ArticlePDF Available

Psychological, immunological and physiological effects of a Laughing Qigong Program (LQP) on adolescents

Authors:
  • 1.National Taiwan University,Taipei, Taiwan 2. mental health Association in Taiwan
  • 國立台北護理健康大學

Abstract and Figures

One objective of this study was to assess the effects of laughter on the psychological, immunological and physiological systems of the body. Another objective was to introduce the Laughing Qigong Program (LQP), as a method of standardization for simulated laughter interventions. A randomized, prospective, experimental study of the LQP was conducted in a group of adolescents (n=67) in Taiwan. During study-hall sessions, experimental subjects (n=34) attended the LQP for eight-weeks. Simultaneously, control subjects (n=33) read or did their homework. All subjects were tested before and after the intervention on the following: Rosenberg Self-Esteem scale (RSE), Chinese Humor Scale (CHS) and Face Scale (FS) as psychological markers; saliva cortisol (CS) as an immunological marker; blood pressure (BP), heart rate (HR), and heart rate variability (HRV) as physiological markers of the body's response to stress. Mood states (FS) were measured before/after each LQP session. Mood states (p=.00) and humor (p=.004; p=.003) improved in the experimental group; no significant changes were found in the controls (p=69; p=60). The immunological marker of stress, cortisol levels, decreased significantly for those who participated in the LQP (p=.001), suggesting lower levels of stress after completion of the program. The LQP is a non-pharmacological and cost-effective means to help adolescents mitigate stresses in their everyday life.
Content may be subject to copyright.
Complementary
Therapies
in
Medicine
(2013)
21,
660—668
Available
online
at
www.sciencedirect.com
ScienceDirect
j
ourna
l
ho
me
pa
g
e:
www.elsevierhealth.com/journals/ctim
Psychological,
immunological
and
physiological
effects
of
a
Laughing
Qigong
Program
(LQP)
on
adolescents
Chueh
Chang
a
,
Grace
Tsai
a,
,
Chia-Jung
Hsieh
b
a
National
Taiwan
University,
Institute
of
Health
Policy
and
Management,
Taiwan
b
National
Taipei
University
of
Nursing
and
Health
Science,
College
of
Nursing,
Taiwan
Available
online
13
September
2013
KEYWORDS
Laughter;
Humor;
Adolescent
health;
Qigong;
Stress;
Coping;
Mood
states
Summary
Objectives:
One
objective
of
this
study
was
to
assess
the
effects
of
laughter
on
the
psycholog-
ical,
immunological
and
physiological
systems
of
the
body.
Another
objective
was
to
introduce
the
Laughing
Qigong
Program
(LQP),
as
a
method
of
standardization
for
simulated
laughter
interventions.
Design:
A
randomized,
prospective,
experimental
study
of
the
LQP
was
conducted
in
a
group
of
adolescents
(n
=
67)
in
Taiwan.
During
study-hall
sessions,
experimental
subjects
(n
=
34)
attended
the
LQP
for
eight-weeks.
Simultaneously,
control
subjects
(n
=
33)
read
or
did
their
homework.
All
subjects
were
tested
before
and
after
the
intervention
on
the
following:
Rosen-
berg
Self-Esteem
scale
(RSE),
Chinese
Humor
Scale
(CHS)
and
Face
Scale
(FS)
as
psychological
markers;
saliva
cortisol
(CS)
as
an
immunological
marker;
blood
pressure
(BP),
heart
rate
(HR),
and
heart
rate
variability
(HRV)
as
physiological
markers
of
the
body’s
response
to
stress.
Mood
states
(FS)
were
measured
before/after
each
LQP
session.
Results:
Mood
states
(p
=
.00)
and
humor
(p
=
.004;
p
=
.003)
improved
in
the
experimental
group;
no
significant
changes
were
found
in
the
controls
(p
=
69;
p
=
60).
The
immunological
marker
of
stress,
cortisol
levels,
decreased
significantly
for
those
who
participated
in
the
LQP
(p
=
.001),
suggesting
lower
levels
of
stress
after
completion
of
the
program.
Conclusions:
The
LQP
is
a
non-pharmacological
and
cost-effective
means
to
help
adolescents
mitigate
stresses
in
their
everyday
life.
©
2013
The
Authors.
Published
by
Elsevier
Ltd.
Corresponding
author
at:
National
Taiwan
University,
Institute
of
Health
Policy
and
Management,
Room
#
622,
No.
17,
Hsu-Chow
Road,
Taipei
100,
Taiwan,
ROC.
Tel.:
+886
2
33668061;
fax:
+886
2
23949769.
E-mail
addresses:
chueh@ntu.edu.tw
(C.
Chang),
grtsuyuki@gmail.com
(G.
Tsai),
chiajung@ntunhs.edu.tw
(C.-J.
Hsieh).
0965-2299
©
2013
The
Authors.
Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.ctim.2013.09.004
Open access under CC BY-NC-SA license
.
Open access under CC BY-NC-SA license
.
Psychological,
immunological
and
physiological
effects
of
LQP
661
Background
In
2005,
the
World
Health
Organization
(WHO)
acknowledged
that
‘‘there
is
no
health
without
mental
health’’.
1
Embrac-
ing
the
WHO
mandate,
this
study
investigates
a
new
mental
health
promotion
plan
developed
in
Taiwan:
the
Laughing
Qigong
Program
(LQP).
The
LQP
is
based
on
findings
in
two
fields:
positive
psychology
2
and
psychoneuroimmunology.
