Article

Extension Trial of Qigong for Fibromyalgia: A Quantitative and Qualitative Study

Department of Pharmacology, Dalhousie University, 5850 College Street, P.O. Box 15000, Halifax, NS, Canada B3H 4R2.
Evidence-based Complementary and Alternative Medicine (Impact Factor: 1.88). 08/2013; 2013(2):726062. DOI: 10.1155/2013/726062
Source: PubMed

ABSTRACT

This extension trial is an open-label observational trial of 20 subjects with fibromyalgia who undertook level 2 Chaoyi Fanhuan Qigong (CFQ) training following an earlier controlled trial of level 1 CFQ. Subjects practiced 60 min/day for 8 weeks and continued some daily practice for 6 months. Quantitative measures, assessed at baseline, 8 weeks, 4 and 6 months, were of pain, impact, sleep, physical and mental functions, and practice time. Qualitative comments also were recorded. Compared to baselines, CFQ practice led to significant improvements in pain, impact, sleep, and physical function in the 13 subjects (65%) who completed the trial; changes were present at 8 weeks and were maintained for the 6-month trial duration. A highly motivated subgroup of N = 5, who practiced the most, had the best outcomes in terms of end symptomology, and qualitative comments indicated health benefits in other domains as well. Qualitative comments by the remaining N = 8 trial completers and N = 7 withdrawals indicate different experiences with the practice. This extension trial indicates that diligent CFQ practice over time produces significant health gains in fibromyalgia in a subset of individuals. Future studies will need to address factors that might predispose to favourable outcomes.

Full-text

Available from: Jana Sawynok, Apr 14, 2014
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Evidence-Based Complementary and Alternative Medicine
Volume , Article ID ,  pages
http://dx.doi.org/.//
Research Article
Extension Trial of Qigong for Fibromyalgia: A Quantitative and
Qualitative Study
Jana Sawynok,
1
Mary Lynch,
2
and Dana Marcon
3
1
DepartmentofPharmacology,DalhousieUniversity,5850CollegeStreet,P.O.Box15000,Halifax,NS,CanadaB3H4R2
2
Departments of Anesthesiology, Psychiatry and Pharmacology, Dalhousie University, QEII Health Sciences Centre, Dickson Centre,
5820 University Avenue, Halifax, NS, Canada
3
Personal Training Clinic, Halifax, NS, Canada
Correspondence should be addressed to Jana Sawynok; jana.sawynok@dal.ca
Received  May ; Revised July ; Accepted July 
Academic Editor: Romy Lauche
Copyright ©  Jana Sawynok 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.
is extension trial is an open-label observational trial of  subjects with bromyalgia who undertook level Chaoyi Fanhuan
Qigong (CFQ) training following an earlier controlled trial of level CFQ. Subjects practiced  min/day for weeks and continued
some daily practice for months. Quantitative measures, assessed at baseline, weeks, and months, were of pain, impact, sleep,
physical and mental functions, and practice time. Qualitative comments also were recorded. Compared to baselines, CFQ practice
led to signicant improvements in pain, impact, sleep, and physical function in the  subjects (%) who completed the trial;
changes were present at weeks and were maintained for the -month trial duration. A highly motivated subgroup of 𝑁=5,who
practiced the most, had the best outcomes in terms of end symptomology, and qualitative comments indicated health benets in
other domains as well. Qualitative comments by the remaining 𝑁=8trial completers and 𝑁=7withdrawals indicate dierent
experiences with the practice. is extension trial indicates that diligent CFQ practice over time produces signicant health gains
in bromyalgia in a subset of individuals. Future studies will need to address factors that might predispose to favourable outcomes.
1. Introduction
Qigong, which means the cultivation of qi or the energetic
essence of the human being, has a long history extending
thousands of years, is part of contemporary Traditional
Chinese Medicine and constitutes a distinct approach to
healing [, ]. Qigong practice (internal qigong) involves
physical movements and postures, breathing practices, and
meditative techniques, and there are many forms [, ]. Mul-
tiple forms of qigong are now practiced in many countries,
and there is an emerging literature reporting health benets
in several chronic health conditions [, ]. More recently,
qigong has been characterized as mindful exercise []or
meditative movement [] and this provides domains in
which components of the practice can be considered.
Fibromyalgia is a chronic pain condition associated with
sleep and mood disturbances and diminished quality of life
[, ]. In , a Swedish study reported long-term benets
in pain, sleep, and psychological function in bromyalgia in
a controlled study involving daily practice of qigong for
weeks []. In Nova Scotia, following completion of a pilot trial
involving a similar regimen [], we conducted a controlled
trial of Chaoyi Fanhuan Qigong (CFQ) []forbromyalgia
in which subjects were trained in level CFQ movements,
practiceddailyforweeks,andwereencouragedtocontinue
practice for months []. Wait list subjects served as a con-
trol group and underwent instruction and practice at the end
of the wait time. In both cohorts (immediate, delayed), there
were signicant improvements in pain, impact, sleep, physical
function, and mental function, and benets were maintained
to months [].Followingthattrial,somesubjects(𝑁=10)
voluntarily undertook level CFQ training (meditation) in
the community, continued their practice, and were known,
anecdotally, to be experiencing further health improvements.
Furthermore, cases of marked benets in bromyalgia in
those undertaking community-based training and engaging
in extensive CFQ practice were documented []. In view of
this, we undertook an extension trial in which participants
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Evidence-Based Complementary and Alternative Medicine
who completed the controlled trial were invited to participate
in a further trial in which level CFQ (meditation) was
added to the level CFQ (movement) instruction. e
goals of the extension trial were (a) to determine whether
level CFQ instruction and further practice would produce
additional benets in bromyalgia and (b) to document
health eects of extensive practice of CFQ. Fibromyalgia
is a complex and dicult condition to treat []andisa
challengeforbothpatientsandclinicians[]. While drugs
areapprovedfortreatingbromyalgia,thesehavelimited
ecacy [, , ]. Furthermore, multimodal treatments show
limited eectiveness in the long-term [], and longitudinal
benets of treatments are generally modest []. It is therefore
important to explore all possible modalities for this condi-
tion, including practices considered as complementary and
alternative medicine or CAM [, ].
