How Can Alternative Exercise Traditions Help Against the Background of the COVID-19 in Cancer Care? An Overview of Systematic Reviews

Abstract

Purpose
To evaluate the quality of systematic reviews/meta-analyses (SR/MAs) on alternative exercise traditions in cancer care.

Methods
PubMed, Cochrane Library, Web of Science, Ovid, EBSCOhost, WanFang Database, China National Knowledge Infrastructure, and VIP Database were searched from their inception to June 30, 2020. The search used a combination of subject words and free words. The search terms included “Tai Chi,” “Qigong,” “Baduanjin,” “Yoga,” “Pilates,” “Cancer,” “Meta-analysis,” and “Systematic review.” Two researchers independently performed literature screening and data extraction and used AMSTAR scale and PRISMA statement to evaluate the methodology and the quality of the evidence.

Results
A total of 26 SR/MAs were included. The AMSTAR scale score was 5–10 points, with an average of 7.46±1.33 points. Overall, the methodological quality was considered to be moderate. The PRISMA list score was 13–24 points, with an average of 19.19±2.86 points. Among the papers evaluated, eight reports were relatively complete. A total of 15 papers indicated certain defects. A total of three papers showed relatively serious information defects.

Conclusion
Relative to the control group, alternative exercise traditions may be effective in improving the quality of life, anxiety, depression, distress, and fatigue of cancer patients. However, they may not necessarily improve patients’ sleep outcome, body mass index, and pain. During convalescence, cancer patients can be encouraged to start engaging in physical exercise, and professionals can develop appropriate exercise alternatives to ensure the expected effect of exercise while ensuring the safety of patients. The methodological quality of the systematic evaluations of the intervention effects of alternative exercise traditions on cancer patients is not satisfactory. Hence, focus should be directed to the improvement of the preliminary design scheme, publication status, literature retrieval, conflict of interest, and other aspects.

Full text

REVIEW
How Can Alternative Exercise Traditions Help
Against the Background of the COVID-19 in
Cancer Care? An Overview of Systematic
Reviews
This article was published in the following Dove Press journal:
Cancer Management and Research
Yang Zhang
1
Fang Yao
1
Xiaohong Kuang
1
Lijuan Li
1
Lihua Huang
1
Qi Zhou
1
Jiazhu Peng
1
Qingyu Chang
2
1
Department of Nursing, Zhangjiagang
TCM Hospital Afliated to Nanjing
University of Chinese Medicine, Suzhou
215600, People’s Republic of China;
2
Department of Surgery, Zhangjiagang
TCM Hospital Afliated to Nanjing
University of Chinese Medicine, Suzhou
215600, People’s Republic of China
Purpose: To evaluate the quality of systematic reviews/meta-analyses (SR/MAs) on alter-
native exercise traditions in cancer care.
Methods: PubMed, Cochrane Library, Web of Science, Ovid, EBSCOhost, WanFang
Database, China National Knowledge Infrastructure, and VIP Database were searched
from their inception to June 30, 2020. The search used a combination of subject words
and free words. The search terms included “Tai Chi,” “Qigong,” “Baduanjin,” “Yoga,”
“Pilates,” “Cancer,” “Meta-analysis,” and “Systematic review.” Two researchers indepen-
dently performed literature screening and data extraction and used AMSTAR scale and
PRISMA statement to evaluate the methodology and the quality of the evidence.
Results: A total of 26 SR/MAs were included. The AMSTAR scale score was 5–10 points, with
an average of 7.46±1.33 points. Overall, the methodological quality was considered to be
moderate. The PRISMA list score was 13–24 points, with an average of 19.19±2.86 points.
Among the papers evaluated, eight reports were relatively complete. A total of 15 papers
indicated certain defects. A total of three papers showed relatively serious information defects.
Conclusion: Relative to the control group, alternative exercise traditions may be effective in
improving the quality of life, anxiety, depression, distress, and fatigue of cancer patients.
