Effects of Qigong Exercise on Fatigue, Anxiety, and Depressive Symptoms of Patients with Chronic Fatigue Syndrome-Like Illness: A Randomized Controlled Trial

Abstract

Background. Anxiety/depressive symptoms are common in patients with chronic fatigue syndrome- (CFS-) like illness. Qigong as a modality of complementary and alternative therapy has been increasingly applied by patients with chronic illnesses, but little is known about the effect of Qigong on anxiety/depressive symptoms of the patients with CFS-like illness. Purpose. To investigate the effects of Qigong on fatigue, anxiety, and depressive symptoms in patients with CFS-illness. Methods. One hundred and thirty-seven participants who met the diagnostic criteria for CFS-like illness were randomly assigned to either an intervention group or a waitlist control group. Participants in the intervention group received 10 sessions of Qigong training twice a week for 5 consecutive weeks, followed by home-based practice for 12 weeks. Fatigue, anxiety, and depressive symptoms were assessed at baseline and postintervention. Results. Total fatigue score [F(1,135) = 13.888, P < 0.001], physical fatigue score [F(1,135) = 20.852, P < 0.001] and depression score [F(1,135) = 9.918, P = 0.002] were significantly improved and mental fatigue score [F(1,135) = 3.902, P = 0.050] was marginally significantly improved in the Qigong group compared to controls. The anxiety score was not significantly improved in the Qigong group. Conclusion. Qigong may not only reduce the fatigue symptoms, but also has antidepressive effect for patients with CFS-like illness.
Trial registration HKCTR-1200.

Full text

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Evidence-Based Complementary and Alternative Medicine
Volume , Article ID ,  pages
http://dx.doi.org/.//
Research Article
Effects of Qigong Exercise on Fatigue, Anxiety,
and Depressive Symptoms of Patients with Chronic Fatigue
Syndrome-Like Illness: A Randomized Controlled Trial
JessieS.M.Chan,
1
Rainbow T. H. Ho,
1,2
Chong-wen Wang,
1
Lai Ping Yuen,
3
Jonathan S. T. Sham,
4
and Cecilia L. W. Chan
1,2
1
Centre on Behavioral Health, e University of Hong Kong, Hong Kong
2
Department of Social Work and Social Administration, e University of Hong Kong, Hong Kong
3
International Association for Health and Yangsheng, Hong Kong
4
Department of Clinical Onchology, Li Ka Shing Faculty of Medicine, e University of Hong Kong, Hong Kong
Correspondence should be addressed to Cecilia L. W. Chan; cecichan@hku.hk
Received  March ; Accepted  May 
Academic Editor: Kevin Chen
Copyright ©  Jessie S. M. Chan et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Background. Anxiety/depressive symptoms are common in patients with chronic fatigue syndrome- (CFS-) like illness. Qigong as
a modality of complementary and alternative therapy has been increasingly applied by patients with chronic illnesses, but little is
known about the eect of Qigong on anxiety/depressive symptoms of the patients with CFS-like illness. Purpose.Toinvestigate
the eects of Qigong on fatigue, anxiety, and depressive symptoms in patients with CFS-illness. Methods. One hundred and thirty-
seven participants who met the diagnostic criteria for CFS-like illness were randomly assigned to either an intervention group or a
waitlist control group. Participants in the intervention group received  sessions of Qigong training twice a week for  consecutive
weeks, followed by home-based practice for  weeks. Fatigue, anxiety, and depressive symptoms were assessed at baseline and
postintervention. Results.Totalfatiguescore[𝐹(1,135) = 13.888, 𝑃 < 0.001], physical fatigue score [𝐹(1,135) = 20.852, 𝑃 < 0.001]
and depression score [𝐹(1,135) = 9.918, 𝑃 = 0.002] were signicantly improved and mental fatigue score [𝐹(1,135) = 3.902, 𝑃=
0.050] was marginally signicantly improved in the Qigong group compared to controls. e anxiety score was not signicantly
improved in the Qigong group. Conclusion. Qigong may not only reduce the fatigue symptoms, but also has antidepressive eect
for patients with CFS-like illness. Trial registration HKCTR-.
1. Introduction
CFS is characterized by unexplained persistent fatigue of at
least  months with no denite eective treatment yet [].