2. Methods
2.1. Participants. e controlled trial of level CFQ was
conducted between September  and July  [].
e current extension trial took place between March and
September  and was conducted at the Pain Management
Unit, Queen Elizabeth II Health Sciences Centre, Halifax,
with Ethics Review Committee approval. Original partici-
pants were invited to a review session of trial results (
attended) and invited to join the extension trial. 𝑁=20
entered the -month open-label extension phase. Participants
wereassignedthesamestudynumberasintheoriginaltrial
for longitudinal tracking. During the initial trial, there were
several training cohorts, so the amount of time between level
and level CFQ instruction was variable.
2.2. Training and Practice. Extension trial participants
received training in level CFQ by a certied instructor
(DM) at two half-day ( hours each) training sessions. is
was followed by weekly group practice sessions ( mins)
for weeks. Participants were required to practice daily for
 mins during these weeks; following that, continued daily
practicewasencouragedtotheendofthetrial.
CFQ was developed in the s []andisavailable
locally in Nova Scotia. Level instruction consists of a set
of movements which are slow and rhythmical and are
accompanied by a relaxed mental state and connection-to-
body feeling. In a set, there are  repetitions of movements
–, and repetitions of movements -; each set takes –
 mins to complete. Level consists of instruction in medi-
tation techniques, primarily sitting meditation, but standing
and lying meditation also were presented as practice options.
Sitting meditation involves bringing attention to the interface
with the chair, feeling the chair, disengaging thought, and
switching into open awareness. With standing meditation,
attention is brought to the lower abdomen and into the feet,
with lying meditation, to the lower abdomen and contact
with the oor, with similar feeling-of-contact and mental
instructions. Meditation is practiced for min intervals.
Participants were required to practice for a total of mins
per day, with a recommendation of level CFQ (movements)
and level CFQ (meditation) for mins each.
2.3. Outcome Measures. Quantitative measures were the
same as in the level CFQ controlled trial []andcom-
ply with recommendations for core domain assessments
in chronic pain and bromyalgia trials [, ]. Measures
included () pain (NRS-PI, -point numerical rating scale
pain intensity, with anchors of no pain and pain as bad as
you can imagine”), () Fibromyalgia Impact Questionnaire
(FIQ), () Pittsburgh Sleep Quality Index (PSQI), and ()
SF-HealthSurvey(physicalandmentalscoresanalysed
separately). Participants also completed the following: ()
Patient Satisfaction Scale (How satised are you with the
qigong treatment? with = very unsatised, = neither
satised nor dissatised, + = completely satised) and ()
Patient Global Impression of Change Scale (How would you
grade your overall bromyalgia condition since using qigong?
with = very much worse, = no change, + = very much
improved). ey were also asked to indicate the following: ()
daily practice time (categories of , , , , min) and ()
side eects from their practice. A qualitative questionnaire,
which invited open-ended comments on experiences, also
was included. (At Baseline: briey describe changes to your
health with completion of the rst phase of the trial. At
weeks: describe changes in your health that you attribute to
CFQ practice over the past weeks. At and months:
describe changes in your health since entering the study that
you attribute to CFQ practice.) ose that had previously
voluntarily undertaken level CFQ training were identied
in this questionnaire. Assessments were completed on the day
of training (baseline) and at the last weekly group session (
weeks); – months reports were returned by mail.
2.4. Statistical Analysis. Statistical analysis was conducted
on the group that completed the trial to months, the per
protocol group. Baselines were compared with -week, - and
-month values. Pain, sleep, and SF-physical comparisons
were performed using one-way repeated measures analysis
of variance (ANOVA), with the Holm-Sidak method for
multiple comparisons versus baseline. FIQ scores failed the
equalvariancetestusingthismethodandwereanalysedusing
one-way ANOVA with the Student-Newman-Keuls test for
pairwise comparisons. SF-mental scores failed variance (one-
way repeated measures ANOVA) and normality (one-way
ANOVA) and could not be further analysed.
3. Results
3.1. Baseline Characteristics. Demographics and baseline
characteristics of trial participants who entered the extension
(𝑁=20) were extracted from the earlier trial [](Table ).
eir baseline scores for pain, impact, sleep, and physical and
mental function indicate that participants are representative
of the original groups (pain ., .; impact ., .;
sleep ., .; SF-physical ., ., SF-mental .,
. for immediate and delayed training groups, resp.).
𝑁=13(%) completed the -month period; 𝑁=5
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Evidence-Based Complementary and Alternative Medicine
T : Demographics and other characteristics of trial participants
entering the extension trial (extracted from information provided at
entry to the earlier controlled trial) [].
Var i able
Extension trial group
(𝑁=20)
GenderF:M :
Age at enrollment, years (SD)  (.)
Duration of bromyalgia, years (SD) . (.)
BMI at enrollment (IQR) . (.)
Pain medications, mean number (SD) . (.)
Other medications, mean number (SD) . (.)
Baseline NRS-PI, mean (SD) . (.)
Baseline FIQ, mean (SD) . (.)
Baseline PSQI, mean (SD) . (.)
Baseline SF-physical, mean (SD) . (.)
Baseline SF-mental, mean (SD) . (.)
had previously voluntarily undertaken level CFQ training;
𝑁=7withdrew from the study ( by week , more by
months) (Figure ). Side eects included pain (𝑁=5), cooler
body (𝑁=1), headache (𝑁=1), discolored hands and feet
(𝑁=1), intermittent cough (𝑁=1), and increased stress
(𝑁=1); none of those reporting side eects withdrew.
