Integrating Tai Chi with Mindfulness Training to Achieve an Effective Mind-Body Exercise (Video) | JoVE

Yan Yue; Min Deng; Shunqi Liao; Guojin Xiao; Yan Huang

doi:10.3791/65421

Medicine

Effects of Mindfulness Training Combined with Tai Chi in Patients with Diabetic Peripheral Neuropathy

Published: July 14, 2023 doi: 10.3791/65421

Yan Yue*¹, Min Deng*¹, Shunqi Liao¹, Guojin Xiao¹, Yan Huang¹

¹Hospital of Chengdu University of Traditional Chinese Medicine

* These authors contributed equally

Summary

When studying exercise for treating diabetic peripheral neuropathy (DPN), achieving mind-body exercise is essential. This study proposes a protocol for mindfulness training combined with Tai Chi to achieve mind-body exercise.

Abstract

Diabetic peripheral neuropathy (DPN) is one of the most prevalent chronic complications of diabetes. One of its crucial therapy approaches is mind-body exercise. Recently, various exercise modalities, including stepping, resistance, aerobics, balance, and whole-body vibration, were investigated to construct the most suitable form of exercise for patients with DPN. The purpose of this study is to describe a standard protocol for mindfulness training combined with Tai Chi. The convenience sampling method was used to select 90 patients with DPN who met the inclusion and exclusion criteria from three communities. The three communities were randomly divided into the control group (CG), the Tai Chi group (TCG), and the mindfulness training combined with the Tai Chi group (MTCG). The CG was given routine health education guidance once a month, a total of three times. Based on the CG, the TCG practiced Tai Chi three times; the MTCG received mindfulness training combined with Tai Chi exercise a week for a total of 12 weeks. Before the intervention and 12 weeks after the intervention, the clinical symptoms, neurological function, attention awareness level, pain, and quality of life of the subjects were evaluated by Toronto Clinical Scoring System (TCSS), Mindful Attention Awareness Scale (MAAS), Visual analog scale (VAS), Diabetes Specificity Quality of life Scale (DSQL) and tumor necrosis factor-α. Overall, the addition of mindfulness training to Tai Chi effectively enhances the exercise effects of Tai Chi. Therefore, mindfulness training combined with Tai Chi is worthy of promotion and application.

Introduction

Diabetes Mellitus (DM) is a serious health concern globally, affecting millions of people worldwide¹. The International Diabetes Federation (IDF) reveals that the prevalence of DM could increase up to 12.2% by 2045². Type 2 diabetes (T2DM) accounts for about 90% of DM². Patients with T2DM, particularly those who struggle to control their blood glucose levels, are likely to suffer from adverse complications, including macrovascular disease, microangiopathy, and diabetic peripheral neuropathy (DPN)³. DPN is a prevalent microvascular complication, with at least 50% of DM patients showing DPN signs and symptoms over time⁴. Unfortunately, DPN is often ignored, and the actual figures of patients suffering are much higher than reported in most cases².

Patients with poor glycemic control are prone to developing DPN with an insidious onset. The initial symptoms of DPN are often unremarkable, which makes it easy for patients to overlook the condition. When obvious symptoms and functional impairment appear, irreversible neurological damage has been caused⁵. DPN has a complex clinical presentation. Patients suffer from long-term metabolic disturbances and oxidative stress damage. This can result in symmetrical limb numbness, pain, or paresthesia⁶^,⁷. As the disease progresses, neurological and vascular injuries are further aggravated, eventually leading to irreversible tissue damage⁸. The incidence of diabetic foot ulcers and amputations is associated with mortality from DPN⁹. In addition, as symptoms of DPN often persist, many patients experience depression, sleep disturbances, and activity limitations, leading to a decrease in overall quality of life and even disability¹⁰.

Currently, lifestyle interventions (including exercise, diet, psychotherapy, etc.) are well recognized as effective treatments for DPN patients in addition to glycemic control and pharmacotherapy¹¹. According to the American Diabetes Association (ADA), "valuable exercise is beneficial to all patients with DM". For example, it can improve glycolipid metabolism and insulin resistance¹. Studies have shown that exercise can improve metabolic, vascular damage, and neurological function in patients with DPN¹²^,¹³. However, patients with DPN are reluctant to exercise due to a lack of motility, pain, and fear of foot injury.