As a large part of the patients with CFS in the community
remain unrecognized by general practitioners [], CFS-like
illness is dened based on self-reported fatigue symptoms
andmedicalhistorywithsimilarcriteriaforCFS,butno
conrmed clinical examination [–]. Current and lifetime
psychiatric disorders were common among the patients with
CFS-like illness [–], with particularly strong association
between unexplained fatigue and depression [, ]. A study
with a multinational primary care sample from  countries
suggested that over % of patients with CFS-like illness
had a lifetime psychiatric disorder such as depression or
generalized anxiety disorder [, ]. Most of the patients
with CFS-like illness are undertreated for psychiatric illness
[]. Unexplained chronic fatigue is also a common disabling
condition in the general population and is strongly associated
with psychiatric morbidity []. In Hong Kong, the lifetime
prevalence of anxiety and depressive disorders was %
among the primary care patients with chronic fatigue (CF)
[]. e patients with CFS-like illness reported poorer
mental health (higher levels of anxiety and depression) than
their non-CFS-like illness counterparts [].
To date, no curative treatment that is eective exists for
thepatientswithCFS-likeillness[]. e use of complemen-
tary and alternative medicine (CAM) is increasing among the

 Evidence-Based Complementary and Alternative Medicine
patients with CFS-like illness. A recent systematic review of
 randomized clinical trials (RCTs) has suggested benecial
eects of CAM including Qigong, massage, and tuina for
patients with CFS []. Qigong is an ancient self-healing
mind-body exercise, which includes meditation, breathing,
body posture, and gentle movement. It focuses to promote
the circulation of vital energy, which is called “Qi” in the
meridian system (Qi vital energy channel) of the human body
to facilitate the harmony of the mind, body, and breathing
[].
A number of empirical studies reported that Qigong had
benecial eects on fatigue symptoms [, ]andother
outcomes related with CFS such as sleep, pain, mental atti-
tude, and general mobility []. Our prior study demonstrated
that Qigong exercise was eective in reducing the severity
of fatigue symptoms, improving health-related quality of life
[],andincreasingtelomeraseactivityforthepatientswith
CFS-like illness []. RCTs of Qigong exercise also suggested
a benecial eect of Qigong for older people with depressive
symptoms secondary to chronic illnesses [, ]. However,
a recent systematic review and meta-analysis of the eect
of Qigong exercise on depressive and anxiety symptoms
suggested that scientic evidence in the eld was still limited,
and that further rigorously designed RCTs were warranted
[]. To date, to our knowledge, no study has examined
the eect of Qigong exercise on depressive and anxiety
symptoms in patients with CFS-like illness. us, the purpose
of this large-scale study was to investigate the eectiveness of
Qigong exercise as a modality of complementary and alter-
native therapy in reducing fatigue, anxiety, and depressive
symptoms of patients with CFS-like illness.
2. Methods
2.1. Study Participants. One thousand four hundred and
forty-oneChineseadultswhoclaimedtohavefatiguesymp-
toms volunteered to ll in an online questionnaire aer the
study was advertised in the media. e screening question-
naire was set according to the US Centers for Disease Control
and Prevention (CDC) Diagnosis criteria for CFS [], which
iswidelyusedintheeld.Asitwasrarethatpatientswith
persistent fatigue symptoms alone stayed in public hospitals,
the participants were recruited from local community.
e diagnosis of CFS-like illness [–]wasmadebased
on subjective chronic symptoms and their medical history
self-reported in the online questionnaire without further
clinical conrmation by medical examination. A partici-
pant was diagnosed as having CFS-like illness if he or she
had unexplained, persistent fatigue over  months which
was of new onset (not lifelong) with presence of four or
more of the following eight symptoms: impaired memory
or concentration, postexertion malaise, unrefreshing sleep,
muscle pain, multijoint pain, new headaches, sore throat, and
tender lymph nodes []. To minimize the impact of other
chronic illness as much as possible, those with any medical
conditions that may explain the presence of chronic fatigue
were excluded.