3.2. Quantitative Assessments. e results for pain, impact,
sleep, and physical and mental functions for the entire group
are presented in Figure . Improvements in quantitative
scores were generally manifested by weeks and maintained
at – months. ere were signicant pre- versus postpractice
eects for pain, impact, sleep, and physical function. Mental
function showed directional trends towards improvement
(see also qualitative comments). Data was also analysed
as subgroups: () those who voluntarily undertook level
training prior to the extension trial and were highly motivated
(𝑁=5), () other participants who completed the trial
(𝑁=8),and()thosethatwithdrewfromthetrial(𝑁=
7). ese results are presented in Figure . Both subgroups
completing the trial showed improvements in pain, impact,
sleep, and physical and mental functions, with similar pre-
post practice dierences. Baseline values appeared dierent
between subgroups, with the highly motivated subgroup
showing less severe symptoms, but only physical function was
signicantly dierent (𝑃 = 0.04, Students 𝑡-test).
Self-reported practice times from the categorical checklist
are indicated in Table . On average, the group completing
thetrialpracticedmin/daythroughout.e𝑁=
5 highly motivated subgroup complied with  mins/day
practice over weeks and maintained this over time (, ,
and mins/day); the remaining subgroup completing the
trial had lower practice times at weeks and these declined
over time (, , and  mins/day). ose that withdrew
from the trial had the lowest practice times at weeks.
Patient satisfaction scores (mean ±SD) for those complet-
ing the trial were uniformly high at all intervals ( indicates
completely satised”): 5.9 ± 1.8 at weeks, 5.8 ± 1.9 at
Completed controlled trial of level
N=73
Entered extension trial of level
2 CFQ for bromyalgia N=20
Withdrawals N=7
Not known N=3
Completed extension trial N=13
Prior exposure to level 2 CFQ N=5
No prior exposure to level 2 CFQ N=8
1 CFQ for bromyalgia
Minimal baseline pain level N=2
Lack of eect at week 8N=2
F : Subject disposition in open-label extension trial of qigong
for bromyalgia.
T : Self-reported qigong practice times (mean ± SD, combined
level and level CFQ) for extension trial participants as indicated
in the categorical checklist (, , , ,  min options).
weeks
(min/day)
months
(min/day)
months
(min/day)
𝑁=13trial completers
44 ± 21 38 ± 23 35 ± 26
𝑁=5motivated
66 ± 13 57 ± 20 60 ± 15
𝑁=8others
38 ± 14 24 ± 13 20 ± 13
𝑁=7withdrawals
20 ± 10 ——
months, and 6.3 ± 1.0 at months. Patient global impression
of change scores (mean ± SD) also were uniformly high (
indicates “very much improved”): 5.6 ± 1.6 at weeks, 5.7 ±
1.4 at months, and 5.6 ± 1.0 at months. No subgroup
analysis of these scores was undertaken.
For those who completed the trial (𝑁=13), the number
of pain medications (mean ± SD) at entry was 3.2 ± 1.3;
at the end of the trial, this was 1.1 ± 1.3. Six participants
(%) reported no longer taking any pain medications at the
end of the trial; all had been taking pain medications at the
beginning of the trial.
3.3. Qualitative Assessments. Table presents qualitative
comments by the 𝑁=5who voluntarily undertook level
CFQ training prior to entering the extension trial. Baseline
comments reect experiences following the previous trial,
as well as subsequent voluntary practice. Improvements in
many areas were identied aer weeks and consolidated at
and months. Comments indicate further health benets
beyondthosedocumentedbyquantitativeresults.us,there
are reports of improvements in asthma (, ), food
allergies (, ), allergies and sinus headaches (),
chemical sensitivities (, ), carpel tunnel symptoms,
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Evidence-Based Complementary and Alternative Medicine
P = 0.028
P = 0.010
P = 0.012
6
5
4
3
2
5.7(1.8)
3.7(2.0) 4.2(2.6)
3.6(2.5)
B
2 months
4 months 6 months
(a) Pain
P = 0.019
P = 0.040
P = 0.036
50
40
30
20
B
50.9(16.5) 31.9(22.1) 32.5(20.6) 29.7
2 months
4 months 6 months
(17.6)
(b) FIQ
P = 0.045
P = 0.002
P = 0.004
12
11
10
9
8
7
B
11.5(3.6) 9.6(3.0) 8.2(4.2) 8.5(4.2)
2 months
4 months 6 months
(c) Sleep
P = 0.012
P = 0.004
45
40
35
30
B
36.2(9.4)
41.3(12.1)
42.1(12.0) 42.9(10.7)
P = 0.008
2 months
4 months 6 months
(d) SF-physical
50
45
40
35
41.0(11.2)
47.9(8.9)
44.2(9.3) 48.1(9.0)
B
2 months
4 months 6 months
All subjects completing 6 months
(e) SF-mental
F : Eects of qigong practice on pain, impact, sleep, and physical and mental functions in all participants who completed the extension
trial over months (𝑁=13). (a) Pain (Numerical Rating Scale Pain Intensity), (b) impact (Fibromyalgia Impact Questionnaire), (c) sleep
(Pittsburgh Sleep Quality Index), (d) physical function (SF-Health Survey, Physical), and (e) mental function (SF-Health Survey, Mental).
Values shown in panels are means; mean (SD) values depicted in the lower panel. 𝑃 values shown for values signicantly dierent (𝑃 < 0.05)
from baseline (B).