3
These
two
fields,
focusing
on
positive
mental
health
and
the
effects
of
emotions
on
physiology,
respectively,
have
engendered
a
new
field
of
research:
gelotology,
4
the
study
of
laughter.
Gelotology
examines
the
notion
that
laughter
attenuates
biochemical
markers
of
stress
in
the
body.
5—7
Literature
review
Comprehensive
reviews
8—11
investigating
the
link
between
humor
and
health
make
distinctions
between
humor
and
laughter.
Martin
9
and
Bennett
and
Lengacher,
8
provide
sim-
ilar
definitions:
‘‘Humor
can
be
used
to
refer
to
a
stimulus
(e.g.,
a
comedy
film),
a
mental
process
(e.g.,
perception
of
amusing
incongruities),
or
a
response
(e.g.,
laughter,
exhilaration).’’
Laughter,
however,
is
defined
as
‘‘a
psy-
chophysiological
response
to
humor
that
involves
both
characteristic
physiological
reactions
and
positive
psycho-
logical
shifts.’’
This
area
of
gelotology
not
only
makes
a
clear
distinction
between
humor
and
laughter,
but
goes
further
to
demarcate
‘‘simulated’’
versus
‘‘spontaneous’’
laughter.
10
The
LQP
is
a
‘‘simulated’’
laughter
program
whereby
laugh-
ter
is
self-induced,
with
no
specific
reason.
Humor
and
laughter
as
coping
Studies
have
demonstrated
the
use
of
humor
as
a
cop-
ing
mechanism
in
different
stages
of
life:
lowered
levels
of
stress
for
undergraduates,
12
increased
self-efficacy
for
those
in
the
workplace,
13
and
decreased
pain
for
arthritis
sufferers.
14
However,
the
mechanism
between
humor
and
laughter
is
still
in
its
infancy
and
further
studies
need
to
differentiate
whether
laughter,
irrespective
of
a
humor
stim-
ulus,
can
be
a
viable
means
of
coping.
Psychological
effects
of
laughter
Many
studies
have
investigated
the
psychological
effects
of
laughter:
these
include
mood
states,
15
self-esteem,
16
self-efficacy,
13
and
depression,
17—19
Though
results
are
still
inconclusive,
20,9,11
it
seems
that
positive
mood
states
accom-
panying
laughter
result
in
positive
psychological
effects,
as
well
as
possible
analgesic
or
immunoenhancing
21
effects.
Immunological
effects
of
laughter
Immunological
effects
of
laughter
involve
the
neuro-
physioanatomical
pathway.
22,23
One
hypothesis
is
that
laughter
affects
the
brain
(i.e.,
amygdala,
thalamic,
hypothalamic
and
subthalamic
areas
of
the
dorsal
brain
sys-
tem)
via
the
central
nervous
system
(i.e.,
parasympathetic
and
sympathetic
responses).
Specific
to
the
central
nervous
system,
researchers
have
investigated
various
pathways,
including
the
hypothalamic-pituitary-adrenal
(HPA)
axis,
24
and
the
sympathetic-adrenomedullary
(SAM)
system.
9
The
effects
of
laughter
on
these
systems
include
reductions
in
serum
cortisol
levels.
25,6
Physiological
effects
of
laughter
It
is
hypothesized
that
laughter
decreases
stress
hormones
and
acts
to
buffer
the
effects
of
stress
on
the
cardiovascular
system.
26
Studies
have
argued
that
vigorous
laughter
can
produce
heat,
sweat
and
stress
relief
similar
to
the
results
of
aerobic
exercise.
27
These
cardiovascular
changes
have
been
investigated
via
blood
pressure
(BP),
26,28,29
and
in
particular
the
vascular
endothelium.
28
Other
studies
have
investigated
heart
rate
(HR)
and
heart
rate
variability
(HRV).
Little
effect
was
seen
on
HR,
30
but
strong,
if
transient,
effects
on
HRV
were
observed.
31
Qigong
Qi
(pronounced
‘‘chee’’)
can
be
translated
loosely
as
‘‘life
force.’’
All
living
things
are
considered
to
possess
qi,
a
field
of
energy
in
and
around
the
body.
Qigong
is
a
term
for
various
disciplines
believed
to
improve
qi
through
body
movements,
calming
the
mind,
and
atten-
tion
to
breathing.
Currently,
it
is
reported
that
more
than
100
million
people
practice
qigong
in
China,
32,33
and
many
more
practice
around
the
world
to
treat
a
host
of
diseases
and
ailments:
cancer,
34,35
fibromyalgia,
36
psy-
chological
symptoms,
37
mood,
38
cardiopulmonary
effects,
39
lung
functioning,
40
and
BP.
41
Laughing
qigong
The
LQP
is
a
combination
of
qigong
techniques
and
simulated
laughter
with
a
focus
on
the
mind
and
body
connection.
It
is
based
on
three
sets
of
principles:
1)
Chinese
medicine
(i.e.,
yin/yang
theory,
qi,
and
meridian
and
organ
functions);
2)
Qigong
(i.e.,
relaxation,
core
strength,
deep
diaphragmic
breathing);
and
3)
Positive
psychology
(i.e.,
one
can
choose
how
to
react
to
situations
or
events).
The
LQP
is
comprised
of
four
stages
(refer
to
Appendix
I),
with
the
third,
‘‘Transformation,’’
stage
being
comprised
of
two
parts:
the
stating
of
emotions
and
simulated
laugh-
ter.
