addiction and respiratory depression, whereas many non-drug interventions remain costly or difficult to access, particularly for older adults with limited mobility. Therefore, safe, simple, and accessible adjunctive therapies are urgently needed.

Emotional Freedom Techniques (EFT) is an evidence-based intervention that integrates Traditional Chinese Medicine meridian theory with cognitive and exposure therapy principles (Church et al., 2022;Stapleton et al., 2023). Through tapping on specific acupoints while focusing on distress and affirming self-acceptance,EFT has been shown to reduce amygdala activation,lower cortisol levels,enhance immune markers,and modulate gene expression (Feinstein, 2008;Church et al., 2012). Meta-analyses indicate large and sustained effects of EFT on anxiety and depression (Nelms and Castel, 2016;Clond, 2016), suggesting potential value for COPD populations with comorbid emotional symptoms.

Building on this evidence, the present study investigates whether a six-week EFT program can improve anxiety, depression, sleep quality, fatigue, and disease-specific quality of life among middle-aged and older adults with COPD. The study was designed to evaluate whether EFT provides benefits beyond routine psychological care and whether improvements extend across follow-up assessments. In addition, the intervention explores a potential mechanistic pathway in which meridian stimulation combined with psychological processing may contribute to emotional regulation - a concept consistent with Traditional Chinese Medicine theories regarding the mutual influence between emotions and meridians.

Overall,this study aims to (1) evaluate EFT's effects on negative emotions and quality of life in COPD patients; (2)provide an integrative and low-risk mind – body management strategy suitable for older adults; and (3)generate internationally relevant evidence linking Traditional Chinese Medicine principles with contemporary psychological therapy approaches.

2. Methods

2.1. Study design and population

A randomized controlled trial was conducted in a tertiary hospital in Nanjing, Jiangsu, China, between December 2024 and July 2025. Ninety eligible COPD inpatients were randomly assigned (1:1) to a control group receiving routine psychological care or an EFT group receiving routine care plus a 6-week EFT program.Randomization was computer-generated by an independent statistician and concealed using opaque sealed envelopes. Outcome assessors and data analysts were blinded to group allocation. The study was approved by the ethics committee of a tertiary hospital in Nanjing, China, complied with the Declaration of Helsinki, and all participants provided written informed consent.

2.1.1. Participants

Middle-aged and older adults with chronic obstructive pulmonary disease (COPD) were recruited through convenience sampling from inpatient wards. Inclusion criteria were: (1)age > 40 years; (2)COPD diagnosed according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD2024) criteria (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2024); (3)clinically relevant anxiety defined by the Anxiety Inventory for Respiratory Disease (AIR-C, 10 items,0–30) with a score ≥ 8(Dong et al., 2016); (4)clinically relevant depression defined by the Self-Rating Depression Scale (SDS) with a standard score > 53(Duan and Sheng, 2012); and(5)intact cognition and communication confirmed by the Mini-Cog(three-item recall+clock drawing) with a score 3/5(McCarten et al., 2012). Exclusion criteria included: (1)major psychiatric disorder, delirium, or impaired consciousness verified through medical history, chart review, and structured clinical interview; (2)severe upper-limb dysfunction preventing tapping (fracture, immobilization, severe pain, or neurological deficit; a brief functional screen was applied if uncertain); (3)life-threatening comorbidities such as hemodynamic instability or active chemotherapy for advanced malignancy; and(4)concurrent participation in other mind - body interventions (e.g.,ongoing EFT, acupressure tapping, or cognitive-behavioral therapy involving tapping exposure). A total of 90 eligible participants were enrolled and randomized (n = 45 per group).

2.1.2. Experimental intervention

Control group (Routine care): Participants in the control group received standard nursing care and education according to the GOLD 2024 recommendations (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2024). Routine care included monitoring vital signs and symptoms, medication adherence support, dietary guidance, and access to ward-based psychological counseling when required. This reflected the hospital's standard clinical management for COPD.