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Evidence-Based Complementary and Alternative Medicine
7
6
5
4
3
2
1
0
4.6(1.7) 2.8(1.9) 2.8(2.4) 2.4(2.3)
6.4(1.5) 4.3(2.0) 5.0(2.5) 4.4(2.5)
B
2 months
4 months 6 months
(a) Pain
60
50
40
30
20
10
0
41.4(16.3) 19.8(24.5) 24.4(8.8) 17.2(11.9)
56.9(14.5) 39.4(18.0) 37.5(21.1) 37.5(16.4)
B
2 months
4 months
6 months
(b) FIQ
14
12
10
8
6
4
2
0
9.4(1.8) 8.0(2.5) 5.6(3.5)
6.0(4.3)
12.8(4.0) 10.6(3.0) 9.8(4.0) 10.0(3.6)
B
2 months
4 months
6 months
(c) Sleep
55
50
45
40
35
30
25
20
42.9(6.3) 50.4(10.1) 49.9(12.0) 50.8(8.6)
31.9(8.7) 35.5(9.7) 37.3(9.8)
37.9(9.0)
B
2 months
4 months 6 months
(d) SF-physical
55
50
45
40
35
30
39.6(10.9) 50.2(4.8) 44.6(10.4) 51.0(6.5)
41.8(12.1) 46.4(10.7) 43.9(9.3) 46.3(10.2)
B
2 months
4 months
6 months
Highly motivated
Other completers
Withdrawals
(e) SF-mental
F : Eects of qigong practice on pain, impact, sleep, and physical and mental functions in subgroups who had previously voluntarily
undertaken level CFQ training (𝑁=5, highly motivated) (black circles) and others who completed the -month extension trial (𝑁=8)
(white circles). (a) Pain (Numerical Rating Scale Pain Intensity), (b) impact (Fibromyalgia Impact Questionnaire), (c) sleep (Pittsburgh Sleep
Quality Index), (d) physical function (SF-Health Survey, Physical), and (e) mental function (SF-Health Survey, Mental). Values shown are
means; mean (SD) values depicted in the lower panel. Mean values for those who withdrew from the trial are depicted by grey squares (𝑁=7
at baseline, 𝑁=3at weeks).
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Evidence-Based Complementary and Alternative Medicine
T : Qualitative comments by 𝑁=5subjects who voluntarily undertook level CFQ training aer the level trial and then completed the
extension trial. Baseline comments relate to experiences following the trial and then community-based instruction and continued practice.
Comments retain original wording and content but are edited to remove identifying and extraneous information. Original trial number, age,
and duration of bromyalgia (FM) are indicated for each subject (mo = month).
Subject Baseline comments Comments following qigong practice
1(006)
Age: 
FM: years
Less pain, more relaxed, slept better,
increased energy. [With level ] when
practice diligently, experience calmness,
less pain, better sleep; when skip practice,
am angry, tired, and [have] major
migraines.
Week : food allergies have greatly improved. No longer have asthma
and am o puers; have been able to increase exercise without
shortness of breath. Wood smoke no longer bothers me. Sleep less and
have more energy, better quality of sleep. Am calmer. Carpal tunnel
[symptoms] and tendonitis are gone. Mind is less brain fogged.
Much less pain and stiness; rare migraines versus frequent migraines.
Month –: have discontinued inhalers, no indication of asthma. Am
exercising more (biking  kms/day). Sleep well and feel well. Food
allergies are nonexistent and chemical sensitivities much reduced
( mo). Have discontinued all prescription medications (Ventolin,
Elavil,Tryptophan,Advil,Imitrex).AmabletodothingsIhavent
done in years, have more energy ( mo).
Note: reports practicing 10–14, then 14–18 hrs per week
2(007)
Age: 
FM:  years
Allergies are much better, pain is reduced,
much happier and more at peace. Can
deal with stress better. [With level ]
quality of sleep has improved, pain
reduced further.
Week : function very well on less sleep. Food allergies are improved.
Asthma has improved and am no longer on puers. Have started
running and hiking. Pollen season had no eect on me this year;
usually have severe pollen allergies. Was allergic to grass [asthma
attack and /or headache]; this year can smell cut grass [with no
symptoms] and it smells good. Better quality of sleep, rarely wake at
night.Mindisclearer,ammorealert.Aminlesspainandhavegonea
very long time without needing Tylenol.
Month –: o all sleep medications (Tryptophan, Elavil), and quality
of sleep has improved. Bike hr ( kms) every weekday morning,
something I couldnt do before. Food allergies have improved, [now]
regularly eat cheese or yogurt [strong allergies before]. Other
allergies (scents) no longer bother me ( mo). Asthma no longer an
issue ( mo).
Note:reportspracticing10,then1415hrsperweek
3(036)
Age: 
FM:years
At the beginning was using a walker and
then a cane; now walk without a cane.
Was depressed and felt hopeless about my
health, now feel grounded and peaceful.
Have reduced amount of medication by
half. Have lost  pounds on my journey
with the practice as well. [With level ]
greater personal peace.
Week : Qigong has changed my life in so many positive ways. Have
learned to accept pain. Am much more accepting and much calmer.
When I started Qigong, I was using a walker, then canes, and now I
am able to walk without canes. Have also lost a lot of weight which I
hadn’t been able to lose before. Feel at home in my body. e benets
of Qigong are many.
Month –: [No comments at mo] Qigong has given me my life
back. When I started, was using a walker, couldnt sleep and was in
terrible pain. Now feel peaceful; am walking, sleeping well; pain levels
have come down considerably. Eyesight has come down from . &
. to . and .. Was housebound, now I can walk the dog and go
outtodoerrands.Stillhaveproblemswithfatiguebutoverall,am
much better ( mo).
Note 1: reports practicing 12, then 7–12 hrs per week
Note 2: 036 also oered written information on experiences with CFQ
prior to entering the extension trial. Before the earlier trial, she was
practicallyhouseboundandhadlittlehopeforimprovement.Shehad
been diagnosed with bromyalgia, psoriatic arthritis, bursitis, asthma,
high blood pressure, irritable bowel syndrome, temperomandibular joint
disorder, depression, and severe sleep apnea. She was taking 4 pain
medications (codeine contin, pregabalin, tramadol/acetaminophen, and
hydromorphone) as well as 7 other medications. By the time she entered
the extension trial, her experiences had allowed her to discontinue
hydromorphone, tramadol/acetaminophen, methotrexate, ovent,
salbutamol, and her codeine contin intake had dropped dramatically.
