Population ageing has become a global issue. Demographic studies predict that the number of individuals aged over 60 will exceed the number of adolescents by about 2047,1 challenging social economics,2 organizational productivity,3 and individual health.4
Physiological changes are inevitable during the ageing process, which diminishes the functional status of older adults. About 81% of people who are 65 years old or older complain of having at least one chronic illness.5 Age-related impairments are prevalent, particularly hearing6 and visual7 deficits that will cause them to misperceive the world around them and miscommunicate with others.8 An increase in neuro-degenerative diseases,9 such as Alzheimer’s disease, increases their vulnerability. Non-communicable illnesses10 devastate mobility of the ageing population; for example, hypertension, and diabetes. Risks of falling increase due to sarcopenia and dynapenia, which refer to age-associated loss of muscle mass11 and muscle strength12,13 respectively. More harmfully, older adults always suffer from emotional disorders,14 especially with depression.15 These ailments intensify disabilities, and thus obstruct normal daily activities,16 resulting not only in social isolation17 and unfavorable quality of life18 but also expanded private and public medical expenses.19
Physical activity20 is a critical strategy21 benefiting physical function, as well as cognitive and mental health for seniors. It includes a variety of resistance exercise training22,23 and aerobic exercises,24 such as rowing,25 swimming,26 walking,27 dancing,28 pilates,29 yoga,30 and conventional fitness exercises.
Traditional Chinese exercise is one of the effective approaches,31 and includes Qigong and Taiji (Tai Chi Quan), which benefit physical and psychological health for the aged.32,33 Ameliorated conditions encompass such items as reductions in knee osteoarthritis incurred pain and stiffness,34 and enhancement in motor function induced by Parkinson’s disease.35 Qigong is an umbrella term, covering a spectrum of exercises such as Baduanjin, Tuna (a kind of breathing method), and Xianggong. Based on traditional Chinese medicinal theory36 and the IChing principle37 (related to the yin-yang principle), Baduanjin, also known as the eight-brocade exercise, eight-section brocades or eight-treasured exercise, was used for health training in the form of a martial art, and has recently been adopted for community- based health promotion by the General Administration of Sport of China.38 A set of eight sequential movements is stipulated39 involving body-trunk, limb and eye movements that are matched with breathing: holding the hands high with palms up to regulate the internal organs (雙手托天理三焦), posing as an archer shooting both left-andright- handed (左右開弓似射鵰), holding one arm aloft to regulate the functions of the spleen and stomach (調理脾胃須單舉), looking backwards to prevent sickness and strain (五勞七傷向後瞧), swinging the head lowering the body to relieve stress (搖 頭擺尾去心火), moving the hands down the back and legs and touching the feet to strengthen the kidneys (兩手攀足固腎腰), thrusting the fists and making the eyes glare to enhance strength (攢拳怒目增氣力), and raising and lowering the heels to cure disease (背後七顛百病消).
In additional to the principal standing form, Baduanjin also has sitting and lying modes. The sitting form focuses on meditation, oral and auricular proliferation, and upper limb training, while the lying method inclines towards self-massaging for facial organs (eyes, ears, mouth, and nose), limbs, and the trunk. These forms are adaptable for practitioners with different movement capabilities and disparate ages,40 being both flexible and safe.41 Therefore, they are suitable for not only healthy older adults but also older people with Parkinson’s disease, 42 cardiovascular autonomic balance,43 cognitive impairment44 or blood lipid levels.45 Baduanjin is beneficial to gait and balance for stroke rehabilitation,46 fall prevention, and emotional health.47
This narrative review investigates the effectiveness of Baduanjin, a body-mind intervention,48 on the biological and psychological health of old adults. Its analysis offers an overview of the research results and highlights encouraging indicators that are favorable for health promotion among seniors, from which medical professionals can integrate this low-intensity exercise into available treatments for geriatric care.