An
increased
awareness
of
emotions
and
current
mood
states
is
elicited
through
the
‘‘stating’’
and
it
is
believed
that
negative
mood
states
can
be
‘‘transformed’’
through
simulated
laughter.
Participants
are
taught
to
accept
neg-
ative
emotional
states
and,
rather
than
feeling
helpless
or
overwhelmed,
actively
engage
in
transforming
them
inter-
nally
and
while
in
the
company
of
others
in
the
LQP
group.
Social
support
is
propagated
because
participants
realize
that
they
are
not
alone
in
feeling
their
negative
emotions.
By
providing
a
safe
context
for
releasing
emotions,
and
then
transforming
them
in
a
group
setting,
the
LQP
process
gen-
erates
a
sense
of
empowerment.
The
LQP
has
been
conducted
in
many
communities
(e.g.,
cancer
groups,
elderly
centers)
in
Taiwan
for
the
past
15
years.
It
is
a
mental
health
promotion
program
drawing
on
both
Eastern
and
Western
paradigms.
662
C.
Chang
et
al.
Laughter
programs
around
the
world
Many
studies
have
been
conducted
recently
around
the
world,
42,10
investigating
simulated
laughter
programs.
From
Tehran
18
to
Canada
23
to
Korea,
19
researchers
are
just
begin-
ning
to
investigate
the
healing
effects
of
laughter
on
the
body
and
mind.
Though
gelotology
is
still
in
its
infancy,
laughter
programs
have
garnered
world-wide
popularity,
particularly
the
Laughter
Club
movement
(Laughter
Yoga).
43
One
objective
of
this
article
is
to
introduce
an
innovative
simulated-laughter
program,
the
LQP,
and
address
some
of
the
weaknesses
of
previous
studies
(e.g.,
nonexistent
con-
trol
groups,
lack
of
standardized
baseline
measures,
etc.)
Adolescents
This
study
relates
to
adolescence,
a
stage
of
life
often
marked
by
anxiety
44
and
fluctuating
mood
states,
45
and
suggests
that
a
laughter
program
can
reduce
associated
stresses.
During
adolescence,
a
time
when
coping
strate-
gies
and
personality
traits
are
being
formed,
46
the
LQP
can
teach
positive
coping
skills
to
deal
with
stressors
particu-
lar
to
adolescence,
such
as
examination
stressors
and
the
increased
need
to
belong
to
peer
groups.
Study
goals
The
aim
of
this
study
was
to
present
a
standardized,
inno-
vative
protocol
for
laughter
interventions
and
to
assess
the
effects
of
the
LQP,
on
the
psychological,
immunological
and
physiological
systems
of
the
body.
Methods
Participants
Participants
were
students
recruited
from
a
public
junior
high
school
in
Taipei,
Taiwan.
Tw o
7th
grade
classes
(n
=
67)
were
chosen
to
participate
as
the
experimental
(n
=
34)
and
control
(n
=
33)
groups.
The
experimental
group
had
18
females
and
16
males;
the
control
group
included
15
females
and
18
males.
Informed
consent
was
obtained
from
both
students
and
parents.
The
study
was
approved
by
an
institutional
review
board.
Participants
were
to
be
excluded
if
past
health
records
from
their
school
folders
indicated
a
medical
diagnosis
of
severe
mental
disorders
or
history
of
substance
abuse.
These
two
criteria
were
chosen
since
a
previous
diagnosis
of
severe
mental
disorders
could
confound
results
of
the
psychologi-
cal
effects
of
the
LQP
and
a
history
of
substance
abuse
could
confound
effects
of
immunological
or
physiological
effects.
Evaluations
were
based
only
on
medical
records
in
the
stu-
dent’s
academic
folders,
however,
and
were
not
directly
asked
of
participants.
None
of
the
participants
met
these
exclusion
criteria.
The
defining
factor
for
participant
inclusion
was
the
time
frame
in
which
the
student
could
engage
in
LQP,
based
on
school
schedules.
The
review
of
gelotology
did
not
find
demographic
characteristics
(e.g.,
SES,
age,
marital
status
etc.)
correlated
with
a
propensity
to
laugh
and
thus
such
factors
were
not
surveyed.
This
may
be
considered
a
lim-
itation
of
the
study
and
future
studies
should
include
a
demographic
survey.
Procedure
A
prospective,
experimental/control
group
design
was
employed,
and
quantitative
and
qualitative
data
were
col-
lected
over
a
two-month
period
(April
and
May)
for
a
total
of
eight
sessions.
During
‘‘study-hall’’
time
(45
min),
the
experimental
group
participated
in
the
LQP
(Appendices
I
and
II),
while
the
control
group
simply
read
books
or
did
their
homework.
Thus,
the
LQP
protocol
consisted
of
one-
hour
sessions
once
a
week
for
8
weeks,
of
which
45
min
was
the
LQP
intervention
and
15
min
consisted
of
data
collec-
tion.
During
the
first
and
the
final
sessions,
both
groups
were
asked
to
complete
psychological
measures
and
sub-
mit
to
BP
measurements,
HR
measurements,
saliva
cortisol
assessments
and
HRV
analysis.
In
the
intervening
sessions,
only
the
experimental
group
completed
the
Face
Scale
(FS),
before
and
after
the
LQP
(refer
to
Fig.
1).
Measures
Psychological
measures
Rosenberg’s
Self-Esteem
Scale
(RSE;
47
)
is
a
10-item
mea-
surement
of
self-esteem
with
high
internal
consistency
ranging
from.86
to.93
48
and
test-retest
reliability
over
a
2-week
period
of.85.