She also no longer needed her cane or CPAP (continuous positive airway
pressure) machine. She had lost a substantial amount of weight. Her case
is interesting, as she started classes with little hope that it would help.
How could these simple movement patterns help?”
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Evidence-Based Complementary and Alternative Medicine
T : C ontinued.
Subject Baseline comments Comments following qigong practice
4(087)
Age: 
FM:  years
Biggest thing is mood; from attempting
suicide to having hope. Mobility much
better, less pain. Able to tolerate things.
Like a weight has been lied o my
shoulders. [With level ] deeper
understanding of energy ows, blockages
which cause pain. Ability (sometimes) to
let the pain come and focus on something
else.
Week : mood elevated. Sugars much better controlled. Blood pressure
is excellent. Less ares of bromyalgia. Better exibility/mobility,
especially with arms and shoulders. Lots of pain aer doing Qigong,
but it is just memories working through. Have had black hands and
feet, dizziness and bruises that appear for no reason. Realistic
expectations with health, especially with my diabetes. Have pain and
tired all the time, but live as best I can. Qigong keeps my mood and
perspective even.
Month –: mood is the huge change from attempting suicide to
going [on a trip] and planning more travel. Enjoy my work and am
more tolerant of others. Body is a lot more exible and mobile, get out
walking a few kms most days. Am doing things that I never thought I
would be able to do again ( mo). Always mood much better aer any
amount of Qigong. Mobility greatly increased ( mo).
Note: reports practicing 4, then 5 hrs per week
5 (098)
Age: 
FM:  years
Improved sleep, decreased pain, more
calm and peaceful. [With level ] allergies
improved, fewer sinus headaches and
infections. Happier and deal with stressful
situations with increased calmness.
Week : fewer sinus headaches due to allergies. Restorative sleep more
frequent. More positive about life and its challenges; more peaceful,
tolerant and understanding. Cut back in the number of hours spent at
work. Not wasting energy on guilt and worry over things I cannot
control.
Month –: decrease in allergies and sinus problems. Decrease in
tolerance to stress due to uncovering underlying anxiety; expect this
to change again as soon as I continue my practice. Overall condition
has improved ( mo). Ability to cope with stress has increased.
Improvement in severity of pain and frequency ( mo).
Note: reports practicing 6, then 4-5 hrs per week
tendonitis (), migraine headaches (), weight loss
(), vision (), blood pressure (), and mood (). In
several instances, there was discontinuation of medications
for asthma (, ), sleep (), mood (), and pain
(,).Insomecases,multipledrugswerediscontinued
(, ). ere are many comments relating to marked
improvements in quality of life (, , , , ). Some
participants indicate substantial amounts of practice in this
open-ended format (– hrs/week) (, , ).
Table summarizes qualitative comments oered by
remaining participants who completed the extension trial
(𝑁=8). Several comments are positive and, in addition to
mentioning symptoms evaluated in quantitative results, there
is mention of improvements in blood pressure () and mus-
cular dystrophy symptoms (). ere are also comments
indicating pain as a result of practice (, , , )
(see also side eects) and diculties with meditation (,
, ). Self-reported practice times in the open format
forthisgrouparelowerthanthoseinthehighlymotivated
group.
Table summarizes qualitative comments by those who
withdrew from the trial. ere are several positive comments
as a result of earlier qigong experiences (, ), including
reduced blood pressure (, ), stopping medications
(, ), and quality of life improvements (). ere are
also challenges with the meditation instruction (). Two
who withdrew had low baseline levels of pain (-) (, )
and would not have been included in the trial if a minimum
symptom severity () was required.
4. Discussion
is was an extension to a previous randomized controlled
trial in which level CFQ (meditation) was added to level
CFQ (movement) for subjects with bromyalgia. Qigong
was recently characterized as meditative movement [], and
we were interested in determining whether components
of the practice could be examined sequentially. We also
wished to document health eects in those who engaged in
extensive qigong practice. e trial is best characterized as
an open-label observational trial; it is also a long-term trial
(- years) and provides valuable longitudinal information
on the eects of diligent practice. Quantitative results in
those who completed the extension trial indicate signicant
improvements in core domains of bromyalgia as a result of
qigong practice. Subgroup analysis indicates that the highly
motivated group and others who completed the trial attained
similar reductions in pain, impact, and sleep impairment, and
improvements in function. Of note in the highly motivated
subgroup is the observation that postpractice absolute values
for pain (scores of -) and impact (scores of –) suggest
mild symptomology. Qualitative comments by the highly
motivated subgroup recapitulate benets in core domains, as
well as indicating diverse further health benets (improve-
ments in allergies/sensitivities, migraines, asthma, blood
pressure, and vision). Benets include resumption of exercise
and weight loss, which further contribute to improved health.
Qualitative comments for others who completed the trial also
contain positive health comments but are more moderate in
tone. Subgroups were distinguished in terms of self-reported
Page 7
Evidence-Based Complementary and Alternative Medicine
T : Qualitative comments of the remaining 𝑁=8subjects who completed the extension trial. Baseline comments relate to experiences
following level CFQ. Comments retain original wording and content but are edited to remove identifying and extraneous information.
Original trial number, age, and duration of bromyalgia (FM) are indicated for each subject (mo = month).
Subject Baseline comments Comments following qigong practice
1(019)
Age: 
FM:  years
Qigong helped me
enormously at rst,
physically and emotionally.