However, they may not necessarily improve patients’ sleep outcome, body mass index, and
pain. During convalescence, cancer patients can be encouraged to start engaging in physical
exercise, and professionals can develop appropriate exercise alternatives to ensure the
expected effect of exercise while ensuring the safety of patients. The methodological quality
of the systematic evaluations of the intervention effects of alternative exercise traditions on
cancer patients is not satisfactory. Hence, focus should be directed to the improvement of the
preliminary design scheme, publication status, literature retrieval, conict of interest, and
other aspects.
Keywords: alternative exercise traditions, cancer care, COVID-19, overview
Introduction
Cancer is one of the deadliest diseases in the 21st century.
1
It is characterized by
high morbidity, high mortality, high treatment costs, and great difculty in curing.
2
It has become a global public health burden.
3
In the United States alone, nearly
1,685,210 new cancer cases were detected in 2016, and nearly 595,690 people died
of cancer.
4
Although treatment options have progressed well, the incidence and
mortality of cancer are still increasing.
5
Estimates indicate that by 2025, the number
Correspondence: Xiaohong Kuang
Email zjgszyyykxh@aliyun.com
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work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
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Cancer Management and Research Dovepress
open access to scientific and medical research
Open Access Full Text Article

of cancer patients could reach 20 million.
4
Those who
survive cancer may experience persistent difculties,
including treatment side effects and physical, cognitive,
and sociopsychological struggles.
6
The World Health Organization recently declared cor-
onavirus disease 2019 (COVID-19) as a global health
emergency.
7
As malignant tumors and anticancer treat-
ments (such as chemotherapy and surgery) reduce the
immunity of cancer patients, cancer patients are more
susceptible to infection than those who do not have cancer,
and their prognosis is worse.
8
The pandemic has changed
the routine cancer care, and clinicians must adapt and nd
the best way to deliver patient care.
9
In China, alternative
exercise traditions play an important role in the ght
against COVID-19. At the Wuhan Fangcang Hospital,
patients with COVID-19 practiced alternative exercise tra-
ditions, such as Qigong and Tai Chi, under the guidance of
Chinese medicine physicians and nurses.
10
This approach
not only enhances the body’s ability to resist pathogens but
also helps improve the mood of medical staff and patients
and establish condence in jointly defeating the
epidemic.
11
In recent years, the number of related systematic
reviews/meta-analyses (SR/MAs) of alternative exercise
traditions for cancer patients has gradually increased.
However, different SR/MAs have varying outcome indica-
tors, literature quality, analysis methods, and levels of
evidence. In general, the evaluation method is to conduct
a comprehensive and systematic evaluation of the effects
of alternative exercise traditions on cancer patients so as to
provide a synthesis of clinical evidence and a basis for
decision-making. As alternative forms of exercise are rela-
tively easy to perform, patients with chronic diseases, such
as cancer, may benet from them, particularly in the con-
text of the ongoing COVID-19 pandemic. This article
attempts to explore this topic comprehensively to provide
rehabilitation guidance and recommendations for patients
in the recovery period.
Materials and Methods
Inclusion and Exclusion Criteria
Research Design
This research is about published SR/MAs of alternative
exercise traditions for cancer.
Research Objects
Patients diagnosed with cancer are not limited by gender,
age, race, time of onset, and source of cases.
Intervention Measures
The intervention measures mainly involve at least one of
the following alternative exercise traditions: Tai Chi,
Qigong, Baduanjin, yoga, and Pilates, all of which can
be supplemented by other forms of therapy.
Outcome Indicators
The main outcome indicators include at least one of the
following: 1) quality of life (QOL), 2) pain, 3) anxiety, 4)
body mass index (BMI), 5) sleep outcome, 6) depression,
7) distress, and 8) fatigue.
Exclusion Criteria
The exclusion criteria are as follows: 1) duplicate publica-
tions, 2) systematic review plan, 3) systematic review
without a quantitative analysis in the included original
research, and 4) non-Chinese or English literature.