Two hundred and thirty-six participants met the inclu-
sion criteria, of which  participants were excluded because
they could not be contacted or were unavailable for the
Qigong training. One hundred and y-four participants
with CFS-like illness were recruited into the study and were
randomly assigned to the intervention group (𝑛 = 77)
and control group (𝑛 = 77),respectively.Amongthese
 participants,  subjects in the intervention group and 
subjects in the control group dropped out before the Qigong
class. Only  subjects ( for intervention group and 
for control group) were included as the nal sample for the
data analysis. A ow chart of the selection of participants is
presented in Figure .
2.2. Study Design and Procedure. is was a prospec-
tive randomized wait list-controlled trial. Each potential
participant was required to complete an online screening
questionnaire and was evaluated for eligibility by a pair
of investigators with any discrepancies being resolved by
discussion. Eligible participants were required to complete
an additional questionnaire to measure the severity of their
chronic fatigue symptoms and depressive and anxiety symp-
toms before intervention (T) aer having signed the written
informed consent form. ey were then randomly assigned
to either an intervention group or a waitlist control group.
Randomization was done using computer-generated random
numbers. Blinding the participants to the allocation was not
possible due to the nature of intervention. e intervention
program lasted  months, with group Qigong training for 
weeks followed by home-based Qigong exercise for  weeks
in the intervention group. e primary outcome was fatigue
symptoms and the secondary outcomes were anxiety and
depressive symptoms. Data for the outcome measures were
also collected at postintervention (T) from each subject in
the intervention group and control group. Ethical approval
was obtained from the local review board.
Sample size was calculated according to power and esti-
mated eect size. In order to achieve statistical power of %
at a signicance level of . (assuming treatment eect =3
and standard deviation =5according to a previous local
study on CFS []),participantswererequiredineach
group. Assuming % dropout rate, at least  subjects were
required in each group (the intervention group and the wait-
list control group).
2.3. Intervention. Participants in the intervention group
attended  sessions of Qigong exercise training (Wu Xing
Ping Heng Gong, 五行平衡功)twiceaweekforconsecutive
weeks, followed by home-based Qigong self-practice for
 weeks. Each session of Qigong exercise training lasted
hours,withabriefintroductionofthebasictheories
of traditional Chinese medicine (such as the concepts of
Qi, yin-yang, ve elements, and meridian system) or the
precautions in doing Qigong exercise including answering
any questions or concerns raised by the participants about
Qigong practice ( min), followed by mindful meditation for
relaxation and then gentle movement or body stretching in
standing postures to facilitate a harmonious ow of Qi along
the energy channels ( min) and a  h session of Qigong
exercise training, which was delivered by an experienced
Taoist Qigong master (Yuen L. P.) with more than  years

Evidence-Based Complementary and Alternative Medicine 
1441 participants lled in online screening
questionnaire
236 participants met the
inclusion criteria
154 subjects were available
for the study
Assigned to the intervention
Assigned to the control group
1205 ineligible participants excluded
82 subjects could not be contacted or
were unavailable for Qigong training
12 dropped out before
intervention
5 dropped out before
intervention
3 dropped out
5 dropped out
4 dropped out
4 dropped out
group (n=77)
(n=77)
Participants (n=65) at T0
Participants (n=72) at T0
Follow-ups (n=62) aer 5 weeks
Follow-ups (n=57) aer 5 weeks
Follow-ups (n=53) aer 4 months
Follow-ups (n=58) aer 4 months
F:Flowchartoftheselectionofparticipantsinthestudy.
of experience in Qigong practice and also a background in
traditional Chinese Medicine.
Apart from mindful meditation, rhythmic breathing and
concentrated relaxation, Xu Xing Ping Heng Gong, was
applied in this study including  forms of movement which
aimsatenhancingthesmoothowofQialongthevarious
meridians of the body and meditation for relaxation and
mind concentration. e movements involve stretching of
arms and legs, turning of torso, relaxing, and deep breathing
with the objectives of fostering harmonious energy ow of Qi
along the various meridians of the body. A description of the
Xu Xing Ping Heng Gong is presented in Appendix.
All participants in the intervention group were also
required to do Qigong self-practice for at least  minutes
every day at home during the -month intervention period.