Have not practiced
faithfully; do about
 mins/day. Most negative
health changes are due to
arthritic changes,
degenerative discs, pinched
nerve in neck, bad
shoulder, foot, and hand.
Week : for the rst weeks felt worse, or not improved; had a lot of
movements during meditation which I found exhausting, woke sti and
sore. By week / was feeling a bit more energetic and woke feeling better,
but tired. By week , was feeling good upon waking. By week /, am
feeling good most of the day. Back gets sore by late aernoon. Burning and
stiness due to bromyalgia are mostly gone. Have more energy, less pain.
Month –: had to stop sitting meditation as it caused lower back pain, so
do lying meditation; very relaxing, fall asleep within minutes. Sleep more
soundly and have more energy. Less bromyalgia pain (still have arthritis
aches—spine and hand) ( mo). Am more relaxed, fall asleep more easily.
Note: reports practicing 5, then 2-3 hrs per week
2(029)
Age: 
FM: years
Weight loss, tightening of
core and leg muscles, walk
further. Blood pressure
decreased [to],o
meds for over a year.
Overall healthier. Immune
system has improved.
Week : there havent been many changes. Stopped doing meditation as
found it hurtful (physically) and depressing (mentally).
Month –: bad fall and having trouble healing. Stopped Qigong due to
injury.
Note: reports practicing 4, then 0–2 hrs per week
3(042)
Age: 
FM:  years
Because of disability, live in
poverty with limited
resources. Stressful housing
situations have created
health issues. CFQ has
gotten me through crises.
When not in crisis, very
noticeable positive eects.
Week : anxiety up and down. Level caused temporary overwhelming
emotional responses; however, they passed. Less muscle tension and
tightness.
Month –: negative changes in health since learning CFQ—central
nervous retinopathy, psoriasis, and high cholesterol. Positive changes—less
pain, headaches, stiness, aches, increased mobility, and sleep.
Note: reports practicing 5, then 3-4 hrs per week
4(043)
Age: 
FM: year
Understand my condition
more and therefore am
more in control.
Week : have learned to control anxiety, am more in control and relaxed.
Pain seems to improve aer practicing Qigong; it helps me cope with pain.
Month –: no changes ( mo). Have not practiced Qigong ( mo).
Note: reports practicing 3, then 0-1 hr per week
5(044)
Age: 
FM: years
[Have] osteoarthritis of
back and knees and
generalized over body, in
both thumbs, ankle, elbows;
have high blood pressure.
Week : feel relaxed; meditation makes me calm and peaceful.
Month –: osteoarthritis in le knee and spinal stenosis have worsened
[with] certain parts of Qigong practice ( mo). Meditation gives me peace
of mind ( mo).
Note: reports practicing 3.5, then 1–4 hrs per week
6(048)
Age: 
FM:  years
Qigong has been of great
benet. Because of
Muscular Dystrophy,
(MD), am limited in moves
and practice. Even though
am getting weaker due to
MD, Qigong has denitely
helped with stiness and
stamina.
Week : am denitely more exible and can raise my arms up further and
for a longer period of time. e meditation aspect has presented challenges.
Month –: even though have not been physically able to practice more
than approximately  mins/day, it has been of some benet to me. Hands
and feet are warmer, feel calmer. Have recently experienced further
progression of MD which has limited me ( mo). Joints are denitely not as
sti when practicing Qigong ( mo).
Note: reports practicing 5, then 1.5–3 hrs per week
7(075)
Age: 
FM: years
Sleep improved, pain
decreased, calmer, clearer
mind.
Week : pain level has increased since starting meditation. Am mostly
relaxed during the lying down meditation; pain dissipates during this time.
Overall pain has increased, interfering with sleep. Stiness increased also.
Month –: pain levels went up while practicing Level . Reduced the
amount of time in the last weeks to get a break. Have started the daily
routine again to see if there is any improvement ( mo) Stopped doing
meditation and pain levels went down. Still practicing [movements] but not
as much as previously. Removed wheat from diet, and stiness, pain levels
and swelling reduced.
Note: reports practicing 6, then 4-5 hrs per week
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Evidence-Based Complementary and Alternative Medicine
T : C ontinued.
Subject Baseline comments Comments following qigong practice
8(091)
Age: 
FM:  years
Felt better, less pain, more
sleep.
Week : more relaxed, and joints feel better. Pain seems to be better most of
thetime.Qigonghashelpedmecopebetter.
Month:helpedmebecomemoreactive,givenmestrengthtodomore
[short walks, biking for rst time in years]. Could do more, but my arthritic
foot stops me. Qigong has not seemed to help this area.
Note: reports practicing 3, then 2–7 hrs per week
T : Qualitative comments of the 𝑁=7subjects who withdrew from the extension trial. Baseline comments relate to experiences
following level CFQ. Comments retain original wording and content and are edited to remove identifying and extraneous information.
Original trial number, age, and duration of bromyalgia (FM) are indicated for each subject.
Subject Baseline comments Comments following qigong practice
1(004)
Age: 
FM: 
Am feeling and doing much better, more happy,
more relaxed, more carefree.
Week : more energetic, less pain, happier; blood pressure
has gone down.
Month : WITHDRAWAL
Note 1: reports practicing 2 hrs per wk at week 8
Note 2: reports pain level 2 at baseline, and 3 at week 8
2(005)
Age: 
FM: 
Lowered pain and tiredness, improved mobility and
[activities].
Week : WI THDR AWAL
Note: pain level 3 at baseline
3(025)
Age: 
FM: 
Same as when started except for taking medications
(none).
Week : WI THDR AWAL
4 (060)
Age: 
FM: 
Improved sleep, but has deteriorated since trial
ended. Improved sense of well-being. Increased
sense of control of my pain even though pain the
same as before.
Week : although had a marked improvement in the rst
level trial, have had no positive response from this second
level. Had great diculty with the training presentation—the
material was presented in ways that challenge my worldview.