Search Strategy
A computer search of PubMed, Cochrane Library, Web of
Science, Ovid, EBSCOhost, WanFang Database, China
National Knowledge Infrastructure, and VIP Database
was performed to lter and extract the SR/MAs that
meet the inclusion criteria. The retrieval date was from
the establishment date of each database to June 30, 2020.
The search used a combination of subject words and free
words. The search terms included “Tai Chi,” “Qigong,”
“Baduanjin,” “Yoga,” “Pilates,” “Cancer,” “Meta-analysis,
” and “Systematic review.” Take PubMed as an example.
Figure 1 shows the specic retrieval strategy.
Literature Screening and Data Extraction
Two researchers (Yang Zhang and Fang Yao) conducted
two independent rounds of screening by reading the title,
abstract, and full text. They then extracted the data accord-
ing to a predesigned Excel data extraction table. In case of
a disagreement, the researchers conducted discussions and
Figure 1 PubMed search strategy.
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consulted a third party to resolve the issue. The data
extraction content included 1) basic information, including
the rst author’s name, publication year, rst author’s
country of origin, number of included articles, sample
size, quality evaluation tools, intervention measures, con-
trol measures, outcome indicators, and research results; 2)
methodology of SR/MAs, including the literature search,
included studies, research samples, and methodological
quality evaluation of included studies; and 3) statistical
analysis results, mainly the quantitative analysis results for
each outcome indicator.
Evaluation of Methodological Quality and
Evidence Quality of Included Studies
The AMSTAR scale was used to carry out the evaluation of
the methodological quality of the included SR/MAs. The
PRISMA scale was utilized to evaluate the report quality.
The items in the AMSTAR scale indicated “full report,”
“partial report,” or “not reported.” Fully meeting the
AMSTAR item explanation and the comprehensive consid-
eration of the unsatised parts will not cause signicant
deviations in the results; hence, the use of the label “full
report,” which is equivalent to 1 point. A “partial report”
means that a part of the AMSTAR item meets the AMSTAR
scale but suffers from major defects; the score in this case is
0.5. The label “not reported” is counted as 0 point. The scale
has a total of 11 points. The AMSTAR scale scores of 0–3
indicate low quality, scores of 4–7 indicate moderate qual-
ity, and scores of 8–11 indicate high quality.
12,13
Each item of the PRISMA scale is described with
1 point for “complete report,” 0.5 point for “partial
report,” and 0 point for “unreported”; the total score is
27 points. When the literature score is 21–27, the report is
considered to be relatively complete. When the score is
15–21, the report is considered to be awed. When the
score is ≤15, the report lacks sufcient information.
14
Results
Identication and Selection of Reviews
The total number of related articles in the database was 663;
317 of these articles were retained after removing the dupli-
cates. After reading the titles and abstracts of the remaining
articles to exclude irrelevant ones, 69 documents were
obtained. Reading the full text content yielded 26 articles,
which were nally included in the study. The literature
screening process and results are shown in Figure 2.
Characteristics of Included Reviews
The 26 SR/MAs included 22 English articles
15–36
and
4 Chinese articles.
37–40
The publication years ranged
from 2007 to 2020, with 12 articles published in the last
5 years. Of the 26 SR/MAs, 13 focused on yoga,
Figure 2 The PRISMA ow diagram of study inclusion in the review.
Notes: PRISMA gure adapted from Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care
interventions: explanation and elaboration. Journal of clinical epidemiology. 2009;62(10). Creative Commons.
41
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12 focused on Tai Chi, 5 focused on Qigong, and 2
focused on Pilates. All SR/MAs evaluated the methodolo-
gical quality of the included original studies; 17 used the
Cochrane criteria, 3 did not mention the quality criteria of
their evaluation, 2 used the Jadad scale, 3 used the PEDro
criteria, and 1 used the NIH Quality Assessment. The
basic characteristics included in the SR/MAs are shown
in Table 1. The clear outcome results of the included SR/
MAs are shown in Table 2.