To assess home exercise, they were required to report the
frequency and duration as well as adverse eects of the self-
practiceathomeattheendoftheprogram.eparticipants
in control group were advised to keep their lifestyle as usual
and to refrain from joining any outside Qigong exercise class
during the study period. No participants in the control group
joined any outside Qigong class as they were provided the
Qigong training aer the nal outcome measurements were
collected.
2.4. Measurements
2.4.1. Screening Measures. e potential participants were
screened by online questionnaire including () whether or not
the fatigue symptoms persisted or relapsed for six or more
months; () a list of eight chronic fatigue symptoms of CDC
diagnostic inclusion criteria for CFS [];()alistofmedical
diseases based on the CDC diagnostic exclusion criteria
for CFS [] according to their self-reported medical history
without further medical examination; () basic demographic
data such as age, gender, employment status, education level,
marital status, religion, and monthly income; () lifestyle
including exercise habits, smoking, alcohol drinking, and
sleep time.
2.4.2. Chalder Fatigue Scale. e severity of fatigue symp-
toms was measured by the Chalder Fatigue Scale, which is
a -item self-rating scale to measure the severity of both
physical fatigue symptoms ( items) and mental fatigue
symptoms ( items). e response pattern for each item is
a ve-point Likert scale (none, better than usual, no more
than usual, worse than usual, much worse than usual), which
is scored from  to . e subscale scores are equal to the
summed scores of all items in the subscale and the total
fatigue score was obtained by adding up all of the  items (the
higher, the worse) []. e Chinese version of the Chalder
Fatigue Scale has shown acceptable psychometric properties
[].
2.4.3. Hospital Anxiety and Depression Scale (HADS).
Depressive and anxiety symptoms were measured by the
HADS [], which is a -item instrument with two subscales

 Evidence-Based Complementary and Alternative Medicine
measuring anxiety symptoms ( items) and depressive
symptoms ( items) separately. Each item is scored on a
– scale and the total score of each subscale is scored on a
– scale, with a higher score indicating a higher level of
anxiety and depressive symptoms. Internal consistency for
HADS Chinese version was revealed to be satisfactory, with
Cronbach’s alpha coecients of . for anxiety subscale and
. for depression subscale, respectively [, ].
2.5. Statistical Analyses. Means and standard deviations were
used to summarize continuous data and frequency was
used to summarize categorical data. Dierences at baseline
for the demographic information, lifestyles, and reported
fatigue, anxiety, and depressive symptoms between the two
groups were compared using a t-test for continuous data and
a Chi-squared test for categorical data. e within group
eects of outcome measures were compared between pre-
and postintervention using pairwise t-test for each group.
e eect size was determined by Cohen’s d statistics for
each outcome. e repeated measures analyses of variance
(ANOVA)werethenconductedtoassesstheinteraction
eect of group and time for each outcome. Intention to
treat analysis was applied in this study and the missing data
were substituted by the last observed values. e correlation
analysis of the changes in all outcomes between pre- and
postintervention and the linear regression analysis using
the change of depression score as a dependent variable and
changes of other outcomes as independent variables were also
conducted. All data analysis was conducted with Statistical
Package for the Social Sciences (SPSS version ., SPSS Inc.,
Chicago, IL, USA). A 𝑃 value of less than . was considered
as statistically signicant.
3. Results
3.1. e Demographic Characteristics and Lifestyles at Base-
line. e data on demographic characteristics and lifestyles
ofthetwogroupsareshowninTable .emeanages
were . (SD = 6.7) in the intervention group and .
(SD = 6.4) in the control group, respectively. More than
% of the participants were female (% and % in the
intervention and control groups, resp.). As shown in the
table, baseline characteristics were well balanced between
the two groups. e average number of reported fatigue
symptoms was . (SD = 1.4) in both groups. Among
eight chronic fatigue symptoms (last at least  months),
the most common symptoms (𝑛 = 129, 94.2%) was sleep
disturbancefollowedbymusclepain(𝑛 = 128,93.4%) and
impaired memory/concentration (𝑛 = 126, 92.0%).ere
was no signicant dierence in fatigue symptoms between
the two groups. Overall, the participants had a moderate level
of anxiety symptoms (mean scores for the anxiety subscale
were . for the intervention group and . for the control
group resp.) and a mild level of depressive symptoms (mean
scores for the depression subscale were . and . for the
intervention and control groups resp.) at baseline.