EFT group (Routine care+EFT): An Emotional Freedom Techniques (EFT) program was specifically adapted for patients with COPD. The protocol was based on Clinical EFT (Church et al., 2022) and followed the standard tapping procedure illustrated in Fig. 1. This clinical method involves nine standard tapping points – the Karate Chop(KC) point for self-acceptance setup, followed by Eyebrow(EB), Side of Eye(SE), Under Eye(UE), Under Nose(UN), Chin CH), Collarbone(CB), Under Arm(UA), and Top of Head(TH) - which are used to regulate emotional and physiological stress responses through acupoint stimulation.

To address respiratory distress and chest tightness characteristic of COPD, the standard Clinical EFT sequence was modified by integrating five Traditional Chinese Medicine (TCM) acupoints that are commonly used to relieve dyspnea and chest oppression:Feishu(BL13), Tiantu(CV22), Shenshu(BL23), Dingchuan(EX-B1), and Danzhong(CV17) (see Fig. 2). This modified “expanded EFT sequence (COPD version)” preserved the nine standard tapping points and the Karate - Chop self-acceptance statement, while adding a supplementary face - chest tapping round that focuses on these five COPD - related acupoints. Together,the adapted sequence was designed to enhance respiratory comfort and emotional regulation in COPD patients. Illustrations of standard Clinical EFT points are available from EFT International and The Tapping Solution. (See Fig. 1).

Fig. 2.

COPD-related acupoints integrated into the expanded EFT tapping sequence. Figure legend:Diagram depicting the five Traditional Chinese Medicine acupoints incorporated into the modified EFT protocol for COPD:Feishu(BL13),Tiantu(CV22),Shenshu(BL23),Dingchuan(EX-B1),and Danzhong(CV17).These acupoints are located on the chest and back and are traditionally used to relieve dyspnea,cough,and chest oppression.

Fig. 1.

Standard Clinical Emotional Freedom Techniques (EFT) tapping points. Figure legend:Illustration showing the nine standard tapping points used in Clinical EFT,including the Karate Chop (KC),Eyebrow(EB),Side of Eye(SE),Under Eye(UE),Under Nose(UN),Chin(CH),Collarbone(CB),Under Arm(UA),and Top of Head(TH).These points are stimulated sequentially to promote relaxation and emotional balance.

Personnel and training: One licensed therapist, two respiratory nurses, and two postgraduate students completed ≥2 weeks of standardized training and passed a competency assessment before delivering the intervention.

Implementation workflow: Preparation phase (≤24 h after admission): Printed/pictorial materials were distributed, and patients received an in-person demonstration followed by one coached practice.

Core inpatient phase (Weeks1–2): Supervised tapping was conducted twice daily (15–30 min/session).

Each session comprised: (1)Emotion focusing – identifying distress and rating intensity on the Subjective Units of Distress (SUD, 0–10); (2)Acceptance statement - three repetitions at the KC point (e.g.,“Even though I feel anxious/depressed, I deeply accept myself and remain hopeful about recovery”); (3)Standard nine-point Clinical EFT sequence: TH → EB → SE → UE → UN → CH → CB → UA (5–8 taps/point), followed by COPD-specific acupoints BL13 → EX-B1 → CV22 → CV17 → BL23; (4)Nine-Gamut procedure - tapping the Gamut point (Triple Warmer meridian, between the ring and little fingers) while sequentially closing eyes, opening eyes, looking down-right/left, rotating eyes clockwise/counterclockwise, humming (∼10s), counting 1–5, and humming again (Feinstein, 2008); (5)SUD re-assessment between rounds; sessions ended when SUD ≤2.

Consolidation phase (Weeks 3–6,post-discharge): Postgraduate supervisors conducted remote follow-up via WeChat twice daily (08:00 and 18:00) to provide reminders, video checks, and troubleshooting. Patients performed one home session daily (15–20 min).

Adherence and fidelity: Session duration, completed points, and SUD (Subjective Units of Distress) changes were logged. One randomly selected weekly video review verified procedural fidelity. When upper-limb limitations prevented self-tapping,trained nurses or family members assisted by applying gentle taps to the anterior chest points. If mild skin discomfort occurred, tapping was replaced with light touch or fewer repetitions.