The diabetic peripheral neuropathy (DPN) patients' physical discomfort and limitations on daily activities, according to the Fear-Avoidance Model (FAM), can reduce their capacity for social interaction, which in turn can contribute to negative emotional reactions like anxiety and depression¹⁴. Conversely, negative emotions can affect glycemic control and increase the rate of complications¹⁵^,¹⁶^,¹⁷^,¹⁸. Therefore, mind-body therapy is recommended for DPN, which focuses on the interaction between thoughts, emotions, bodies, and behaviors. The aim is to achieve homeostasis of the body and mind.

Tai Chi is a traditional Chinese mind-body exercise. Tai Chi has received much attention from scholars worldwide because of its unique exercise modes and therapeutic effects on diseases. Multiple high-quality clinical trials published in international journals have confirmed the effectiveness of Tai Chi for the treatment and rehabilitation of chronic diseases such as Parkinson's disease¹⁹, stroke²⁰, metabolic syndrome²¹, knee arthritis²², and breast cancer²³. Tai Chi belongs to a class of moderate-intensity aerobic exercises that uses continuous body spiral exercise and regulated breathing to improve aerobic capacity, muscle strength, balance, and exercise capacity. Traditional Chinese medicine holds that Tai Chi can balance yin and Yang, run Qi and blood, and relax meridians²⁴. It is a suitable form of exercise for patients with DPN. Many studies have found that Tai Chi improves insulin resistance and blood lipids, and reduces the incidence of anxiety and depression²⁵^,²⁶. In addition, Tai Chi could improve quality of life and decrease body mass index for patients with T2DM ²⁷.

Mindfulness training is another prominent mind-body intervention that focuses on cultivating an intentional, moment-to-moment, nonjudgmental awareness of experience²⁸. It helps to enhance attention to the present experience, including thoughts, feelings, breathing, and body sensations. Zeidan's research found that mindfulness training could make patients more objectively evaluate discomfort and improve self-regulation²⁹. Wielgosz's study showed that the biggest problem of exercise intervention was poor compliance, which could be solved by adding mindfulness training to exercise³⁰. Mindfulness training combined with exercise could effectively improve patients' willingness to move, increase the time and frequency of movement, and promote patients' perceiving body sensations in activity.

Meanwhile, exercise combined with mindfulness training can expand patients' vision and enhance their understanding of themselves. This helps the body to become more flexible, relaxed, and balanced, effectively relieving the negative experience of patients. The concept of mindfulness training is consistent with the idea of "unity of form and spirit" of Tai Chi. Most patients with DPN often receive misinformation from the feet provided by the brain due to impaired sensory function³¹. Mindfulness training can enhance the effect of movement through psychological regulation and nervous regulation³². Therefore, this study aims to verify the feasibility of mindfulness training combined with Tai Chi and explore its effect on DPN patients.

Subscription Required. Please recommend JoVE to your librarian.

Protocol

This study strictly adheres to the principle of ethical respect, beneficence, and justice. There were 30 subjects in each group, a total of 90 cases. This subject was approved by the ethics committee of the Hospital of Chengdu University of Traditional Chinese Medicine (2021KL-040). Informed consent was obtained from patients included in this study.

1. Study subjects

Select 3 communities in Chengdu using the convenience sampling method.
Recruit patients with T2DM peripheral neuropathy from three communities.
Use the following inclusion criteria.
1. Include patients of age 40-75.
2. Include patients diagnosed with DPN.
3. Include patients who can perform moderate-intensity aerobic exercises.
4. Include patients who do not use any other complementary or integrative therapies during the study period.
Exclude patients with the following conditions: neurological conditions caused by other conditions, such as cervical and lumbar spondylosis, cerebrovascular illness, Guillain-Barré syndrome, and vasculopathy; pregnant or lactating women; the inability of mental anomalies to cooperate.
Draw lots to assign patients from the three communities at random to the control group (CG), the Tai Chi group (TCG), and the mindfulness and Tai Chi group (MTCG).

2. Method 1: Practice methods of the CG

Conduct 3 collective health education sessions, each lasting 40 min.
NOTE: The health education content mainly consisted of diabetes diet, exercise, medication, blood glucose monitoring, foot care, and prevention and care of foot complications¹². Three groups conduct health education separately.