49
Higher
scores
on
the
RSE
indicate
higher
self-esteem.
A
Chinese
translation
of
the
RSE
was
used
in
this
study.
The
Chinese
Humor
Scale
(CHS)
is
a
30-item
measure-
ment
which
assesses
four
dimensions
(subscales)
of
humor:
a)
creativity;
b)
tendency;
c)
perceptivity
and
d)
attitude
(refer
to
Appendix
II).
Humor
creativity
(HC)
measures
the
ability
to
use
humor
creatively
or
in
novel
situations.
Humor
tendency
(HT)
assesses
the
ability
to
laugh
or
find
humor
in
situations
where
others
may
not.
Humor
perceptivity
(HP)
assesses
perceptions
of
humor
in
oneself
and
others.
Humor
attitude
(HA)
measures
attitudes
regarding
humor
and
mood
states.
The
CHS
uses
a
Likert
4-point
response
from
‘‘never’’
to
‘‘always’’,
with
higher
scores
indicating
an
increased
abil-
ity
to
use
humor
to
mitigate
the
stresses
of
everyday
life.
Internal
consistency
Cronbach’s-alpha
reliability
coefficient
is.93
and
alpha
coefficients
for
each
of
the
four
factors
range
from
.76
to
.94.
50
The
Face
Scale
(FS)
measures
current
mood.
It
is
a
pic-
torial
array
of
20
faces
arranged
in
sequence,
from
the
most
positive
mood
(1
point)
to
the
most
negative
mood
(20
points).
Inter-rater
reliability
and
construct
validity
have
all
been
assessed
(r
=
0.81;
51
).
The
FS
has
become
widely
accepted
and
is
an
effective
nonverbal
method
for
con-
veniently
assessing
moods.
52
Measurements
promptly
after
LQP
prevented
recall
bias.
Immunological
measures
Enzyme
link
immunoassays
(saliva
cortisol
samples)
were
collected
by
two
medical
technologists
using
cotton
swab
extraction.
Subjects
kept
cotton
wads
in
their
mouths
for
two
minutes,
after
which
samples
were
evaluated
using
an
enzyme-linked
immunosorbent
assay
(ELISA).
53
Psychological,
immunological
and
physiological
effects
of
LQP
663
Baseline
Intervention
Pos
t-I
ntervention
Alloca
ted to LQ
P Intervention
Participants given anonymous
ID
.
Two 7
th
grade classrooms identified
Informed co
nsent forms signed by parents
and
studen
ts
A
dole
sce
nt partic
ipan
ts
(n=67
)
Experi
mental Group (n
= 34
)
Baseline
questionnaires
completed
(RSE,
CH,
C
ortisol, BP
and HRV assessed
)
Cont
rol grou
p (n
= 33)
Baseline questionnaires completed (RSE,
CH, Cortisol, BP
an
d HRV assess
ed )
LQP for Experimental group
(n = 34
)
Face Sc
ale
(FS)
co
mpleted be
fore and
after
each LQP ses
sion
Exper
imen
tal
group
Post Questionnaires completed (n = 34)
(RSE, CH,
Cort
isol, BP
and
HRV
reassess
ed)
Control group
Post Qu
estionn
aires complet
ed (n = 33
)
(RSE,
CH,
Cortiso
l,
BP
and
HRV
rea
ssess
ed)
Fig.
1
LQP
study
protocol.
Physiological
measures
Blood
pressure
(BP)
and
Heart
Rate
Variability
(HRV).
Systolic
(SYS)
and
diastolic
(DIA)
pressure
and
HRV
were
measured
with
the
right
arm
in
the
supine
position
using
an
autonomic
nervous
system
wristwatch
(ANSWatch,
ITRI
Taiwan
Science
Co).
All
participants
were
instructed
to
remain
absolutely
still
for
7
min.
HRV
rates
were
measured
in
high-frequency
(HF)
and
low-frequency
(LF)
components,
and
the
ratio
LF/HF
was
calculated.
The
HF
component
reflects
parasympathetic
activity
and
LF
reflects
both
sym-
pathetic
and
parasympathetic
tone.
54
Statistical
analysis
Statistical
analyses
were
performed
using
SPSS
version
17.0
for
Windows.
Paired
t-tests
were
conducted
to
assess
differ-
ences
before
and
after
the
LQP;
ANCOVA
was
used
to
account
for
pre-test
scores
and
control
for
the
possible
effect
of
gen-
der
in
the
psychological,
immunological
and
physiological
measures.
Results
Psychological
measures
After
completing
eight
sessions
of
the
LQP,
experimental
and
control
groups
were
compared
using
four
psychologi-
cal
measures:
self-esteem
(RSE),
humor
(CHS),
and
mood
states
(FS).
Mean
CHS
scores
significantly
increased
in
the
experimental
group
from
78.15
(±19.13)
to
85.27
(±20.00)
after
the
LQP
(p
=
.004)
and
one
of
the
subscales
of
the
CHS,
Humor
Creativity
(HC),
also
showed
a
significant
increase
for
theexperimental
group
from
39.59
(±11.46)
to
44.38
(±12.30)
after
the
LQP
(p
=
.003).
ANCOVA
results
showed
significant
influence
of
the
LQP
on
CHS
(P
=
.01)
and
HC
(P
=
.01).
There
were
no
significant
changes
in
the
control
group
for
any
of
the
psychological
measures.