2.2. Measurements

All assessments were administered at baseline (T0), 2 weeks (T1), and 6 weeks (T2) by evaluators blinded to group allocation. Validated Chinese versions of all instruments were used to ensure reliability and cultural relevance.

Anxiety Inventory for Respiratory Disease (AIR-C): The AIR-C is a 10-item self-report questionnaire developed for patients with respiratory conditions. Each item is rated on a 4-point scale (0=“not at all” to 3=“most of the time”), yielding a total score of 0–30, with higher scores indicating greater anxiety. A total score ≥ 8 denotes clinically significant anxiety. The Chinese version demonstrates excellent internal consistency (Cronbach's α = 0.92), test–retest reliability (r = 0.88) and strong construct validity in COPD populations(Dong et al., 2016;Dong, 2017).

Self-Rating Depression Scale (SDS): The SDS comprises 20 items rated on a 4-point scale (1=“a little of the time” to 4=“most of the time”). The raw score is multiplied by 1.25 to obtain a standardized value. Scores >53 indicate depression (53–62 = mild, 63–72 = moderate, ≥73 = severe). The Chinese version exhibits good reliability (Cronbach's α = 0.84) and satisfactory content validity (Duan and Sheng, 2012).

Pittsburgh Sleep Quality Index (PSQI): The PSQI evaluates subjective sleep quality over the previous month across seven domains: sleep latency, duration, disturbances, efficiency, use of medication, daytime dysfunction, and overall quality. Each component is scored 0–3, with a total score range of 0–21. Higher scores represent poorer sleep quality, and a cutoff ≥8 indicates sleep disturbance. The Chinese version demonstrates good reliability (α = 0.84), test–retest stability (r = 0.81), and strong structural validity (Lu et al., 2014).

Manchester COPD Fatigue Scale (MCFS): The Chinese version of the MCFS includes 27 items assessing physical, cognitive, and psychosocial aspects of fatigue. Each item is rated from 1 (“never”) to 5 (“always”), with total scores ranging from 27 to 135. Higher scores indicate greater fatigue severity. The instrument has excellent reliability (α = 0.86; ICC = 0.97) and is sensitive to changes among COPD patients (Kou, 2022).

COPD Assessment Test (CAT): The CAT consists of eight items rated from 0 to 5, producing a total score between 0 and 40. Higher scores indicate poorer COPD-specific health status. The Chinese version has demonstrated high internal consistency (α = 0.88) and strong correlations with the St.George's Respiratory Questionnaire (SGRQ) (Jones et al., 2009).

Subjective Units of Distress (SUD): The SUD is a single-item scale (0−10) that measures momentary emotional distress, where 0 indicates “no distress” and 10 represents “extreme distress.” It was used to monitor immediate emotional changes during EFT sessions but was not included as a primary study outcome.

Data collection and quality control: A triple-blind design was implemented, with independent teams conducting the intervention, assessment,and data analysis. Questionnaires were administered face-to-face within 24 h after enrollment (T0), at 2 weeks (T1), and at 6 weeks (T2) by assessors blinded to group allocation. If the T2 assessment occurred after discharge,participants completed evaluations in the outpatient follow-up room. Intervention fidelity was maintained through standardized checklists, random video audits, and documentation of therapist training. To prevent cross-group contamination, the EFT and control groups attended educational activities in separate wards and time slots. Nursing staff were required to sign confidentiality agreements to ensure adherence.

2.3. Statistical analysis

Continuous variables were tested for normality using the Shapiro–Wilk test and presented as mean ± standard deviation (mean ± SD), whereas categorical variables were summarized as frequency and percentage. Baseline characteristics were compared using chi-square tests for categorical variables, independent-samples t-tests for normally distributed continuous variables, and Mann–Whitney U tests for non-normal distributions.

Within-group changes were analyzed using paired t-tests, and between-group differences at each time point were assessed using independent-samples t-tests. Longitudinal effects were examined using repeated-measures analysis of variance (ANOVA). When interaction effects were significant, Bonferroni post hoc corrections were applied. Effect sizes were reported as Cohen's d for t-tests and partial η² for ANOVA. Statistical significance was defined as two-tailed P < 0.05.