AMSTAR Evaluation Results
The AMSTAR scale was used to evaluate the methodological
quality of the included SR/MAs. As shown in Table 3, the
AMSTAR scale scores of the 26 SR/MAs ranged from 5
points to 10 points, with an average of 7.46±1.33 points.
Among them, 16 received ≥8 points, which indicated high-
quality studies that accounted for 61.5% of the total number;
10 of the articles were moderate-quality studies (4–7 points),
and they accounted for 38.5%. Generally, the methodological
quality was regarded as moderate. No literature fully met the
requirements of the 11 items in the AMSTAR scale.
Relatively complete reports (≥70%) included entry
2 (80.8%), entry 5 (88.5%), entry 6 (100%), entry
7 (96.2%), entry 8 (100%), and entry 9 (100%).
PRISMA Evaluation Results
As shown in Table 4, the PRISMA scores of the 26 SR/MAs
ranged from 13.0 to 24.0, with an average of 19.19±2.86
points. Among them, 8 reports were relatively complete
(21–27 points, including 27 points), accounting for 30.8%;
15 reports were awed (15–21 points, including 21 points),
accounting for 57.7%; 3 reports had relatively serious informa-
tion deciency (≤15 points), accounting for 11.5%. No litera-
ture fully met the requirements of the 27 items in the PRISMA
scale. Report information was lacking (<50%) in the following
13 entries: entry 2 (7.7%), entry 3 (30.8%), entry 5 (11.5%),
entry 7 (34.6%), entry 8 (26.9%), entry 9 (30.8%), entry 10
(38.5%), entry 12 (19.2%), entry 15 (38.5%), entry 16 (15.4%),
entry 19 (30.8%), entry 22 (23.1%), and entry 23 (11.5%).
Discussion
The Methodological Quality of the SR/
MAs of Alternative Exercise Traditions
for Cancer Treatment Needs to be
Improved
This study included 26 SR/MAs of alternative exercise
traditions for cancer treatment. All included SR/MAs
were mainly published from 2007 to 2020. Among these
articles, 12 were published in the last 5 years; hence, the
popularity of alternative exercise traditions for cancer
treatment is on the rise. Only high-quality systematic
reviews can provide relatively unbiased and scientic evi-
dence for clinical practice and health decision-making.
Therefore, systematic reviews need to strictly control the
quality of the included studies and methodologies. In the
current work, the AMSTAR scale was used to evaluate the
methodological quality of the included SR/MAs. The
results showed that 16 articles were of high quality, and
they accounted for 61.5%; 10 articles were of moderate
quality, and they accounted for 38.5%.
A total of 23 papers (88.5%) lacked preliminary
design plans; 4 papers (15.4%) did not pay attention to
the repeatability of document extraction; 15 papers
(57.7%) did not search the necessary databases, such as
the Cochrane Library, Web of Science, and PubMed; 22
papers (84.6%) did not consider the unpublished status in
the inclusion criteria (if gray literature was not fully
considered); 3 papers (11.5%) lacked a specic list of
included and excluded studies (if specic reasons for
exclusion were not included); 1 paper (3.8%) did not
evaluate and report the scientic nature of the included
research; 8 papers (30.8%) did not evaluate the publica-
tion deviation (such as a one-sided description); 14
papers (53.8%) did not state the relevant funding sources
and the presence of relevant conicts of interest. The
above methodological quality defects may affect the
rigor of the system evaluation, the accuracy of the results,
and the overall objectivity.
Therefore, the quality of methodology needs to be
further improved. For example, if only electronic retrie-
val is performed and paper journals and books are not
manually retrieved, then relevant articles may be
missed. In such a case, the included articles may not
be comprehensive enough. This deciency may affect
the accuracy of the results and reduce the quality of the
methodology.