3. Method 2: Practice methods of the TCG

Select a public, quiet area to practice one of the 24 style simplified Tai Chi³³.
NOTE: Implementation methods: It was divided into 3 parts: warm-up, training, and relaxation. The focused exercise was performed 3 times a week for 60 min each for 12 weeks.
Instruct the participants to complete two sets of adductor (i.e., internal rotation), abductor (i.e., external rotation), hamstring (i.e., single stiff leg forward bending stretch), gluteal (i.e., hip flexion and extension), and ankle-oriented (i.e., ankle rotation) dynamic stretching exercises for 10 min, as part of a warm-up preparation exercise³⁴.
Under the direction of Tai Chi instructors, let the participants perform Tai Chi movements to Tai Chi music for 40 min.
NOTE: The movements of the Tai Chi include commencing from part the wild horse's mane on both sides, white crane spreads its wings, brush knee and twist step on both sides, play pipa, repulse monkey, grasp the bird's tail, single whip, wave hands like clouds, high pat on horse, kick with right heel, strike opponent's ears with both fists, turn and kick with left heel, snake creeps down, jade lady weaves shuttles, needle at sea bottom, flash the arm turn, deflect downward, parry and punch, cross hands and closing form³³.
Do upper and lower limb relaxation exercises and breathing adjustment exercises for 10 min as a relaxation exercise³⁵.
NOTE: First, stand and repeatedly shake shoulders and arms. Then beat and massage legs. Finally, sit and adjust the breathing pattern.

4. Method 3: Practice methods of the MTCG

Choose an open and quiet place to spread Yoga mats to sit.
NOTE: Mindfulness training combined with Tai Chi practice was performed 3 times a week for 60 min each for 12 week sessions. Subjects were encouraged to adhere to mindfulness exercises daily at home. The aim is to integrate mindfulness into daily life.
Start mindfulness training combined with Tai Chi.
NOTE: The specific training arrangement is shown in Table 1.
1. Mindfulness training combined with Tai Chi-specific practice methods
  1. Mindfulness meditation:
    1. Sit on Yoga mats.
    2. Slowly inhale and exhale 3-4 deep breaths.
    3. Feel the air entering the nose, filling the chest and abdomen, and leaving the body as exhaled.
    4. Adjust the breathing rhythm back to normal. Do not try to control breathing.
    5. Adjust the breathing rhythm back to normal. Do not try to control breathing.
    6. Pay attention to the things such as breathing, body, voice, thoughts, and emotions, slowly relaxing the body.
  2. Mindfulness body scan:
    1. Supine on yoga mats with legs naturally apart, eyes barely closed, and arms naturally seated without touching the body.
    2. Pay attention to how the complete body feels, from the toes to the brain. Choose to sit to prevent falling asleep when doing mindfulness body scanning exercises.
  3. Mindfulness movement (Tai Chi):
    1. Focus on each movement of Tai Chi.
      NOTE: In Tai Chi practice, use gentle language to guide the practitioner to feel the pressure and relaxation brought by the alternating contraction and relaxation of the leg muscles and feel the sensation of contact between the feet and the ground.
    2. Try to maintain a state of mindfulness at all times as much as possible.
    3. Feel stress and relaxation as the leg muscles alternately contract and relax. At the same time, feel the sensation of the feet touching the ground.
End activities
1. Do upper and lower limb relaxation exercises and breathing adjustment exercises for 10 min as a relaxation exercise³⁵.
  NOTE: First, stand and repeatedly shake shoulders and arms. Then beat and massage legs. Finally, sit and adjust breathing.
2. Sit in meditation without making any judgments about the various thoughts that enter the mind, and accept these concepts always.
3. Convert each daily task, such as brushing the teeth, showering, or cooking, into a mindfulness exercise.

5. Collect information

Select data collection staff and carry out unified training.
NOTE: Collect data before and after the intervention, respectively. Data collectors were solely responsible for data collection and were blinded to group allocation to reduce data collector subjectivity bias.
1. Collect data for Toronto clinical scoring system (TCSS)³⁶, visual simulation scale (VAS)³⁷, mindfulness and attention awareness scale (MAAS)³⁸, diabetes-specific quality of life scale (DSQL)³⁹, and serum tumor necrosis factor-α(TNF-α) levels.
Before the study begins, debate and decide on the detailed collecting criteria for each indicator by the research team members.
Thoroughly explain to the subjects what the scale means, what each item means, and how to use it.
Help the participants get into position, do physical evaluations, and record in detail.
Collect the blood samples from the participants at neighborhood hospitals, then send them immediately to the lab.
Promptly check the accuracy and completeness of the information gathered.