Mood
states
were
assessed
using
the
FS
after
each
session
(
Table
2)
and
significant
differences
were
observed
in
the
experimental
group
during
sessions
2,
3,
4,
6,
and
7
(p
<
.00).
ANCOVA
results
showed
that
those
who
attended
the
LQP
sig-
nificantly
improved
in
mood
state
(P
=
04;
refer
to
Table
2).
664
C.
Chang
et
al.
Table
1
Experimental
and
control
group:
analysis
of
pre-
and
post-test
scores
of
psychological
measures;
RSE,
CHS,
SS,
FS.
Experimental
(n
=
34)
Control
(n
=
33)
ANCOVA
Pre-test
Post-test
t-test
Pre-test
Post-test
t-test
P
Mean
SD
Mean
SD
p
Mean
SD
Mean
SD
p
RSE
28.24
5.35
27.38
6.13
.283
28.12
6.18
27.70
5.29
.588
.74
CHS
78.15
19.13
85.27
20.00
.004
*
77.94
18.12
76.97
19.84
.686
.01
**
HC
39.59
11.46
44.38
12.30
.003
*
40.79
9.71
40.03
11.50
.596
.01
**
HT
14.41
4.10
15.70
4.08
.058
14.24
4.16
14.21
4.59
.961
.13
HP
11.53
3.53
12.32
3.15
.169
10.73
3.01
11.24
3.29
.359
.36
HA
12.62
3.20
12.59
3.30
.948
12.18
2.96
11.48
3.49
.154
.25
FS
4.62 3.10 4.03
3.42
.335
6.30
5.28
7.09
5.42
.309
.04
**
RSE:
Rosenberg
Self-Esteem
scale;
CHS:
Chinese
humor
scale;
HC:
humor
creativity;
HT:
humor
tendency;
HP:
humor
perceptivity;
HA:
humor
attitude;
FS:
face
scale.
*
Significance
p
<
.05,
paired
t-test.
**
Significance
P
<
.05,
ANCOVA.
There
were
no
significant
changes
in
the
control
group
for
mood
states
(FS).
Immunological
and
physiological
measures
Cortisol
showed
significant
differences
between
pre-test
48.35
(±12.53)
to
38.50
(±13.10)
and
post-test
levels
(p
=
.001)
in
the
experimental
group.
ANCOVA
results
show
a
borderline
significant
result
with
a
P-value
of.058.
There
were
no
significant
changes
in
cortisol
levels
in
the
con-
trol
group
(Table
3).
Paired
t-tests
did
detect
significant
differences
between
pre-test
and
post-test
levels
for
HF
(63.68
±
9.11
to
55.24
±
12.90;
p
=
.007);
LF
(36.32
±
9.11
to
44.76
±
12.90;
p
=
.007)
and
LF/HF
ratios
(.610
±
.274
to
942
±
745;
p
=
.036)
in
the
control
group
(Table
3).
This
will
be
discussed
below.
Discussion
This
study
was
designed
to
determine
the
effects
of
the
LQP
on
a
group
of
junior
high
school
students.
Mood
states
and
humor
improved
in
the
experimental
group,
while
they
showed
no
significant
changes
in
the
control
group.
More-
over,
the
immunological
markers
of
stress,
cortisol
levels,
showed
significant
decreases
for
those
who
participated
in
the
LQP,
suggesting
lower
levels
of
stress
after
completion
of
the
program.
Given
that
the
Transformation
stage
of
the
LQP
consists
of
stating
of
emotions
and
simulated
laughter,
it
is
difficult
to
determine
which
aspect
dominated
the
effects.
Research
has
shown
that
laughter
affects
the
HPA
axis
by
instigat-
ing
sympathetic
and
parasympathetic
responses
9
;
we
further
hypothesize
that
the
act
of
‘‘stating’’
helps
participants
become
aware
of
their
emotional
states
(i.e.,
psychologi-
cal
effect)
and
that
simulated
laughter
generates
heat
in
the
body
(i.e.,
physiological
and
immunological
effects).
Unfortunately,
we
do
not
have
the
technology
to
discrim-
inate
between
the
two.
However,
promising
advances
in
the
research
of
vascular
endothelium
28
may
help
to
differentiate
the
effects
of
each
component
of
LQP
in
future
studies.
Psychological
effects
Humor
is
believed
to
benefit
health
through
the
positive
emotional
states
accompanying
laughter.
Our
results
showed
significant
increases
in
mood
states
immediately
after
com-
pleting
the
LQP
for
every
session
except
one
(refer
to
Table
2)
as
well
as
significant
improvements
in
mood
over
the
span
of
the
experiment.
These
findings
support
other
studies,
55,25,56
that
have
found
improved
mood
states
after
engaging
in
laughter.
After
completion
of
the
LQP,
the
experimental
group
showed
significant
increases
in
humor
scores
and
in
par-
ticipants’
abilities
to
find
humor
in
creative
new
ways
or
situations.
Those
in
the
control
group
showed
no
significant
Table
2
Mean
differences
for
mood
states
(FS)
in
the
experimental
group
for
each
session.
Session
2
3
4
5
6
7
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Pre-test
FS
4.96
2.43
5.76
3.87
5.18
3.18
4.29
3.04
4.53
3.39
5.44
3.71
Post-test
FS
2.86
1.78
3.15
2.27
3.68
3.14
4.09
3.18
2.97
2.89
2.85
2.44
Paired
t-test
p
.00
*
.00
*
.01
*
.69
*
.00
*
.00
*
FS:
face
scale.
*
Significance
p
<
.05.