Month : WITHDRAWAL
Note: reports practicing 2 hrs per wk at week 8
5(063)
Age: 
FM: 
Pain reduced, better sleep. Diagnosis of diabetes, so
was a confusing time.
Week : WI THDR AWAL
6(082)
Age: 
FM:
Qigong helped me relax. Stopped taking too many
pain pills because Qigong is helping.
Week : WI THDR AWAL
7(089)
Age: 
FM:
Now know the connection between relaxation and
how we perceive pain. Qigong makes me feel rested
and calm.
Week : qigong relaxes me and improves my peace of mind.
Am less anxious and less depressed. Can work pain free for
longer periods of time. Found the movements benecial for
lower back problems. Find it hard to put time aside [for
Qigong], would benet from longer practice sessions. It has
to become a way of life to get full benets.
Month : WITHDRAWAL
Note: reports practicing 5 hrs per week at week 8
qigong practice times (highly motivated >completers > with-
drawals).
Collectively, these quantitative and qualitative results
indicate that dedicated CFQ practice over time produces
marked and sustained benets in core domains relevant to
bromyalgia, as well as additional health benets. ese
outcomes are generally supported by other trials of bromyal-
gia and related conditions, where sustained qigong practice
(daily for – weeks) is involved [, , ]. Other trials
of qigong for bromyalgia used qigong as part of a weekly
regimenoverweeksandreportedmoreequivocalresults
[]. Improvements in some conditions in the present
trial noted in qualitative comments (e.g., blood pressure) are
supported by an emerging literature []. Of particular note
is the magnitude of change in several conditions (asthma
resolving, improved mobility, weight loss, improved eyesight,
resolution of carpel tunnel symptoms, and resolution of aller-
gies/sensitivities). Benecial eects were most prominent in
the group that engaged in the most qigong practice. Similar
marked improvements in diverse conditions were observed
aer extended CFQ practice in case reports []. Based on
these results, and recognizing that these benets occur in
those who have been compromised for an extended period
of time (bromyalgia mean duration . years, 𝑁=13),
further studies on the health benets of qigong practice,
and especially extended practice, in bromyalgia as well as
Page 9
 Evidence-Based Complementary and Alternative Medicine
other chronic health conditions, are encouraged. In some
frameworks, bromyalgia is considered a central sensiti-
zation syndrome along with other disorders (e.g., chronic
fatigue syndrome, regional pain disorders, irritable bowel
syndrome, and headache disorders) [, ], and it would be
interesting to ascertain eects of qigong in these conditions.
us, it was recently reported that qigong is of benet in
chronic fatigue syndrome [].
ere are several methodological issues to consider in
relation to this extension trial. () Qigong, a Complex Practice.
Qigong, along with tai chi, is characterized as meditative
movement []andisacomplexinterventionwithmany
components potentially contributing to ecacy [, , ]. It is
impossible to blind qigong practice, and trial designs such as
randomized controlled trials of xed protocols, community-
based observational trials, cross-sectional studies of long-
term practitioners, and studies that integrate qualitative
methods to capture the richness of participant experiences
have been encouraged []. e current extension trial incor-
porates several of these recommended trial design elements.
() Plurality of Forms, Components. ere are many forms of
qigong [, ], and the contribution of a particular component
of activity to the outcome is not clear. Considering qigong
as meditative movement [] is useful as it provides domains
for comparison, and future trials can compare qigong with
exercise regimens or with meditation groups. However, there
are various forms (aerobic, strength, and exibility) and
intensities (mild, moderate) of exercise, and this area has
its own research challenges [, ]. Additionally, there
is a multiplicity of mind-body interventions (mindfulness,
meditation) and this eld also contends with methodological
challenges []. e current trial did not have a comparison
group and assessed pre- versus post-intervention outcomes
in a quantitative and qualitative manner; it is pragmatic
and akin to clinical practice. () Extent of Practice, Eective-
ness of Practice. How much qigong practice is needed for
clinically meaningful eects (“minimal dose”), and whether
further practice leads to better outcomes (“dose-response
relationship), are important issues. Furthermore, there is
the issue of eectiveness (“bioavailability”), of whether all
time spent seemingly engaged in an activity is equivalent
[]. Post hoc analysis of outcomes in relation to extent of
practice indicated dierences between those who practiced
per protocol or minimally in the earlier controlled trial [].
In the present trial, we also observed a practice-response
relationship, as those who practiced the most had the best
outcomes. Systematic assessment of practice time is feasible
using standard protocols in controlled trials, as well as with
observational trials, and is encouraged for all qigong trials.
Furthermore, meta-analysis of qigong trials for bromyal-
gia will need to consider this factor in clustering studies
for analysis [, ]. Finally, motivation for or barriers to
continued/extensive practice (e.g., use of booster sessions,
group versus individual sessions, nature of instruction, and
eectiveness of dierent instructors) will need to be con-
sidered in future studies. () Identifying ose Who Benet
from Qigong. In this trial, / (%) undertook additional
instruction, completed months, and experienced signicant
pre- versus postpractice benets. is subgroup represents
% of original trial completers (/). Extensive qigong
practice requires a considerable commitment and will not
be suitable for everyone for many reasons. However, because
multiple health benets can result from diligent practice,
as documented here and in case studies of CFQ [], there
will be some willing to engage in such practice if it means
relief from a long-standing condition which has not been
amenable to other approaches. Future studies on qigong
could include additional assessments of participant factors
(e.g., psychosocial prole, locus of control, and attitudes
towards CAM), to determine those that might predispose to
favourable outcomes. us, those with bromyalgia exhibit
dierences in health related locus of control, cognitive
attributes, and perceived social support compared to other
chronic pain populations and/or controls, for example, [,
]. is approach ts within the conceptual frameworks of
attribute-treatment interactions [], preference trials [],
and personalized medicine.