3.2. e Ecacy of Intervention. Table  shows the within-
group and between-group dierences of fatigue symptoms
as measured by the Chalder Fatigue Scale and anxiety and
depressive symptoms as measured by the HADS for the two
groups. At baseline (T), two groups were comparable in
terms of total fatigue score, physical fatigue score, mental
fatigue score, anxiety score, and depression score (𝑃 > 0.05
for all variables). Compared with baseline values, the total
fatigue score (𝑑 = −1.2, 𝑃 < 0.001),physicalfatigue
score (𝑑 = −1.4, 𝑃 < 0.001),mentalfatiguescore(𝑑 =
−0.9, 𝑃 < 0.001),anxietyscore(𝑑 = −1.1, 𝑃 < 0.001),and
depression score (𝑑 = −0.5, 𝑃 < 0.001) were signicantly
improved in the intervention group aer  months of Qigong
intervention, while the total fatigue score, physical fatigue
score,mentalfatiguescoreandanxietyscoreinthecontrol
groupwerealsosignicantlyimprovedmonthsaer(𝑑=
−0.8, 𝑃 < 0.001; 𝑑 = −0.8, 𝑃 < 0.001; 𝑑 = −0.6, 𝑃 <
0.001; 𝑑 = −0.6, 𝑃 = 0.006, resp.). However, the change of
the depression score in the control group was not signicant
(𝑑 = 0.1, 𝑃 = 0.365).
e between-group dierence in the change of each
outcome measure was then examined by interaction eect of
time and group. Compared with controls, the total fatigue
score [𝐹(1,135) = 13.888, 𝑃 < 0.001],physicalfatigue
score [𝐹(1,135) = 20.852, 𝑃 < 0.001], and depression score
[𝐹(1,135) = 9.918, 𝑃 = 0.002] were signicantly improved,
and the mental fatigue score [𝐹(1,135) = 3.902, 𝑃 = 0.050]
was marginally signicantly improved in the intervention
group, whereas the change in the anxiety score in the
intervention group was not signicant aer adjusting for
control [𝐹(1,135) = 0.302, 𝑃 = 0.584]. No adverse eects
were reported in both groups during the implementation of
intervention and self-practice at home throughout the study.
3.3. Predictors of Changes in Depressive Symptoms. In correla-
tion analysis, change in the depression score was signicantly
correlated with changes in the total fatigue score (𝑟 =
0.331, 𝑃 < 0.001) and anxiety score (𝑟 = 0.579, 𝑃 < 0.001).
Linear regression analysis further revealed that the change in
the total fatigue score (𝛽 = 0.182, 𝑃 = 0.013) and anxiety
score (𝛽 = 0.528, 𝑃 < 0.001) signicantly explained the
change in the level of depressive symptoms (adjusted 𝑅
2
=
0.356).
4. Discussion
To the best of our knowledge, this study is the rst large-scale
randomized control trial to investigate the anti-depressive
eectofQigongexerciseforthepatientswithCFS-likeillness.
e ndings of this study showed that Qigong exercise
could improve depressive symptoms and fatigue symptoms
among the patients with CFS-like illness, which provided
additional evidence to support the conclusive statement of a
recent systematic review [] that Qigong exercise may have
benecial eect on depressive symptoms. An earlier study
[] showed that depressive symptoms were not signicantly
improved aer Qigong intervention in elderly with chronic
illnesses, probably due to the small sample size (𝑛 = 50) and
short intervention period ( weeks). e current study with
a larger sample suggested that Qigong exercise could reduce
depressive symptoms for persons with CFS-like illness. Our

Evidence-Based Complementary and Alternative Medicine 
T : Patients’ demographic information and lifestyles at baseline (𝑛 = 137).
Demographic
Intervention (𝑛=72)Control(𝑛=65)
P
∗
Mean (SD) 𝑁 (%) Mean (SD) 𝑁 (%)
Age (years) . (.) . (.) .
Gender .
Female  (.%)  (.%)
Employment .
Full-time  (.%)  (.%)
Part-time  (.%)  (.%)
Housewife  (.%)  (.%)
Unemployed  (.%)  (.%)
Other  (.%)  (.%)
Education .