The Quality of the Reports on
Alternative Exercise Traditions for
Cancer Treatment Needs to be
Strengthened
This study used the PRISMA scale to evaluate the
quality of the reports. The results showed that 8 reports
(30.8%) were relatively complete, 15 reports (57.7%)
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Table 1 Characteristics of Included SR/MAs
Authors,
Year
Country Number
of
Studies/
Sample
Size
Quality
Criteria
Duration
of Studies
Intervention Group Control Group Main
Outcome
Outcome
Results
Luo et al,
2020
15
China 15/885 Cochrane
criteria
2006–2019 RRT+8-form TCC; Usual care
+8-form TCC; RRT + Chen-
style TCC; Usual care +18-
form TCC; RRT + 24-form
simplied
TCC;RRT + Tai Chi Yunshou;
15-move short-form of Yang-
style TCC
Usual care;
Cognitive
behavioral
therapy; RRT;
Standard support
Therapy;
Psychosocial
support therapy
①②③ TCC is effective
on quality of life,
pain and anxiety
in breast cancer
patients.
Lee et al,
2010
16
South
Korea
7/235 Cochrane
criteria
2003–
2009
Tai Chi;Yang style;Combining
Yang and Sun style
No treatment;
Psychosocial
support therapy;
Spiritual growth;
Standard health
Care; Walking;
Education
Program
①Tai Chi is not
effective on
quality of life for
supportive breast
cancer care.
Pan et al,
2015
17
China 19/322 Cochrane
criteria
2004–2013 Tai Chi; Yang-style TCC;
8-form TCC
Health education;
Psychosocial
Therapy; Standard
support therapy;
Usual care;
Spiritual growth
and standard
health care
②④ Tai Chi is not
effective on pain
and BMI in breast
cancer patients.
Yan et al,
2014
18
China 5/407 Jadad scale 2004–2012 15-move short-form of Yang-
style TCC; 24-form of TCC;
8-move short form of TCC
Psychosocial
Therapy; Standard
support therapy;
Usual care;
Standard
rehabilitation
①④ Tai Chi is not
effective on quality
of life (except
emotional well-
being) and BMI in
breast cancer
patients.
Zhang
et al,
2012
19
China 6/382 Cochrane
criteria
2007–2012 Hatha yoga; Restorative yoga;
Iyengar yoga; Vini yoga;
Patanjali’s yoga
Wait-list;
Nontreatment
①③⑤⑥⑦ Yoga is effective
on quality of life,
but not effective
on anxiety,
depression,
distress and sleep
outcome in
women with
breast cancer
(Continued)
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Table 1 (Continued).
Authors,
Year
Country Number
of
Studies/
Sample
Size
Quality
Criteria
Duration
of Studies
Intervention Group Control Group Main
Outcome
Outcome
Results
Buffart
et al,
2012
20
Netherlands 13/695 Not
mentioned
2003–
2011
Integrated yoga program;
Viniyoga; Yoga asanas;
Savasana; Tibetan yoga
Non-exercise;
Wait-list
③⑤⑥⑦⑧ Yoga is effective
on anxiety,
depression and
distress, but not
effective on sleep
outcome and
fatigue in cancer
patients and
survivors.
Cramer
et al,
2012
21
Germany 12/742 Cochrane
criteria
2003–2011 Iyengar Yoga; Integrated yoga;
Yoga of Awareness; Patanjali’s
yoga Sutras; Integrated yoga;
Hatha yoga; Restorative yoga;
Viniyoga
Wail-list;
Supportive
counseling and
advice to take
light exercise;
Health education
①③⑥ Yoga is effective
on quality of life,
and short-term
yoga is effective
on anxiety and
depression in
breast cancer
patients.