Missing data were managed under the intention-to-treat (ITT) principle using last observation carried forward (LOCF) imputation to preserve statistical power and reduce bias.

All statistical analyses were performed using SPSS version 26.0 (IBM Corp.,Armonk,NY,USA).

3. Results

3.1. Baseline characteristics

No significant differences (all P > 0.05) existed between control and EFT groups in gender, age, education, occupation, marital status, or clinical indices (See Table1), confirming comparability.

Table 1.

Baseline characteristics of participants in the EFT and control groups in Nanjing,China,December 2024–July 2025.

Variable		EFT Group (n = 45)	Control Group (n = 45)	X2/t/z	P
Gender	Male	39(86.67)	35(77.78)	1.22a	0.27
	Female	6(13.33)	10(22.22)
Age (years)	–	72.36 ± 7.97	69.64 ± 7.58	1.66b	0.10
Educational Level	Primary school or below	13(28.89)	16(35.56)	-0.65c	0.51
	Junior high school	18(40.00)	17(37.78)
	Senior high school or technical secondary school	12(26.67)	10(22.22)
	College/university or above	2(4.44)	2(4.44)
Occupational Status	Retired/unemployed	39(86.67)	43(95.56)	1.24a	0.27
	Employed	6(13.33)	2(4.44)
Marital Status	Unmarried	1(2.22)	0(0.00)	1.91a	0.49
	Married	43(95.56)	45(100.00)
	Divorced/Widowed	1(2.22)	0(0.00)
Disease Stage	Acute exacerbation	39(86.67)	33(73.33)	2.50a	0.11
	Stable	6(13.33)	12(26.67)
Comorbidity	Yes	36(80.00	31(68.89)	1.46a	0.23
	No	9(20.00)	14(31.11)
Disease Duration	0–5 years	14(31.11)	21(46.67)	-1.65c	0.10
	6–10 years	12(26.67)	11(24.44)
	11–15 years	10(22.22)	8(17.78)
	>15 years	9(20.00)	5(11.11)
Acute Exacerbations in 1 Year	0	1(2.22)	1(2.22)	-0.76c	0.45
	1–2	30(66.67)	34(75.5)
	3–4	11(24.44)	6(13.33)
	>4	3(6.67)	4(8.89)

Note: Values are presented as n (%) unless otherwise indicated. Continuous data are expressed as mean ± standard deviation (SD).ᵃ Chi-square test;ᵇ Independent samples t-test;ᶜ Mann-Whitney U test.The p-value is calculated using the chi-square test,t-test,and mann-Whitney U test.

3.2. Comparative analysis of respiratory anxiety (AIR-C) and depression (SDS) scores

Both groups showed significant AIR-C and SDS reduction vs baseline (P < 0.01). The EFT group had significantly lower scores than controls at T1 and T2 for both AIR-C anxiety (P < 0.01) and SDS depression (P < 0.01). Repeated-measures ANOVA revealed significant main effects of time (P < 0.01), group (P < 0.01), and group×time interaction (AIR-C:P < 0.01;SDS:P = 0.03) (See Table 2). Improvement magnitude increased with intervention duration.

Table 2.

Changes in AIR-C and SDS scores before and after the EFT intervention among middle-aged and older adults with COPD in Nanjing,China,December 2024–July 2025.