This narrative review utilized ProQuest to search potential studies, in which there are 27 prominent electronic databases, including British Nursing Index, Medical Database, MEDLINE, ProQuest Medical Library, PsycARTICLES, and PsycINFO. Inputting the keywords Baduanjin and aged OR elderly OR elders OR old OR senior resulted in 45 references. Additionally, the China National Knowledge Infrastructure (CNKI) and Taiwan Electronic Periodical Services (TEPS) were searched using the keywords 八段錦and 老年人, retrieving 85 Chinese works.
A two-tiered selection process was performed under the following eligibility criteria: they were required to be empirical studies (quantitative, qualitative or mixed inquiries) published in peer-reviewed, scholarly journals prior to October 2017. Non-resultant trials, duplicates, literature reviews, book reviews, dissertations, editorials, letters to the editor, and commentaries were excluded. First, 75 (n=30 in English, n=45 in Chinese) out of 130 potential articles were selected (Figure 1) according to the exclusion criteria; second, 58 (n=10 in English, n=48 in Chinese) studies were chosen for further analysis in light of the inclusion criteria.
Findings and Discussion
The reviewed 58 projects (Table 1)49-106 involved 5084 participants, most of whom were aged 60-84. This narrative review analyzed how Baduanjin can benefit older adults, initially detailing its contribution to physiological refinement, and subsequently enumerating its efficacy on ageing problems, including bone diseases, cardiovascular and cardio-pulmonary illnesses, metabolic disorders, digestive sicknesses, cognitive impairment, and mental health.
Baduanjin positively influences antioxidant capacity and immune cells, achieving anti-ageing.85 It indicates a range of health enhancements, with the aid of measurements, for instance, Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36), Chinese Version of the Personal and Social Performance Scale (PSP-CHN), Chronic Disease Self- Management Study Measures, and tests for arithmetic, figure recognition, reaction time, digit width, and digit symbol. It delays hypophrenia (connected to intelligence recession) and metabolic oxygen consumption, and regulates the endocrine system, hemodynamics, hemorheology, cardiac functions, and nervous system.106 It is conducive to the reduction of bodily pain, and the increase of vitality, general health perception, health transition, physical functioning, physical-role functioning, emotionalrole functioning, social functioning and mental health.105 Also, this exercise alleviates retirement syndrome58 and therefore strengthens self-awareness, attention, emotion coping, sense of well being linked to self-care, and social relationships, resulting in self-efficacy84 even among older adults with chronic illnesses.
Sixty-two elderly males (aged 60-69) who practiced Baduanjin regularly over three years enhanced their body quality, balance ability and cardiovascular capability.49 Managing obesity with better body weight, body fat mass, waist-hip ratio, body total moisture, and protein quality, they improved their balance, showing amelioration of issues with muscle strength, seat body flexion, hand grip, and standing on one leg while closing their eyes. Their vital capacity, systolic blood pressure, diastolic blood pressure, and resting pulse became more acceptable. According to evidence from another 139 women,67 Baduanjin produced refinements in the respiratory system and body anteflexion in the sitting position, increased lower limb strength, decreased waist circumference, hip circumference, and thickness of abdominal skinfold, the upper arm and the scapular. Overall improvements were attained in body shape, body composition, physical fitness, nervous response, immune function, sex hormone level, and free radical scavenging ability,81,98 as supported by pertinent research.72,79
Bone disease and arthritis
Osteoporosis is a common disease among older adults, causing fractures, disability, and pain.107 Pain alleviation was reported by 60 patients with primary osteoporosis51 who also experienced better mental states after undertaking eight weeks of Baduanjin training, such as vitality, emotional role functioning and social role functioning. Consistent outcomes were delivered by Peng and team in their research.77
Although osteoarthritis may be avoidable within the ageing population, degenerative joint condition is attributable to this disease,108 particularly with knee osteoarthritis,109 for which various treatments are provided.110 An and colleagues88 offered a one-year program to 22 patients who suffered from knee osteoarthritis. The participants saw significant easing of pain, stiffness, and disability, probably caused by a decrease in body-mass index when practicing 30 minutes of Baduanjin daily, five times a week, which enhanced knee extensors, flexor strength, and aerobic ability. Their earlier research also reported enhanced quadriceps strength.103 The effectiveness of Baduanjin on this illness has been ostensive.65 Similarly, patients with chronic neck pain benefited from 30-minute daily sessions for six months.86
Falling and fear of falling disturbs this frail population, especially for those with osteoporosis111 or osteoarthritis,112 giving rise to threats such as hip and vertebral fractures,113 and limb function limitations. 114 Recent studies illustrated that Baduanjin practitioners are capable of preventing falls,55,63 as a result of boosting balance50,64 and coping with the fear of falling.76 A reduction in fall risk not only satisfactorily adjusts functional behavior,62 but also more importantly provided a better quality of life.59
Cardiovascular and cardio-pulmonary diseases
Cardiovascular and cardio-pulmonary diseases weaken heart function and the respiratory system of seniors115 who suffer from hypertension, coronary artery disease, or obstructive pulmonary disease.