Dong
et al,
2019
22
China 12/2183 Cochrane
criteria
2009–2018 Hatha yoga+home-based
yoga; Integrated yoga;
Restorative yoga; Iyengar
yoga; Viniyoga+home-based
yoga; Satyananda yoga;
Anusara yoga; Classical yoga;
Home-based yoga; Classical
yoga; Dru yoga+home-based
breathing and relaxation
exercise; Tibetan yoga
+booster class +home-based
practice; Yoga +usual care;
Yoga+Aerobic exercise
Standard care;
Supportive
counseling; Wait-
list
Non-intervention;
Health education ;
Usual self-care;
Usual care;
Strengthening
exercise
Conventional
physical exercise;
Aerobic exercise
⑧Yoga is effective
on fatigue in
patients with
breast cancer.
Ford et al,
2020
23
USA 17/666 NIH
Quality
Assessment
2000–
2017
Taichi; Qigong; Yoga Usual care; Wait-
list; Education
groups; Attention
controls
①TaiChi/Qigong
and Yoga are
effective on
quality of life in
male cancer
survivors.
Hashimi
et al,
2019
24
Canada 8/545 Not
mentioned
2008–2018 Vivekananda Yoga
Anusandhana Samsthana;
Hatha yoga; Anusandhana
Samsthana;
Tibetan yoga; Iyengar yoga;
Integrated Yoga; Classic yoga
Stretching;
Standard exercise;
Physical exercise;
Shoulder
exercise; Strength
training;
Physical exercise;
Aerobic exercise
①Yoga is not
effective on
quality of life of
women with
breast cancer.
(Continued)
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Table 1 (Continued).
Authors,
Year
Country Number
of
Studies/
Sample
Size
Quality
Criteria
Duration
of Studies
Intervention Group Control Group Main
Outcome
Outcome
Results
Harder
et al,
2012
25
UK 18/164 PEDro
criteria
2006–
2012
Integrated yoga; Lyengar yoga;
Hatha yoga; Restorative yoga;
Yoga of Awareness; Lyengar
yoga; Integrated yoga;
Modied Hatha yoga; Patanjali
yoga
Supportive
therapy; Wait-list;
Health education;
Standard care
①Yoga may be
a useful practice
in improving the
quality of life of
women with
breast cancer.
Lee
et al,
2007
26
UK 4/226 Jadad
Assessment
2003–2006 Tai Chi Walking exercise;
Psychosocial
support;Education
program
①Tai Chi is not
effective on
quality of life for
cancer.
Pan
et al,
2015
27
China 16/930 Cochrane
criteria
2007–2012 Integrated yoga;Iyengar yoga;
Yoga of awareness Program;
Patanjali’s yoga; Modied
yoga;
Restorative yoga; Viniyoga
Supportive
therapy; Wait-list;
Health education;
Usual care;
Standard
physiotherapy;
Brief supportive
therapy
①③⑤⑥⑧ Yoga is effective
on sleep
outcome,quality
of life,
anxiety and
depression, but
not effective on
fatigue
for patients
recovering from
breast cancer.
Wang
et al,
2020
28
China 19/1832 Cochrane
criteria
2009–
2019
Iyengar Yoga; Asanas yoga;
Viniyoga; Restorative yoga;
Hatha yoga; Tibetan yoga;
Mindful yoga; Yoga breathing
exercise in warm water
Wait-list; Health
education;
Usual care; Social
support
⑤Yoga is an
effective
supportive
treatment for
cancer in sleep
outcome.
Sadja
et al,
2013
29
USA 10/583 Not
mentioned
2004–
2012
Iyengar yoga; Tibetan yoga;
Yoga of awareness; Patanjali’s
yoga tradition; Based on
Hatha; Integrated yoga
program
Wait-list; Health
education
⑧Yoga may be
benecial for
reducing fatigue
in women with
breast cancer.
Liu
et al,
2020
30
China 16/1268 PEDro
criteria
2003–
2017
Tai Chi; Tai Chi+Standard
rehabilitation training
Cognitive
behavior therapy;
Standard
rehabilitation
training;
Usual care;
Walking;
Psychosocial
support therapy;
Spiritual growth
group
①④⑤⑥
⑧
Tai Chi is
effective on
quality of life, but
not effective on
sleep outcome,
BMI, depression
and fatigue in
breast cancer
patients.