6. Statistical analysis

Collect and analyze data using any statistical analysis software.
NOTE: In this study, SPSS 24.0 was used.
Depict data by mean ± standard error of mean, frequency, or composition ratio.
Use chi-square test, ANOVA, Kruskal Wallis H test, paired t-test, and Wilcoxon signed rank test.
Take readings at least three times at all time points for each sample.

Subscription Required. Please recommend JoVE to your librarian.

Representative Results

In this study, 7 individuals failed to complete the trial. All necessary data were gathered from 83 individuals who completed the trial. There were 38 women and 45 men. The age ranged from 44 to 75 years old, with an average age of (60.57 + 8.76). DM might last anywhere between 4 and 22 years, with an average of 14.10 + 4.85 years. DPN lasted anywhere from one and fifteen years, with a mean of 5.76 + 2.78 years. The general data of the three groups did not differ significantly (p>0.05).

After the intervention, there was a statistically significant difference in the TCSS scores of the three groups (P < 0.001) (see Table 2). Further multiple comparisons showed that the TCSS score of the MTCG was significantly lower than that of the TCG and lower than the CG, and the difference was statistically significant (P < 0.05) (see Figure 1). These results revealed that the neurological symptoms improved after the intervention.

After the intervention, the MAAS scores of the three groups were significantly different (P < 0.05) (see Table 2). Further multiple comparisons showed no significant difference in the MAAS scores between the CG and the TCG (P > 0.05). The MAAS score of MTCG was significantly higher than that of TCG and CG (P < 0.05) (see Figure 2). The MAAS score revealed that mindfulness training combined with Taijiquan could improve the subjects' mindfulness levels. At the same time, it shows that the improvement of the exercise effect may be related to the improvement of mindfulness level.

After the intervention, there was a statistically significant difference in the VAS score between the three groups (P < 0.05) (see Table 3). Further multiple comparisons showed that the pain relief effect of mindfulness combined with MTCG was significantly better than that of TCG and CG, and the difference was statistically significant (P<0.05). (see Figure 3)

After the intervention, there was a statistically significant difference in the levels of TNF-α among the three groups (P < 0.05) (see Table 3). Further multiple comparisons showed that the level of serum TNF-α in the MTCG was significantly lower than that in the TCG and lower than that in the CG, and the difference was statistically significant (P < 0.05). (see Figure 4)

After the intervention, there was a statistically significant difference in the DSQL scores (P<0.05) (see Table 4). Further multiple comparisons showed that the DSQL score of the CG was significantly lower than that of the TCG and lower than the MTCG, and the difference was statistically significant (P < 0.05) (see Figure 5). This suggests that mindfulness training combined with Tai Chi can significantly improve the quality of life of patients with DPN.

Figure 1: Comparison of TCSS scores among the three groups. **P < 0.01 intergroup comparisons, *P < 0.05 intergroup comparisons, ^##P < 0.01 within-group comparisons, ^#P < 0.01 within-group comparisons. TCSS, Toronto Clinical Scoring System; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.

Figure 2. Comparison of MASS scores among the three groups.**P < 0.01 intergroup comparisons, ^##P < 0.01 within-group comparisons, and ^#P < 0.01 within-group comparisons. MAAS, Mindful Attention Awareness Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.

Figure 3. Comparison of VAS scores among the three groups. **P < 0.01 intergroup comparisons, and ^##P < 0.01 within-group comparisons. VAS, Visual analog scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.

Figure 4. Comparison of serum TNF- α level among the three groups. **P < 0.01 intergroup comparisons, *P < 0.01 intergroup comparisons, and ^##P < 0.01 within-group comparisons. TNF-α, Serum tumor necrosis factor-α; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.

Figure 5. Comparison of DSQL scores among the three groups. **P < 0.01 intergroup comparisons, ^##P < 0.01 within-group comparisons. DSQL, Diabetes Specificity Quality of life Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.

Table 1: Mindfulness training combined with Tai Chi training program schedule. Please click here to download this Table.