The effects of Baduanjin on hypertension82,93 include improvements in heart rate68 and blood pressure: showing a decrease in systolic blood pressure but an increase in diastolic blood pressure,73 along with a reduction in serum endothelia levels,54 improved sleep quality, sleep duration and sleep efficiency.71 Consequently, this exercise diminishes the risk of heart failure, stroke, and arteriosclerosis.75
Supported by 50 patients with coronary artery disease, a randomized controlled trial showed reductions in angina attacks and their duration after three months of Baduanjin exercise.65 Furthermore, improved rehabilitation was observed from another 60 patients with coronary artery bypass grafting who completed 23 weeks of training in which they performed 30-minute daily practice sessions.95
Interaction between hypertension, heart sickness, and stroke has been unveiled,116,117 for the management of which Baduanjin plays a positive role.118 This exercise is suitable for stroke rehabilitation,100 and is related to physical and psychological health. In addition to 30 minutes of daily practice, 83.3% of 60 older patients who underwent acupoint (a specific point for acupuncture) massage 2-3 times every day saw relief from constipation during the post-stroke period.91
An estimated 14% of individuals aged 65 or over suffer from chronic obstructive pulmonary disease due to ageing respiratory systems.119 Baduanjin may represent an optional intervention.120 With the aid of an XXG-D cardiovascular function tester and a pneumometer, 48 elderly patients with cardio- pulmonary problems who practiced 30 minutes of Baduanjin daily for one year increased the compensatory force of the heart pump, cardiac contractility, cardiac output stroke volume, as well as pulmonary function, together with enhancements in myocardial oxygen supply, their bodies’ scavenging ability of oxygen free radicals, and respiratory endurance.104 Feng and team102 added that the efficacy of this exercise could increase the forced expiratory volume in one second (FEV1), and forced vital capacity (FVC). A positive correlation between the strength of lung function and emotional stability connects this exercise to such issues as depression and anxiety,61 and to quality of life.69
Metabolic abnormality is fatal in the ageing population.121 Baduanjin is a possible vehicle for combating this.
Comparing pre- and post-test outputs, a study of a 10-week Baduanjin training program74 discerned increases in levels of nitric oxide (with a lower level in patients with diabetes) and superoxide dismutase (which is a key component in anti-oxidative and anti-inflammatory activities), particularly in elderly males, and a decrease in malondialdehyde (a hazardous compound inducing oxidative stress), particularly in elderly females.