(Continued)
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Table 1 (Continued).
Authors,
Year
Country Number
of
Studies/
Sample
Size
Quality
Criteria
Duration
of Studies
Intervention Group Control Group Main
Outcome
Outcome
Results
Espíndula
et al,
2017
31
Brazil 4/150 Cochrane
criteria
2010–2016 Pilates; Pilates+home exercise Home exercise;
No exercise
②⑧ Pilates may be
benecial for
reducing pain and
fatigue of breast
cancer patients.
Carral
et al,
2018
32
Spain 4/246 Cochrane
criteria
2008–2013 Pilates exercise+home pilates;
Pilates mat exercise+
information and home
drainage and walking exercise;
Pilates mat exercise; Pilates
MVe Fitnesess Chair; Pilates
mat exercise+Pilates-based
theraband exercises; Pilates+
home standard lymphedema
exercises
Information and
drainage and
walking exercise;
No exercise;
Information and
drainage and
walking exercise;
Traditional
resistance
training;
Conventional
exercise and
breast prosthesis
counseling;
Exercise
programme;
Lumbopelvic
stability
①② Pilates has
a certain effect
on quality of life
and pain for
women with
breast cancer.
Zeng
et al,
2014
33
China 13/592 Cochrane
criteria
2003–2013 Taichi; Guolin new qigong;
Yang style of taichi; Medical
qigong
Health education;
Wait-list;
Walking exercise;
Psychosocial
support; Usual
medical care;
Standard support
therapy
①③④⑥ Qigong/Tai Chi
are effective on
quality of life and
anxiety,but not
effective on BMI
and depression of
cancer patients.
Wayne
et al,
2017
34
USA 15/1283 Cochrane
criteria
2008–2013 Taichi; Qigong Psychosocial
support; Usual
care;
Health education;
No treatment;
Spiritual growth;
Stretching
exercise
①②⑤⑥ Qigong/Tai Chi
are effective on
sleep outcome,
quality of life,
depression and
fatigue,but not
effective on pain
of cancer
patients.
(Continued)
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Table 1 (Continued).
Authors,
Year
Country Number
of
Studies/
Sample
Size
Quality
Criteria
Duration
of Studies
Intervention Group Control Group Main
Outcome
Outcome
Results
Zeng
et al,
2019
35
China 12/915 Cochrane
criteria
2014–2018 Taichi; Qigong; Taichi
+Qigong;
Medical qigong
Usual care;
Support groups;
Wait-list
①③⑤⑧ Qigong/Tai Chi
are effective on
sleep outcome
and fatigue, but
not effective on
quality of life,
anxiety,
depression of
cancer patients.
Lin et al,
2011
36
China 10/788 PEDro
criteria
2000–2009 Restorative yoga; Integrated
yoga; Gentle yoga; Hatha
yoga; Asanas+shevasana;
Tibetan yoga
Wait-list; Support
therapy
③⑥⑦ Yoga is effective
on anxiety,
depression and
distress of cancer
patients.
Pan et al,
2016
37
China 12/1979 Cochrane
criteria
2004–2013 19-move short-form of TCC;
Qigong + Short-form of Yang-
style TCC; Short-form of
Yang-style TCC; 24-form of
TCC
Rehabilitation
nursing; Health
education;
Psychosocial
therapy;
Standard
rehabilitation;
Usual care; Music
Rehabilitation
exercise
①②④ Tai Chi is
effective on BMI,
but not effective
on quality of life
and pain of
postoperative
patients
with breast
cancer.
Yan et al,
2013
38
China 4/169 Cochrane
criteria
2003–2010 Yang-style TCC; Short form
of TCC; 24-move short form
of TCC
Psychosocial
Therapy; Walking;
Standard Therapy;
Usual
rehabilitation
①④ Tai Chi is not
effective on
quality of life and
BMI in breast
cancer patients.