Psychological,
immunological
and
physiological
effects
of
LQP
665
Table
3
Experimental
and
control
group:
analysis
of
pre-
and
post-test
scores
of
immunological
and
physiological
measures;
CS,
SYS,
DIA,
HR,
HRV,
HF,
LF,
LF/HF.
Experimental
(n
=
34)
Control
(n
=
33)
ANCOVA
Pre-test
Post-test
t-test
Pre-test
Post-test
t-test
P
Mean
SD
Mean
SD
p
Mean
SD
Mean
SD
p
CS
48.35 12.53 38.51 13.13 .001
*
36.47 14.53
35.87
14.01
.677
.058
SYS
124.34
24.25
119.91
14.03
.261
112.87
11.97
113.19
17.55
.929
.314
DIA
78.22
11.10
80.22
8.21
.374
78.94
8.14
76.19
12.29
.366
.147
HR
89.47
14.12
85.69
11.58
.206
88.48
16.36
87.48
13.15
.775
.547
HRV
209.82
140.36
178.91
183.42
.389
253.90
160.67
247.77
189.66
.883
.234
HF
62.06
7.1
57.42
13.47
.102
63.93
9.17
54.73
12.99
.004
*
.458
LF
38.09
7.1
43.03
13.49
.075
36.07
9.17
45.27
12.98
.004
*
.534
LF/HF
.64
.22
.85
.56
.073
.61
.28
.99
.75
.015
*
.431
Immunological
measure:
CS:
cortisol;
Physiological
measures:
SYS:
systolic
blood
pressure;
DIA:
diastolic
blood
pressure;
HR:
heart
rate;
HRV:
heart
rate
variability;
HF:
high
frequency
levels;
LF:
low
frequency
levels;
LF/HF:
low
frequency/high
frequency
ratio.
*
Significance
p
<
.05,
paired
t-test.
changes
in
humor
scores.
These
results
suggest
that
those
who
attended
LQP
were
able
to
increase
their
ability
to
laugh
by
finding
humor
in
new
ways
and
use
to
use
simulated
laughter
as
a
means
to
reduce
stress.
The
‘‘stress-moderator
theory’’
9
contends
that
stress
depends
upon
cognitive
appraisal
of
events
and
on
cop-
ing
skills.
Those
with
a
better
sense
of
humor
seem
to
frame
more
positive
appraisals.
The
LQP
appears
to
engen-
der
humor
as
a
stress
moderator,
providing
participants
with
a
coping
strategy
and
a
means
to
relieve
embar-
rassing
situations.
A
secondary
effect
of
the
LQP
is
to
provide
social
support.
Humor
is
commonly
cited
in
laughter
research
as
going
hand-in-hand
with
social
support,
resulting
in
stress-buffering
and
health-enhancing
effects,
57,13
When
participants
could
actively
voice
their
current
mood
states
individually
and
in
the
context
of
a
group,
social
support
was
prompted.
By
meeting
continuously
for
8
weeks,
par-
ticipants
began
to
feel
more
comfortable
voicing
current
moods
and
transforming
them
in
a
group
context.
It
is
worthy
to
note,
however,
that
there
were
only
lim-
ited
significant
changes
in
the
indexes
of
Table
1
(refer
to
Table
1):
RSE,
HT,
HP
and
HA
showed
no
significant
changes.
One
explanation
may
be
that
self-esteem
(RSE)
is
an
endur-
ing,
stable
personality
trait
46
which
takes
more
time
and
exposure
to
the
intervention
to
change.
Moreover,
compo-
nents
of
humor
such
as
HT,
HP
and
HA
are
also
more
stable
traits
and
perhaps
the
current
8-week
intervention
only
had
a
‘‘low-dose’’
effect.
Future
studies
may
focus
on
a
longer
intervention
with
more
sessions
during
each
week.
Immunological
effects
The
present
study
found
lowered
levels
of
cortisol
for
LQP
participants
and
no
significant
changes
were
found
in
the
control
group.
These
immunological
effects
are
similar
to
those
described
by
Toda
and
Ichikawa,
25
who
found
that
‘‘laughter,
particularly
in
young
people,
may
relieve
stress
(p.
496).’’
During
adolescence,
a
time
when
peer
influence
is
at
its
greatest,
an
increase
in
‘‘social
identification’’
is
one
of
the
strongest
factors
indicating
why
laughter
can
be
a
viable
means
of
increasing
social
support.
58
A
shared
laugh
during
the
upheavals
and
differing
mood
states
of
adoles-
cence
can
go
a
long
way
toward
making
a
teenager
feel
a
sense
of
belonging
and
thus
toward
reducing
stress.
Physiological
effects
This
study
examined
BP,
HR
and
HRV
as
physiological
indica-
tors.
There
were
no
significant
changes
in
these
variables
for
the
experimental
group.
However,
there
were
unex-
pected
significant
changes
in
the
control
group
for
HRV,
HF,
LF
and
LF/HF
ratios.
Given
the
constraints
of
the
envi-
ronment
(i.e.,
administration-approved
time
periods
in
the
school
day),
the
control
group
may
have
been
engaging
in
stress-relieving
activities
such
as
reading
or
writing.
It
can
be
argued
that
‘‘down
time’’
for
the
control
group
was
also
stress-relieving.
In
the
fields
of
public
health
and
social
sciences
this
issue
is
not
uncommon.
Fitzpatrick
and
colleagues
59
note,
‘‘But
public
health
interventions
can
rarely
replicate
the
controlled
environment
of
the
clinic.