Serum lipid levels correlate to illnesses such as cardiovascular diseases and diabetes. 122 An investigation into the effectiveness of Baduanjin on blood lipid and antioxidant levels70,80 indicated decreases in triglyceride, total cholesterol, malonyldialdehyde, low-density lipoprotein, whole blood viscosity, low shear blood viscosity and plasma viscosity, in contrast to increases in high-density lipoprotein, superoxide dismutase and glutathione peroxidase. Thus, these are able to ameliorate problems in the respiratory system.89
A decrease in blood glucose among elderly individuals who carried out a 30- minute Baduanjin session twice a day for three months99 shows promise for dealing with diabetes. Such a reduction in glycosylated hemoglobin (HbA1c) together with this exercise is linked to better psychological health,87 including a decrease in depressive symptoms.96 In research carried out by Xiao and colleagues,60 Baduanjin was shown to be beneficial to balance, body flexibility and glucose metabolism among elderly people with diabetes who received 96 45-minute sessions; following which they exhibited stronger physical function, limb strength and flexibility of the joints, fortified nerves, and improved glucose and lipid parameters.
Age-related changes in intestinal microbiota increase the risks of illness, including inflammatory bowel disease, colon rectal cancer, and immune system deficiencies.123 Indicators presented advantageous effects of Baduanjin in positive changes in intestinal flora,97 decreasing the quantity of enterobacter and fusobacterium, while increasing the quantity of bifidobacterium, lactobacillus and the ratio of bifidobacterium and enteric bacilli.
Approximately 10-20% of elderly people experience irritable bowel syndrome,124 with pain, cramping, and other negative signs. Looking into the efficacy of Baduanjin on irritable bowel syndrome,101 60 patients saw improvements in abdominal pain, abdominal distension, constipation, and abnormal defecation.
Age-directed cognitive decline deteriorates individual health, social connections, and social economy,125 for which both pharmaceutical and non-medication measures are given to combat this decline. Lin53 recruited 47 participants who suffered from mild cognitive impairment and who received Baduanjin with standard treatment (including diet control, psychoeducation, and counseling) for six months. The data marked significant improvements in memory, attention, association, and language. Another set of data56 inferred these benefits from a decrease in rsFC between the DLPFC and the left putamen and insula, whereas mental control enhancement is negatively associated with rsFC and DLPFC-putamen changes. Tao and team57 identified an evident increase in grey matter volume in the insula, medial temporal lobe, and putamen among their informants who participated in 60 30-minute Baduanjin sessions. As a result, practicing this exercise positively correlates to mental control, recognition, touch, cognition and comprehensive memory.
The detrimental effects of psychotic disorders consist of personal ill-being and social deprivation126 among older people, for which the scope of traditional and innovative approaches pinpoint Baduanjin127 as an effective countermeasure.128 One study, which interviewed 20 informants who practiced Baduanjin 40 minutes daily for 12 weeks, reiterated that they felt relaxed physically and psychologically due to self-tranquility, pleasure, and relief from emotional symptoms.78 Another 180 participants saw improvements in somatization, obsession and interpersonal sensitivity, and lessened depression, anxiety, hostility, phobia, paranoia and psychotic symptoms after 20 weeks, during which they received six onehour Baduanjin training sessions each week.90 In particular, these sessions favor housebound elderly people52 who are afterwards able to reconnect with society.
Practitioner calmness92 also helps abate sleep difficulties, accomplishing overall sleep quality,94 including subjective sleep quality, sleep latency, sleep duration, sleep efficiency, and controlled daytime dysfunction.
Methodological limitations and future research directions
This narrative review addresses methodological limitations among the reviewed articles, which arise from conducting randomized controlled research with small sample sizes and a cross-sectional design, particularly focusing on Chinese population and using mainly psychometric surveys. It also gives suggestions for future studies.
Despite there being 36 (62%) randomized controlled trials among the reviewed research, incomplete fulfillments are notable. While this method values evidence- based assessment,129 it requires strong reliability and validity, especially through randomization. However, most randomized controlled projects in this review failed to demonstrate random allocation, blinding, prevention of selection bias, and details of p-value. This study suggests the need for well-designed scientific research, such as through a proper randomization process, not only for convincing results but also for research replication.