Secondary school  (.%)  (.%)
Tertiary or above  (.%)  (.%)
Marital status .
Single  (.%)  (.%)
Married/cohabiting  (.%)  (.%)
Divorced/separated/widowed  (.%)  (.%)
Have religion .
Yes  (.%)  (.%)
Monthly income .
<,  (.%)  (.%)
,–,  (.%)  (.%)
,–,  (.%)  (.%)
≥,  (.%)  (.%)
No income/not available  (.%)  (.%)
Not want to answer  (.%)  (.%)
Lifestyles
Do exercise regularly  (.%)  (.%) .
Smoking  (.%)  (.%) .
Alcohol drinking  (.%)  (.%) .
Sleep time (hours) . (.) . (.) .
Average number of reported fatigue symptoms . (.) . (.) .
∗
Chi-squared test for categorical variable and 𝑡-test for continuous variable.
ndings coincided with the results reported in other stud-
ies that Qigong exercise might have a benecial eect on
depressive symptoms in depressed elderly with chronic illness
[, ], mild essential hypertension [], subhealth [], and
female college students [].
In this study, participants’ anxiety symptoms were sig-
nicantly improved in both groups compared with baseline
values, but there was no signicant dierence in the change
of anxiety symptoms between the intervention group and
the control group. To date, only a very few studies [–
] have examined the eect of Qigong exercise on anxiety
symptoms but the ndings were inconsistent, probably due
to diversity of participants or sample size, variability in
the severity of comorbidities or anxiety symptoms, and
heterogeneity in outcome measures. Our results supported
theconclusivestatementofarecentsystematicreviewthatthe
limited existing evidence did not support the eect of Qigong
exercise on anxiety symptoms []. Further well-designed
RCTs were still warranted to test the eect of Qigong on
anxiety disorders.
Interestingly, we found that the total fatigue, physical
fatigue, mental fatigue, and anxiety symptoms in the waitlist
control group were also signicantly improved four months
aer. ese results may be explained by two schools of
mechanism. e rst one may be that the results were due
to the eects of self-care or other self-applied treatments.
Generally, eorts to manage their symptoms are always under
way for patients with chronic illnesses. In our study, most
participants reported that they had tried other numerous
therapies to manage their symptoms or treat their illnesses
before joining this study, even though those therapies were
ineective. e second possible reason may be related to a
benecial eect of hope on physical health and psychological
or emotional wellbeing []. In our study, all participants in
thecontrolgroupweretoldthattheycouldjointheQigong
training aer completing the study, so they might have

 Evidence-Based Complementary and Alternative Medicine
T : Within-group and between-group comparisons for Chalder Fatigue Scale, anxiety, and depression at T and T (𝑛 = 137)using
repeated measures ANOVA.
Within-group eects Between-group eects
Baseline (T)
a
Post-intervention (T)
b
T-T Time × group
Mean (SD) Mean (SD) 𝑃
b
Eect Size (d)Mean(SD)𝐹(1,135) P
Total fatigue score . .
Intervention group (𝑛=72) . (.) . (.) <. −. −. (.)
Control group (𝑛=65) . (.) . (.) <. −. −. (.)
Physical fatigue score . .
Intervention group (𝑛=72) . (.) . (.) <. −. −. (.)
Control group (𝑛=65) . (.) . (.) <. −. −. (.)
Mental fatigue score . .
Intervention group (𝑛=72) . (.) . (.) <. −. −. (.)
Control group (𝑛=65) . (.) . (.) <. −. −. (.)
Anxiety score . .
Intervention group (𝑛=72) . (.) . (.) <. −. −. (.)
Control group (𝑛=65) . (.) . (.) . −. −. (.)
Depression score . .
Intervention group (𝑛=72) . (.) . (.) <. −. −. (.)
Control group (𝑛=65) . (.) . (.) . . . (.)
a
Compared with control group using independent 𝑡-test,
b
Compared with baseline using pairwise 𝑡-test.
a desirable expectation that might exert a benecial eect
on their psychological wellbeing and physical symptoms.
Previous studies have shown that hope is inversely associated
with total fatigue, mental fatigue and level of anxiety and
depression [–].