.
.
maintaining
pure
control
groups
without
cross-
contamination
may
be
impossible
or
impractical.
.
.
(p.
9)’’.
In
this
particular
case,
‘‘cross-contamination’’
could
have
occurred
during
the
experimental
protocol.
While
admin-
istering
the
physiological
measures,
experimental
subjects
were
prohibited
from
speech
or
movement
for
over
7
min.
This
proved
difficult
for
some
subjects.
These
factors
could
explain
the
unexpected
results
in
the
control
group.
Limitations
First,
the
size
of
this
study
was
relatively
small
(experimen-
tal
n
=
33;
control
n
=
34),
so
generalizations
to
the
general
population
are
difficult.
Future
studies
may
focus
on
sur-
veying
demographic
variables
and
seeing
if
they
moderate
the
effects
of
the
LQP.
Second,
this
study
did
not
include
a
follow-up
to
evaluate
long-term
effects.
Finally,
cortisol
lev-
els
were
only
measured
once
a
day
due
to
time
constraints
of
students’
schedules,
but
future
studies
should
consider
measurements
throughout
the
day.
60
Given
the
unexpected
666
C.
Chang
et
al.
results
of
the
control
group
in
this
study,
the
suggestion
for
two
control
groups,
9,42
seems
astute,
in
the
context
of
future
studies.
Conclusion
This
study
provides
the
field
of
gelotology
with
an
innovative
new
mental
health
promotion
program.
The
LQP
is
offered
as
a
standardized
laughter
therapy
protocol
which
can
facil-
itate
cross-study
comparisons
in
future
research.
Martin
9
noted,
‘‘the
need
for
researchers
to
address
questions
of
how
much
laughter,
of
what
intensity
and
for
how
long
it
is
needed
to
produce
various
physiological
effects.’’
The
present
study
provides
a
good
starting
point
for
narrowing
quantitative
parameters
for
simulated
laughter
programs.
Based
on
this
study,
a
minimum
of
at
least
1
session
per
week,
for
at
least
20
min
and
at
an
intensity
that
would
elicit
deep
abdominal
breathing,
is
recommended
as
a
baseline
for
realizing
benefits.
Those
in
clinical
medicine
(e.g.,
physicians,
school
nurses,
etc.)
are
often
the
‘‘first
responders’’
when
an
adolescent
seeks
help
with
mental
health
issues
(often
via
psychosomatic
complaints).
Given
the
increasing
popular-
ity
of
laughter
programs
worldwide,
more
patients
may
now
be
willing
to
try
laughter
as
an
alternative
means
of
stress
relief.
Evidence-based
studies
are
greatly
needed
to
ensure
that
health
care
practitioners
can
confidently
recommend
this
treatment.
Unpredictable
mood
states
during
adolescence
seem
uni-
versal;
changes
in
the
body
go
hand-in-hand
with
fluctuating
hormones
and
the
increased
importance
of
peer
opinions.
Alternative
and
complementary
treatments
such
as
the
LQP
provide
non-invasive,
non-pharmacological
means
of
man-
aging
these
transitions,
simultaneously
moderating
stress
levels
and
providing
social
support
through
the
simple
act
of
sharing
a
good
laugh.
Author’s
contributions
CC
was
responsible
for
the
concept,
design
and
supervision
of
the
study,
and
was
the
guarantor
for
the
paper.
GT
did
the
statistical
analysis
and
prepared
the
first
and
all
subsequent
drafts.
CH
gave
advice
on
the
statistical
analysis,
helped
with
preparation
of
figure
and
revised
final
draft.
Disclosure
statement
No
competing
financial
interests
exist.
Acknowledgements
‘‘In
loving
memory
of
Master
Kao
for
creating
and
teach-
ing
Laughing
Qigong.’’
Funding
provided
by
National
Science
Council,
Taipei,
Taiwan
(Grant
NSC-97-2511-S-002-002-MY3).
Special
thanks
to
Yu
Hwa
Lin
for
her
dedication
to
teaching
LQP
to
people
around
the
world.
Appendix
A.
Laughing
Qigong
Program
(LQP)
Protocol
Warm-up
stage
(2
3
minutes):
The
goal
of
this
stage
is
to
loosen
and
stretch
the
muscles
of
the
body
and
mentally
prepare
for
laughter
exercises.
Participants
are
starting
to
‘‘clear
and
clean’’
(qing,
ganjing)
their
bodies
of
thoughts
and
‘‘toxic’’
qi.
Participants
stretch
forward
to
touch
their
ankles
with
hands
crossed,
slowly
stretch
upwards,
yawn
and
then
rest.
This
stage
is
similar
to
stretching
when
rising
from
bed
in
the
morning.
Repeat
3
times.
RenMai
-
DuMai
stage
(3
4
minutes):
The
goal
of
this
stage
is
to
generate
warmth
in
the
body.
The
RenMai
-
DuMai
stage
is
based
on
the
Chinese
meridians
known
as
the
Ren
conception
vessel
(starts
from
perineum,
up
in
front
of
torso,
to
area
of
lower
lip)
and
the
Du
govern-
ing
vessel
(starts
from
the
tip
of
the
coccyx,
up
along
the
spinal
column,
over
the
head
and
ending
at
the
upper
lip).
The
focus
of
this
stage
is
deep
breathing
from
the
dantian
(1.5
cm
below
navel)
also
known
as
diaphragmic
breath-
ing.