Nineteen (32%) of the reviewed articles were carried out with less than 61 participants. A small sample size can potentially undermine data performance, cross-validation, and statistical power.130 In order to attain data confidence, this study proposes future research on the efficacy of Baduanjin in senior health with a larger number of informants, which would enable such studies to be more powerful.
The reviewed studies are cross-sectional inquiries: 16 (27%) were six-month programs, two (3%) were one-year projects, and the remainder was less than these or unspecified. This research strategy restricts the findings to within a specific time span, which offers insufficient cause-and-effect results, and is inappropriate for age-associated research.131 Instead, longitudinal studies would feasibly rectify these weaknesses and measure intra-individual changes:132 which is why they are usually utilized for age-oriented research.
All the reviewed projects involve only a Chinese population, which may engender sampling bias. Such a constraint leads to homogeneity and limits representativeness and generalization. It is therefore necessary to extend the research to non-Chinese elderly people in order to bolster the evaluation.
The reviewed studies are dominated by self-administered psychometric surveys and basic physiological measurements (for example, blood pressure, and forced vital capacity). However, they tend to refrain from elaborating on the mechanisms of physiological changes that occur when practicing Baduanjin, such as on cardiac function and antioxidant capacity. It is advisable to adopt the medical tools necessary to measure the biomarkers that underpin clinical data for scientific research. Furthermore, this review proposes the use of evaluation tools, such as Performance Oriented Mobility Assessment (POMA), in future research to measure practical advantages of this exercise.
Despite positivist quantitative research acquiring a larger pool of data in a shorter time, there is a lack of qualitative inquiries (only one within the reviewed references) and therefore it is unable to represent the social reality experienced by the participants. This study recommends that qualitative or mixed research be conducted that allows informants (perhaps with case examples) to disclose their experience in practicing Baduanjin.
Owing to the presence of more promising results, combined therapy is not rare within the reviewed research: 14 (24%) projects demonstrate this; Baduanjin with varied instruments, such as cognitive behavioral therapy,52 medication,54 meditation, 58 dance,68 diet management,72 or massage. 91 An integrative model is therefore suggested, for instance, simultaneously using with music therapy,133 which may further enhance the physical and emotional health of the aged.
Although positive signals are exhibited, the findings do not suffice to confirm the curative effects of Baduanjin, owing to the methodological weaknesses explained previously. However, it is apparent that older patients with different illnesses show significant enhancements in health when practicing this exercise, demonstrating rehabilitative and preventive capabilities. Baduanjin likely contributes to health promotion through disease prevention, such as through the prevention of ischemic stroke,134 and relapse prevention.
A healthy state and long-term engagement in physical activity are positively correlated. 135 It is highly recommended that Baduanjin be practiced 30 minutes regularly either in an individual or group setting: the latter also promotes psychological health136 and social relationships.137
Despite the fact that Baduanjin is safe and learner-friendly, this review suggests to recruit a qualified instructor in order to maximize the benefits of this exercise, especially for the elderly. The General Administration of Sport of China provides a set of training programs for various levels of instructors, associated with development, theories and techniques of Baduanjin.
A sound lifestyle substantially determines life expectancy. Baduanjin cannot be the sole agent of older adults’ health and well-being. This study encourages active ageing138 or successful ageing139 that connects to holistic involvement, including healthy habits,140 nutrition,141 relaxation,142 religious participation,143 lifetime learning,144 volunteering,145 and leisure/recreation activities146 such as handicrafts,147 and travel.148
Baduanjin, a traditional Chinese exercise, is a body-mind, learning-friendly, safe, self-paced, cost-effective, convenient, non-intrusive, low-intensity exercise. Its anti-ageing capabilities rejuvenate the physical and psychological health of the older individuals. This narrative review reveals that this physical activity is conducive to health promotion due to its rehabilitative and preventive effectiveness, resulting in quality of life and well-being and a large population of people who age successfully.