Our study also showed a signicant correlation between
alleviation of depression and fatigue reduction, as well as
reduced anxiety following Qigong exercise. Regression anal-
yses further revealed that the improvements of fatigue and
anxiety symptoms signicantly predicted the alleviation of
depressive symptoms aer Qigong intervention. e results
conrmed an established association between fatigue symp-
toms and psychiatric disorders [, , ].
Qigong as a mind-body integrative exercise is distin-
guished from conventional forms of exercise []. e under-
lying physiological mechanism of mind-body intervention
may be of interest. Tsang and Fung []havehypothe-
sized three possible neurobiological pathways of the anti-
depressive eect of Qigong exercise including monoamine
neurotransmitters in the brain, the hypothalamic-pituitary-
adrenal (HPA) axis, and the brain-derived neurotropic fac-
tors (BDNF), but these hypotheses need to be further tested.
Although the results of our study are promising, some
limitations of this study should be noted. First, the partici-
pants with CFS-like illness were recruited from local com-
munity, who did not receive medical examinations conducted
by clinicians. us, some of them may not fully meet the
CDC criteria for CFS. Although around three-quarters of
the participants were female, it is similar to the proportion
of females with CFS in other earlier studies []. Second,
this study was a waitlist controlled trial, so social interaction
eects might have been existed in the intervention group.
It is recommended that active controls should be applied
in future studies to avoid possible placebo eect. ird, the
dosage and quality of home-based Qigong exercise were not
adjusted for in our data analysis. Given that some studies
havesuggestedarelationshipbetweenamountofQigong
practice and health outcomes [], it should be measured and
takenintoaccountindataanalysisinfuturestudies.Finally,
some other factors such as diet, physical activities, social
interaction, body weight, and comorbidities may aect the
outcomes, which should be adjusted in further trials. Despite
these limitations, this study was the rst RCT to examine the
eect of Qigong exercise on anxiety and depressive symptoms
among patients with CFS-like illness, which may provide
complementary evidence to the body of knowledge in this
eld.
5. Conclusion
In conclusion, the results of this study show that Qigong
exercise may be eective in reducing fatigue symptoms and
alleviating depressive symptoms for patients with CFS-like
illness and that the improvement of fatigue symptoms may
predict the alleviation of depressive symptoms aer Qigong
intervention. e ndings suggest that Qigong exercise may
be used as an alternative and complementary therapy or
rehabilitation program for patients with CFS-like illness.
Appendix
Description of the Movements in Wu Xing
Ping Heng Gong
Warm-up Movement. Swinging of arms by turning the torso
with relaxed shoulders (preferably to be practiced in a relax-
ingoutdoorspacewithtrees).

Evidence-Based Complementary and Alternative Medicine 
Movement 1.Standingontoeswithhandmovementstothe
front and to the side.
Movement 2. Circular movements of hands, wrists, hips;
stretching by arching backwards of neck and torso.
Movement 3. Movement of ngers, wrists, elbow and shoul-
ders; stretching of arms.
Movement 4. Movement of wrists; stretching shoulder mus-
cles; twisting movements of shoulders.
Movement 5. Massage of ears.
Movement 6. Swinging of hands to gently hit the chest and
back; standing on one foot and hitting back of the standing
foot’scalfbythedorsumofotherfoot.
Movement 7. Stretching of trunk and hip joints by stepping
forward and backward.
Movement 8. Swinging movements of lower body; squatting
and bending forward to stretch the back of the torso.
Movement 9. Movement of legs with hands in cupping pose;
turning of torso in kneeling position.
Sitting meditation. Sitting meditation with deep breathing can
be conducted for – minutes aer the movement exercises
if possible. If not, move directly to the concluding movement.
Sitting meditation is recommended in the evening, before
going to bed.
Concluding movement. Hands in cupping pose in front of the
lower abdomen for about  seconds; rub hands and then
usepalmstomassageface(upwardmovementlikewashing
face), followed by the use of ngertips to massage the scalp in
combing movement.
Conflict of Interests
e authors declare that they have no conict of interests.
Acknowledgments
isstudywassupportedbytheCentreonBehavioralHealth
Research Fund of the University of Hong Kong. e authors
thank the colleagues in the Centre on Behavioral Health and
all participants who made this study possible.
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