5. Conclusion
is open-label extension trial indicates that diligent practice
of CFQ, a particular form of qigong, produces sustained ben-
ets in bromyalgia as indicated by quantitative assessments
in core domains for bromyalgia. Qualitative comments
indicatehealthbenetsinotherareasaswell.Benetisrelated
to extent of practice.
Conflict of Interests
Jana Sawynok and Mary Lynch have no conict of interests
relating to this study. Dana Marcon is a community-based
CFQ instructor.
Acknowledgments
e authors thank Paulette Nauss and Joan Falkenham
for their valued contributions as trial coordinators. ey
also thank Allison Reid for statistical processing, generating
gures, and independently checking qualitative comments
in tables against original comments to ensure accuracy of
information reported. is study was funded in part by the
Department of Anesthesiology and a private donation.
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  • Source
    • "There is another case of extended qigong practice in a community setting providing marked health benefits in several areas [41]. Effects of long-term practice of qigong in FM also were addressed in an extension trial in which í µí± = 20 who had completed an earlier controlled trial went on to a further 6-month phase (total practice ≥ 1 year) [39]. í µí± = 13 completed the extension, and their outcomes indicate that extended qigong practice resulted in significant gains in core FM areas (pain, impact, sleep, and physical function and mental function) in quantitative assessments. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction. Qigong is currently considered as meditative movement, mindful exercise, or complementary exercise and is being explored for relief of symptoms in fibromyalgia. Aim. This narrative review summarizes randomized controlled trials, as well as additional studies, of qigong published to the end of 2013 and discusses relevant methodological issues. Results. Controlled trials indicate regular qigong practice (daily, 6-8 weeks) produces improvements in core domains for fibromyalgia (pain, sleep, impact, and physical and mental function) that are maintained at 4-6 months compared to wait-list subjects or baselines. Comparisons with active controls show little difference, but compared to baseline there are significant and comparable effects in both groups. Open-label studies provide information that supports benefit but remain exploratory. An extension trial and case studies involving extended practice (daily, 6-12 months) indicate marked benefits but are limited by the number of participants. Benefit appears to be related to amount of practice. Conclusions. There is considerable potential for qigong to be a useful complementary practice for the management of fibromyalgia. However, there are unique methodological challenges, and exploration of its clinical potential will need to focus on pragmatic issues and consider a spectrum of trial designs. Mechanistic considerations need to consider both system-wide and more specific effects.
    Full-text · Article · Nov 2014 · Evidence-based Complementary and Alternative Medicine
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    [Show abstract] [Hide abstract] ABSTRACT: Objectives: A randomized controlled trial (RCT) and an extension trial of qigong (Chaoyi Fanhuan qigong [CFQ]) in patients with fibromyalgia were recently completed. In the present study, a qualitative analysis of comments from the RCT was undertaken using motivation and amount of practice to determine whether initial experiences provided information relevant to outcomes. Intervention: Participants in the RCT received instruction in qigong (level 1 CFQ), practiced 45 min/day for 8 weeks and continued practice to 6 months; open-ended qualitative comments on experiences were invited at 8 weeks and 4 and 6 months. Extension trial participants received further instruction (level 2 CFQ) and practiced regularly for 8 weeks-6 months. Comments from the original RCT were considered as narratives for the extension trial subgroup (n=20) and thematically, according to amount of practice, for all participants who completed the RCT (n=73). Results: Narrative comments from the RCT for those who completed the extension trial (n=13) and those who withdrew from that trial (n=7) were considered separately. Participants reporting benefits within the first 8 weeks were more likely to maintain practice and report continued benefits at 4-6 months than those who withdrew from the trial. Thematic comments for all who completed the RCT (n=73) were considered in relation to amount of practice (per protocol, intermediate, minimal). Participants who practiced per protocol during the initial 8 weeks (≥5 hours/wk) were more likely to maintain practice over 4-6 months and to report beneficial health effects from qigong. Conclusions: This retrospective qualitative analysis of information collected in an RCT of qigong for fibromyalgia indicates that favorable initial experiences with the practice over 8 weeks predispose to continued practice and more health effects. Future individual trials and meta-analyses of qigong will need to attend to the amount, and potentially quality, of practice undertaken in considering trial outcomes.
    Full-text · Article · Jul 2014 · Journal of alternative and complementary medicine (New York, N.Y.)
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    [Show abstract] [Hide abstract] ABSTRACT: The year 2013–2014 has been designated the Global Year Against Orofacial Pain by the International Association for the Study of Pain. Accordingly, a multidisciplinary Canadian and international group of clinical, research and knowledge-transfer experts attended a workshop in Montreal, Quebec. The workshop had two aims: to identify new pathways for innovative diagnosis and management of chronic orofacial pain states; and to identify opportunities for further collaborative orofacial pain research and education in Canada. Three topics related to chronic orofacial pain were explored: biomarkers and pain signatures for chronic orofacial pain; misuse of analgesic and opioid pain medications for managing chronic orofacial pain; and complementary alternative medicine, topical agents and the role of stress in chronic orofacial pain. It was determined that further research is needed to: identify biomarkers of chronic orofacial post-traumatic neuropathic pain, with a focus on psychosocial, physiological and chemical-genetic factors; validate the short-and long-term safety (ie, no harm to health, and avoidance of misuse and addiction) of opioid use for two distinct conditions (acute and chronic orofacial pain, respectively); and promote the use of topical medications as an alternative treatment in dentistry, and further document the benefits and safety of complementary and alternative medicine, including stress management, in dentistry. It was proposed that burning mouth syndrome, a painful condition that is not uncommon and affects mainly postmenopausal women, should receive particular attention.
    Full-text · Article · Dec 2014 · Pain research & management: the journal of the Canadian Pain Society = journal de la societe canadienne pour le traitement de la douleur