Outcome Measure	Time Point	Control Group (n = 45)	EFT Group (n = 45)	Between-Group t Value	Between-Group P Value
AIR-C Score	T0 (Baseline)	19.78 ± 4.40	20.64 ± 3.89	0.99	0.33
	T1 (Week 2)	15.04 ± 2.84	11.98 ± 3.06	−4.93	<0.01**
	T2 (Week 6)	9.93 ± 3.19	7.53 ± 1.70	−4.45	<0.01**
Repeated-measures ANOVA	Main effect (group):F = 16.68,P < 0.01,Partial η2 = 0.16(large effect) Main effect (time):F = 260.73,P < 0.01,Partial η2 = 0.84(large effect) Interaction effect (group×time):F = 8.69,P < 0.01,Partial η2 = 0.09(medium effect)
SDS Score	T0 (Baseline)	51.09 ± 8.05	50.87 ± 4.71	−0.16	0.87
	T1 (Week 2)	44.11 ± 6.8	39.58 ± 5.26	−3.51	<0.01**
	T2 (Week 6)	39.31 ± 7.57	34.82 ± 3.58	−3.60	<0.01**
Repeated-measures ANOVA	Main effect (group):F = 15.04,P < 0.01,Partial η2 = 0.15(large effect) Main effect (time):F = 120.86,P < 0.01,Partial η2 = 0.58(large effect) Interaction effect (group×time):F = 3.71,P = 0.03*,Partial η2 = 0.04(small effect)

Note: Values are expressed as mean ± standard deviation (SD)；*P < 0.05;**P < 0.01;Partial η²(partial eta-squared) interpretation:small effect = 0.01–0.059,medium effect = 0.06–0.139,large effect ≥ 0.14;AIR-C = Anxiety Inventory for Respiratory Disease;SDS=Self-Rating Depression Scale.The p-value is calculated using the t-test and ANOVA test.

3.3. Comparative analysis of sleep quality (PSQI), fatigue (MCFS), and quality of life (CAT)

Both groups improved significantly in PSQI, MCFS, and CAT vs baseline (P < 0.01). EFT surpassed controls on all measures at T1/T2 (P < 0.01). Repeated-measures ANOVA confirmed significant time/group main effects (P < 0.01) and group×time interactions for PSQI/MCFS (P < 0.01), but not CAT (P = 0.08) (See Table 3). Improvements progressed with time.

Table 3.

Changes in PSQI,MCFS,and CAT scores before and after the EFT intervention among middle-aged and older adults with COPD in Nanjing,China,December 2024–July 2025.

Outcome Measure	Time Point	Control Group (n = 45)	EFT Group (n = 45)	Between-Group t Value	Between-Group P Value
PSQI Score	T0 (Baseline)	25.56 ± 4.58	26.84 ± 4.86	1.30	0.20
	T1 (Week 2)	22.36 ± 5.32	17.56 ± 4.00	−4.84	<0.01**
	T2 (Week 6)	19.62 ± 3.62	10.96 ± 3.52	−11.52	<0.01**
Repeated-measures ANOVA	Main effect (group):F = 67.66,P < 0.01,Partial η2 = 0.44(large effect) Main effect (time):F = 132.44,P < 0.01,Partial η2 = 0.60(large effect) Interaction effect (group×time):F = 27.83,P < 0.01,Partial η2 = 0.24(large effect)
MCFS Score	T0 (Baseline)	32.99 ± 5.22	34.54 ± 5.42	1.39	0.17
	T1 (Week 2)	27.03 ± 3.23	22.03 ± 4.46	−6.09	<0.01**
	T2 (Week 6)	23.19 ± 4.40	19.64 ± 3.92	−4.03	<0.01**
Repeated-measures ANOVA	Main effect (group):F = 20.76,P < 0.01,Partial η2 = 0.19(large effect) Main effect (time):F = 171.94,P < 0.01,Partial η2 = 0.66(large effect) Interaction effect (group×time):F = 12.35,P < 0.01,Partial η2 = 0.12(medium effect)
CAT Score	T0 (Baseline)	23.27 ± 7.12	22.07 ± 5.67	−0.89	0.38
	T1 (Week 2)	19.69 ± 5.74	15.04 ± 4.05	−4.44	<0.01**
	T2 (Week 6)	17.07 ± 4.20	13.16 ± 4.25	−4.39	<0.01**
Repeated-measures ANOVA	Main effect (group):F = 27.72,P < 0.01,Partial η2 = 0.24(large effect) Main effect (time):F = 46.54,P < 0.01,Partial η2 = 0.35(large effect) Interaction effect (group×time):F = 2.55,P = 0.08,Partial η2 = 0.03(small effect)

Note:Values are expressed as mean ± standard deviation (SD); *P < 0.05;**P < 0.01;Partial η²(partial eta-squared) interpretation:small effect = 0.01–0.059,medium effect = 0.06–0.139,large effect ≥ 0.14;CAT = Chronic Obstructive Pulmonary Disease Assessment Test;MCFS = Manchester COPD Fatigue Scale;PSQI=Pittsburgh Sleep Quality Index.The p-value is calculated using the t-test and ANOVA test.