Table 2: Comparison of TCSS and MAAS and scores among the three groups. TCSS, Toronto Clinical Scoring System; MAAS, Mindful Attention Awareness Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with the Tai Chi group. Please click here to download this Table.

Table 3: Comparison of VAS scores and TNF-α among the three groups. VAS, Visual analog scale; TNF-α, Serum tumor necrosis factor-α; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with the Tai Chi group. DSQL, Diabetes Specificity Quality of Life Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with the Tai Chi group. Please click here to download this Table.

Table 4: Comparison of DSQL scores among the three groups. DSQL, Diabetes Specificity Quality of Life Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with the Tai Chi group. Please click here to download this Table.

Subscription Required. Please recommend JoVE to your librarian.

Discussion

Many previous studies have reported how to apply Tai Chi to treat and rehabilitate chronic diseases⁴⁰^,⁴¹. Although Tai Chi has shown positive effects in the treatment and rehabilitation of chronic diseases, truly achieving physical and mental exercise is vital to the enhanced effects of Tai Chi. This study combined Tai Chi with mindfulness training, which successfully improved the practice effectiveness of Tai Chi and indeed achieved physical and mental movement.

This study successfully integrated mindfulness training into Tai Chi. Participants must understand the significance of mindfulness training and the combination of Tai Chi. Tai Chi is a traditional Chinese mind-body exercise different from other aerobic exercises. The entire set of actions of Tai Chi is done under the guidance of consciousness and emphasizes controlling the activities of the limbs with consciousness. Most Tai Chi practitioners, particularly beginners, pay more attention to whether the movements are correct but ignore attention and awareness. In this study, mindfulness breathing was the first step in mindfulness training with Tai Chi exercise. The subjects were then progressively encouraged to become cognizant of what is occurring and direct their attention to performing Tai Chi. Previous studies suggest that mindfulness training as a complementary therapy may not have a direct therapeutic effect on disease⁴². But mindfulness training can enhance treatment effects by increasing self-efficacy, illness cognition, mindfulness levels, and improving adverse emotions⁴³. Therefore, the significance of mindfulness training combined with Tai Chi should be explained in detail before formally beginning the exercises.

It is also essential to guide the subjects to focus on the present and improve their attention to the body during exercise. First, a comfortable, quiet, and safe environment is favorable for entering the state of mindfulness. Secondly, we should not start Tai Chi in a hurry. The purpose is to make the participant completely relax physically and mentally before starting to practice Tai Chi. If necessary, we can extend the time of mindfulness meditation. Meanwhile, guiding the participant to focus on body sensations with mild language during Tai Chi exercises is also essential. For example, the practitioner is guided to focus on the arm while doing the reaching movements of the upper limbs, feeling the Qi in the body running from the shoulder to the fingertip. In addition, the participant is reminded to feel the sensation of pressure and relaxation brought about by the alternating contraction and relaxation of muscles in both legs. Therefore, it is important to remind the participants to be consciously aware of each action of Tai Chi.

As the understanding of mindfulness has advanced, some participants may perceive physical or psychological discomfort. At this time, the participants should be guided not to evaluate the discomfort subjectively but to accept the objective existence of the discomfort.

This protocol has several advantages. Mindfulness training combined with Tai Chi belongs to moderate-intensity exercise and is suitable for most people. Tai Chi and mindfulness training is simple and easy to learn, requires no equipment and is not limited by place⁴³. Thus, Tai Chi is easy to promote in the population. Although mindfulness training combined with Tai Chi has unique advantages over Tai Chi, it also has limitations. First, mindfulness training combined with Tai Chi is inappropriate for those unable to be calm. Second, the concept of mindfulness needs to be correctly understood. Third, mindfulness training combined with Tai Chi requires long-term adherence to practice.

It was confirmed that the addition of mindfulness training to Tai Chi could effectively enhance the training effect of Tai Chi. Therefore, mindfulness combined with Tai Chi is worthy of promotion and application in patients with DPN.

Subscription Required. Please recommend JoVE to your librarian.

Disclosures

The authors have nothing to disclose.

Acknowledgments

This study was supported by a grant from the Science and Technology Development Fund of the Hospital of Chengdu University of Traditional Chinese Medicine (20HL01) and the Sichuan Province cadre health research project (2023-505). This study was supported by a grant from the Sichuan Provincial Cadre Health Department (Chuan Gan Yan 2023-505).