Participants
stretch
forward,
tucking
the
chin
towards
the
chest,
and
then
back
pushing
the
abdomen
forward.
While
stretching
upwards
they
start
laughing
and
making
‘‘ha-ha’’
sounds.
Other
sounds
are
also
emitted
(‘‘Yi’’,
‘‘Wu’’,
‘‘Ou,’’
‘‘Ah,’’
and
‘‘E’’)
in
accordance
with
the
five
Chinese
meridians
(Spleen/Stomach,
Lung,
Kidney,
Liver
and
Heart).
Chinese
medicine
believes
that
ailments
are
caused
by
energy
blockages
which
create
disharmony
and
imbalance
in
the
body.
By
emitting
sounds,
one
can
aid
in
the
healing
of
blocked
meridians
because
these
sounds
emit
an
‘‘energy’’
which
can
help
heal
the
body.
By
giving
voice
to
these
blocked
energies,
one
is
able
to
help
release
pent-up
energy
systems.
Each
sound
is
emit-
ted
3
times:
the
1
st
time
for
1-2
seconds
fairly
quickly;
the
2
nd
time,
3-5
seconds,
still
quick;
and
the
3
rd
time
for
8
seconds,
more
slow
and
drawn
out.
The
3
rd
time
the
sound
is
made,
the
syllable
is
much
longer,
almost
similar
to
mantra
chanting.
The
duration
and
speed
is
also
depen-
dent
on
individual
tempo;
if
one
is
too
tired,
slow
down
the
speed.
This
‘‘release’’
is
also
a
major
component
of
the
next
stage,
the
Transformation
stage.
Transformation
stage
(10
minutes):
The
goal
of
this
stage
is
physical
movement,
exercise
of
the
body
and
trans-
formation
of
negative
energy
(qi)
into
positive
energy.
Participants
are
asked
to
release
bottled
up
emotions
by
starting
with
feeling
‘‘cold’’
in
the
body.
By
stating,
‘‘I’m
cold!’’
or
‘‘I’m
angry!’’
or
‘‘I’m
afraid!’’
partici-
pants
simulate
a
temper
tantrum
with
stomps,
shivers,
and
screams,
and
then
stretch
arms
overhead
and
shout
‘‘ha’’
releasing
energy
upwards.
Interspersed
are
‘‘ha-
ha’’
sounds
and
laughing.
During
this
stage,
participants
are
asked
to
‘‘transform’’
their
current
mood
states.
Not
only
does
this
offer
a
positive
means
to
deal
with
emotions
such
as
anger,
frustration,
anxiety
or
fear;
it
also
gives
voice
to
one’s
current
mood
states.
Instead
of
‘‘bottling
up’’
or
‘‘pushing
away’’
perceived
‘‘negative’’
emotions;
participants
are
encouraged
to
display
a
whole
range
of
emotions.
Many
times,
participants
shout,
‘‘I’ve
had
enough!’’
‘‘I’m
tired
of
all
this!’’
or
‘‘I’m
so
angry
I
can’t
take
it
anymore!’’
with
much
emotion
and
pent-
up
frustration.
By
giving
participants
a
way
to
vent
in
a
Psychological,
immunological
and
physiological
effects
of
LQP
667
controlled
and
supportive,
they
are
able
to
express
their
emotions
and
realize
that
these
are
just
passing
thoughts;
in
essence,
they
can
be
‘‘laughed’’
away.
The
actual
phys-
ical
gestures
and
simulations
serve
as
a
means
of
active
transformation.
Similar
to
a
car
engine
which
begins
to
motor,
one
actively
‘‘motors’’
the
negative
mood
states
into
positive
energy
through
self-induced
laughter.
There-
after,
participants
laugh
for
2
3
minutes
continuously.
After
laughing,
participants
take
deep
breaths
from
the
dantian
and
rest.
During
this
stage,
participants
take
turns
coming
to
the
center
of
the
circle
to
lead
the
group.
Cool-down
stage
(5
minutes):
The
goal
of
this
stage
is
to
cool
down
the
body
and
mind,
and
close
with
a
tai-chi
self-
massage
(sweeping
the
hands
over
the
arms
and
legs
and
simulating
‘‘washing’’
the
face)
or
meditation.
In
addi-
tion,
this
stage
ends
with
all
participants
going
around
and
thanking
other
participants
with
a
‘‘ha’’
as
each
par-
ticipant
claps
hands.
Not
only
is
there
a
formal
way
of
ending
the
LQP
session,
but
in
essence,
the
closing
offers
a
chance
for
participants
to
feel
that
they
are
part
of
social
group.
A.1.
LQP
Fundamental
Tenets
The
LQP
requires
three
changes
to
be
successfully
imple-
mented:
Changes
in
the
Body
Opening
&
Stretching:
Goal:
Stretch
tendons,
ligaments
and
muscles
in
order
for
qi
to
flow.
Changes
in
Physiological
States
of
the
Body
Through
Laughter:
Goal:
Release
‘‘toxic’’
qi
and
cleanse
the
body
and
spirit.
Changes
in
the
Mind
Deep
Sighing,
Yawning
&
Letting
Go:
Goal:
Letting
go
of
mental
attachments
and
relaxing
the
body
and
mind.
Appendix
B.
Supplementary
data
Supplementary
data
associated
with
this
article
can
be
found,
in
the
online
version,
at
http://dx.doi.org/10.1016/
j.ctim.2013.09.004
.
References
1.
World
Health
Organization.Amendment
to
constitution:
51st
world
health
assembly.
2005.
2.
Seligman