4. Discussion

This randomized controlled trial evaluated the effects of Emotional Freedom Techniques (EFT) as an adjunct to usual care in middle-aged and elderly patients with chronic obstructive pulmonary disease (COPD). Compared with usual care alone, EFT significantly improved anxiety, depression, sleep quality, fatigue, and disease-specific quality of life. These improvements appeared within two weeks of intervention and persisted through week six, indicating a rapid and multidimensional therapeutic effect over a short treatment duration. The consistency and magnitude of improvements across multiple domains imply that EFT may act on several interconnected pathways-emotional, cognitive, and physiological-that jointly contribute to symptom burden and functional decline in COPD. Such rapid cross-domain gains are clinically relevant because psychological distress, sleep disruption, and fatigue often reinforce dyspnea perception and limit participation in rehabilitation.

Regarding emotional outcomes, both anxiety and depression scores declined significantly in the EFT group, with reductions exceeding those of the control group. The Anxiety Inventory for Respiratory Disease (AIR-C), designed to distinguish psychological from somatic anxiety in respiratory patients (Dong, 2017), effectively captured these changes. The findings align with meta-analyses reporting large effect sizes of EFT for anxiety and depression (Clond, 2016;Nelms and Castel, 2016). The present results extend previous evidence to a chronic pulmonary population, supporting EFT as an accessible, low-risk, and self-administered psychological intervention, particularly suitable for older adults who may face barriers to conventional psychotherapy (e.g.,mobility constraints, stigma, or limited specialist access). In addition,prior evidence suggests EFT may influence stress-related biochemistry and inflammatory activity, including reductions in cortisol and improvements in physiological health markers (Bach et al., 2019); this provides a plausible supportive pathway for the emotional improvements observed in COPD inpatients.

This study incorporated the Nine-Gamut procedure, a distinctive element of Gary Craig's original EFT protocol, combining rhythmic tapping on the dorsum of the hand with structured eye movements, humming, and counting. This sequence is proposed to promote bilateral hemispheric activation and cognitive-emotional integration (Craig, 2011;Feinstein, 2022). Although neurophysiological mechanisms such as interhemispheric synchronization were not assessed, inclusion of this procedure may have contributed to the rapid reduction of anxiety observed. Emerging neuroimaging evidence indicates that acupoint tapping may modulate activity in brain regions central to emotional regulation (e.g.,limbic and prefrontal networks), offering a potential neurobiological substrate for EFT's effects (Peta et al., 2022). Future research employing electroencephalographic or neuroimaging techniques could further elucidate whether the Nine-Gamut sequence yields additive benefits beyond standard tapping rounds. Future research employing electroencephalographic or neuroimaging techniques could further elucidate its neural underpinnings.

Beyond emotional symptoms, EFT produced significant improvements in sleep quality, fatigue, and disease-specific quality of life. Sleep quality, measured by the Pittsburgh Sleep Quality Index (Lu et al., 2014), improved markedly, consistent with previous evidence linking EFT to enhanced sleep (Church et al., 2012). Since sleep disturbance in COPD is often associated with anxiety and depression (Wang et al., 2018), the observed improvements may reflect reduced psychological distress and improved autonomic balance. Fatigue, assessed by the Manchester COPD Fatigue Scale (Kou, 2022), also decreased significantly, supporting prior findings that mind-body interventions can alleviate fatigue and enhance functional capacity. Furthermore, COPD-specific quality of life, measured by the COPD Assessment Test (Jones et al., 2009), improved beyond the minimal clinically important difference of two points (Kon et al., 2014), suggesting clinically meaningful gains. These results indicate that EFT complements standard rehabilitation by addressing both psychological and physical dimensions of well-being, consistent with previous reports on cognitive-behavioral interventions in COPD (Chen et al., 2024). Notably, psychological distress is a recognized risk factor for acute exacerbations, hospitalization, and mortality in COPD; therefore, effective emotion-focused adjuncts may have downstream value for long-term prognosis and healthcare utilization(Kham-Ai et al., 2024).