Materials

Name	Company	Catalog Number	Comments
SPSS 24.0	IBM	version 24.0	Statistical analysis

DOWNLOAD MATERIALS LIST

References

Chinese Diabetes Society. Guidelines for the prevention and control of type 2 diabetes in China (2020 Edition). International Journal of Endocrinology and Metabolism. 41 (05), 482-548 (2021).
Ogurtsova, K., et al. IDF diabetes atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Research and Clinical Practice. 128, 40-50 (2017).
Teck, J. Diabetes-associated comorbidities. Primary Care. 49 (2), 275-286 (2022).
Yang, K., et al. Progress in the treatment of diabetic peripheral neuropathy. Biomedical Pharmacotherapy. 148, 112717 (2022).
Barrell, K., Smith, A. G. Peripheral neuropathy. The Medical Clinics of North America. 103 (2), 383-397 (2019).
Martin, C. L., Albers, J. W., Pop-Busui, R. Neuropathy and related findings in the diabetes control and complications trial/epidemiology of diabetes interventions and complications study. Diabetes Care. 37 (1), 31-38 (2014).
Zhang, P., et al. Global epidemiology of diabetic foot ulceration: A systematic review and meta-analysis. Annals of Medicine. 49 (2), 106-116 (2017).
Chen, L., Sun, S., Gao, Y., Ran, X. Global mortality of diabetic foot ulcer: A systematic review and meta-analysis of observational studies. Diabetes, Obesity & Metabolism. 25 (1), 36-45 (2023).
Kioskli, K., Scott, W., Winkley, K., Kylakos, S., McCracken, L. M. Psychosocial factors in painful diabetic neuropathy: A systematic review of treatment trials and survey studies. Pain Medicine. 20 (9), 1756-1773 (2019).
Feldman, E. L., et al. Diabetic neuropathy. Nature Reviews. Disease Primers. 5, 42 (2019).
Colberg, S. R., et al. Physical activity/exercise and diabetes: A position statement of the American diabetes association. Diabetes Care. 39 (11), 2065-2079 (2016).
Hua, S. S., LI, G. C., Cai, H., Lu, Y. F., Chen, L. The effects of exercise on diabetic peripheral neuropathy: a literature review. Chinese Journal of Nursing. 52 (10), 1252-1256 (2017).
Streckmann, F., et al. Exercise and neuropathy: Systematic review with meta-analysis. Sports Medicine. 52 (5), 1043-1065 (2022).
Vlaeyen, J. W. S., Kole-Snijders, A. M. J., Boeren, R. G. B., van Eek, H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 62 (3), 363-372 (1995).
Leeuw, M., et al. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioral Medicine. 30 (1), 77-94 (2007).
van Laake-Geelen, C. C. M., Smeets, R., Quadflieg, S., Kleijnen, J., Verbunt, J. A. The effect of exercise therapy combined with psychological therapy on physical activity and quality of life in patients with painful diabetic neuropathy: a systematic review. Scandinavian Journal of Pain. 19 (3), 433-439 (2019).
Nieto, R., Miró, J., Huguet, A. The fear-avoidance model in whiplash injuries. European Journal of Pain. 13 (5), 518-523 (2009).
Marin, T. J., et al. Multidisciplinary biopsychosocial rehabilitation for subacute low back pain. The Cochrane Database of Systematic Reviews. 6 (6), Cd002193 (2017).
Li, F., et al. Tai chi and postural stability in patients with Parkinson's disease. The New England Journal of Medicine. 366 (6), 511-519 (2012).
Taylor-Piliae, R., Dolan, H., Yako, A. Stroke survivors' personal efficacy beliefs and outcome expectations of Tai Chi exercise: A qualitative descriptive study. International Journal of Environment Research and Public Health. 18 (24), 13001 (2021).
Siu, P. M., et al. Effects of Tai Chi or conventional exercise on central obesity in middle-aged and older adults: A three-group randomized controlled trial. Annals of Internal Medicine. 174 (8), 1050-1057 (2021).
Wang, C., et al. Comparative effectiveness of Tai Chi versus physical therapy for knee osteoarthritis: A randomized trial. Annals of Internal Medicine. 165 (2), 77-86 (2016).
Irwin, M. R., et al. Tai Chi compared with cognitive behavioral therapy for the treatment of insomnia in survivors of breast cancer: A randomized, partially blinded, noninferiority trial. Journal of Clinical Oncology. 35 (23), 2656-2665 (2017).
Yang, L., Liu, W. L. Research progress on the application of Taiiquan in exercise rehabilitation practice of the elderly. Chinese Journal of Health Education. 38 (10), 939-959 (2022).
Chau, J. P. C., et al. Effects of Tai Chi on health outcomes among community-dwelling adults with or at risk of metabolic syndrome: A systematic review. Complementary Therapy in Clinical Practice. 44, 101445 (2021).
Guo, S., et al. Effect of Tai Chi on glycaemic control, lipid metabolism and body composition in adults with type 2 diabetes: A meta-analysis and systematic review. Journal of Rehabilitation Medicine. 53 (3), jrm00165 (2021).
Qin, J., et al. Effect of Tai Chi on quality of life, body mass index, and waist-hip ratio in patients with type 2 diabetes mellitus: A systematic review and meta-analysis. Frontiers in Endocrinology (Lausanne). 11, 543627 (2020).
Ameli, R., et al. Effect of a brief mindfulness-based program on stress in health care professionals at a US biomedical research hospital: A randomized clinical trial. JAMA Network Open. 3 (8), e2013424 (2020).
Zeidan, F., Grant, J. A., Brown, C. A., McHaffie, J. G., Coghill, R. C. Mindfulness meditation-related pain relief: evidence for unique brain mechanisms in the regulation of pain. Neuroscience Letters. 520 (2), 165-173 (2012).
Wielgosz, J., Goldberg, S. B., Kral, T. R. A., Dunne, J. D., Davidson, R. J. Mindfulness meditation and psychopathology. Annual Reviews of Clinical Psychology. 15, 285-316 (2019).
Gao, S., et al. The therapeutic effects of mild to moderate intensity aerobic exercise on glycemic control in patients with Type 2 Diabetes Mellitus: A meta-analysis of randomized trials. Diabetes Therapy. 12 (10), 2767-2781 (2021).
Bühlmayer, L., Birrer, D., Röthlin, P., Faude, O., Donath, L. Effects of mindfulness practice on performance-relevant parameters and performance outcomes in sports: A meta-analytical review. Sports Medicine. 47 (11), 2309-2321 (2017).
Wang, Z. Y. Tai Chi Manua. , People's Physical Culture Publishing House. (1991).
Shellock, F. G., Prentice, W. E. Warming-up and stretching for improved physical performance and prevention of sports-related injuries. Sports Medicine. 2 (4), 267-278 (1985).
Cayco, C. S., Labro, A. V., Gorgon, E. J. R. Hold-relax and contract-relax stretching for hamstrings flexibility: A systematic review with meta-analysis. Physical Therapy in Sport. 35, 42-55 (2019).
Perkins, B. A., Olaleye, D., Zinman, B., Bril, V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care. 24 (2), 250-256 (2001).
Woodforde, J. M., Merskey, H. Some relationships between subjective measures of pain. Journal of Psychosomatic Research. 16 (3), 173-178 (1972).
Brown, K. W., Ryan, R. M. The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology. 84 (4), 822-848 (2003).
Tang, Z., et al. Validation of the simplified Chinese version of the brief diabetes quality of life (DQoL) questionnaire based on a cross-sectional study. International Journal of Environmental Research and Public Health. 17 (23), 8792 (2020).
Li, X., et al. Effects of fitness qigong and tai chi on middle-aged and elderly patients with type 2 diabetes mellitus. PLoS One. 15 (12), e0243989 (2020).
Lee, S. H., Jeon, Y., Huang, C. W., Cheon, C., Ko, S. G. Qigong and Tai Chi on human health: An overview of systematic reviews. American Journal of Chinese Medicine. 50 (8), 1995-2010 (2022).
Qin, j, Li, X., Bo, S., Geng, F. Research progress on the mechanism of mindfulness-based stress reduction and itsapplication in chronic diseases. China Journal of Health Psychology. 28 (10), 1593-1597 (2020).
Deuel, L. M., Seeberger, L. C. Complementary therapies in Parkinson disease: A review of acupuncture, Tai Chi, Qi Gong, Yoga, and cannabis. Neurotherapeutics. 17 (4), 1434-1455 (2020).

Medicine