Overall, the findings suggest that EFT-through structured self-acceptance, guided tapping, and focused attention-offers a practical, low-cost, and non-invasive strategy to improve mental health and overall well-being in COPD. From a preventive medicine and public health perspective, these results are important because anxiety and depression are prevalent yet under-treated in COPD, contributing to poorer self-management, reduced adherence, increased exacerbations, and higher healthcare burden. EFT is brief, nurse-deliverable after short training,and easily transitioned to self-practice at home, indicating potential scalability within hospital respiratory wards and community-based chronic disease management programs,especially for older adults with limited access to mental-health services. Its adaptability to both inpatient and community settings makes it a viable adjunct to integrated respiratory care programs.In addition, the culturally adapted “COPD-version” tapping sequence that integrates TCM acupoints may enhance acceptability and engagement in Chinese settings, supporting integrative models that bridge traditional meridian concepts with standardized psychological care.

Several limitations should be noted. This single-center trial involved a small sample and short-term follow-up, limiting generalizability and precluding assessment of long-term outcomes such as exacerbation frequency or hospital readmissions. The sample was predominantly male, and sex-specific effects remain unclear. All outcomes were self-reported, introducing possible expectancy bias. Moreover, the control group received usual care rather than an active psychological intervention, so nonspecific attention effects cannot be excluded. Finally, biological and neuroimaging measures were not included; therefore, potential mechanistic explanations, such as neurotransmitter modulation or memory reconsolidation,remain speculative. The expanded COPD-specific acupoint sequence was evaluated as a package with standard EFT, so the incremental contribution of added points cannot be inferred. Future multicenter studies with larger, balanced samples and objective assessments are warranted to validate these findings and further clarify EFT's mechanisms in COPD management, including biomarker panels, actigraphic sleep monitoring,autonomic indices, and cost-effectiveness analyses to support real-world implementation.

5. Conclusion

EFT combined with routine management significantly reduced anxiety and depression and improved sleep quality, fatigue, and COPD-specific quality of life in middle-aged and elderly patients with clinically meaningful gains evident by week two and sustained through week six. These results highlight EFT's potential as a non-pharmacological,non-invasive,and low-burden mind-body intervention for integration into pulmonary rehabilitation and chronic disease management, with potential public-health value for reducing psychological comorbidity burden and improving self-management capacity in aging COPD populations. Large-scale studies with extended follow-up and neurophysiological measures are needed to confirm these effects and define the optimal implementation of EFT within comprehensive COPD care frameworks.

CRediT authorship contribution statement

Chang Mengting: Writing – original draft, Visualization, Supervision, Resources, Funding acquisition, Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing – review & editing. Xu Jing: Validation, Investigation, Writing – review & editing. Luo Tiantian: Project administration, Data curation, Software, Visualization, Writing – review & editing. Chen Hongxin: Visualization, Investigation, Resources, Supervision, Writing – review & editing. Chen Lixia: Visualization, Validation, Supervision, Software, Resources. Cheng Xirong: Writing – review & editing, Supervision, Funding acquisition, Conceptualization, Resources.

Funding

This research was supported by the Open Fund Project of the Key Laboratory of Elderly Long-Term Care, Ministry of Education (Grant No.LNYBPY-2023-21), the 2025 Jiangsu Postgraduate Practice Innovation Program (Grant No.SJCX25_0916), and the List of Open Research Topics for Nursing Discipline at Nanjing University of Chinese Medicine:Phase IV of Jiangsu Higher Education Institutions' Advantage Discipline Project (Grant No.YSHL202510). The funding bodies had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscript.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.