Zhang
et al,
2015
39
China 9/623 Cochrane
criteria
2007–2014 Anusara yoga; Lyengar yoga;
Patanjali’s yoga; Restorative
yoga; Hatha yoga; Viniyoga
Usual care; Health
education; One-
to-one meeting
⑧Yoga is effective
on fatigue of
breast cancer
patients.
Wu
et al,
2018
40
China 7/671 Cochrane
criteria
2015–2017 Yoga Wait-list; Health
education; Usual
care; Social
support
①③⑤⑥ Yoga is effective
on quality of life,
anxiety and
depression, but
not effective on
sleep outcome in
patients with
breast cancer.
Notes: TCC, Tai Chi; ①quality of life;②pain;③anxiety;④BMI;⑤sleep outcome; ⑥ depression; ⑦ distress; ⑧ fatigue.
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had certain defects, and 3 reports (11.5%) had relatively
serious information defects. Most of the researchers did
not write a plan and performed registration before their
systematic reviews, and the complete report rate of
plans and registrations was only 11.5%. In the results,
only three articles (11.5%) discussed the results of other
analyses (such as sensitivity analysis or subgroups). In
terms of the methodology, only ve articles (19.2%)
described the bias in the evaluation of a single study
(such as the suitability for random allocation sequence,
blinding, and proportion of patients lost to follow-up).
In conducting an SR/MA, the PRISMA statement should
be used as basis in preparing a normative report to
improve the overall report quality.
Therefore, report quality needs to be further improved.
For example, the randomization and allocation conceal-
ment schemes included in the original study were not
perfect, and the loss to follow-up and adverse events
were not fully reported. Specic information, such as the
individuals who conducted the search and those who
implemented it and the details about resolving disagree-
ments, was lacking.
The Effectiveness of Alternative Exercise
Traditions in Cancer Treatment Should be
Discussed Further
QOL is a multidimensional assessment with physical sig-
nicance and is a commonly used indicator to measure the
effect of cancer treatment.
42
The 18 SR/MAs included in
this study analyzed the intervention effects of alternative
exercise traditions on QOL. Among the 18 articles, 11
reports showed that alternative exercise traditions can
improve the QOL of cancer patients. Tai Chi, Qigong,
yoga, and others that serve as traditional exercise activities
can increase a person’s strength, improve one’s physical
exibility, and promote relaxation and well-being.
24,42
Pain is one of the most common symptoms of cancer,
and it may be due to tumors, surgery, chemotherapy,
radiation therapy, targeted therapy, supportive care, and
diagnostic procedures.
43
The evaluation of control-related
and nonsurgical pain is essential for cancer patients. From
the 26 articles, 6 reports analyzed the intervention effects
of alternative exercise traditions on pain, and 3 of them
showed that alternative exercise traditions may not neces-
sarily improve the pain of cancer patients. Pain has
Table 2 Outcome Results of Included SR/MAs
Outcome Authors, Year Outcome
Results
Outcome Authors, Year Outcome
Results
Outcome Authors, Year Outcome
Results
Quality of
life
Luo et al, 2020
15
* Pain Luo et al, 2020
15
* BMI Pan et al, 2015
17
#
Lee et al, 2010
16
# Pan et al, 2015
17
# Yan et al, 2014
18
#
Yan et al, 2014
18
# Espíndula et al,2017
31
* Liu et al, 2020
30
#
Zhang et al, 2012
19
* Carral et al, 2018
32
* Zeng et al, 2014
33
#
Cramer et al, 2012
21
* Wayne et al, 2017
34
# Pan et al, 2016
37
*
Ford et al, 2020
23
* Pan et al, 2016
37
# Yan et al, 2013
38
#
Hashimi et al, 2019
24
# Anxiety Luo et al, 2020
15
* Sleep
outcome
Zhang et al, 2012
19
#
Harder et al,2012
25
* Zhang et al, 2012
19
# Buffart et al, 2012
20
#
Lee et al, 2007
26
# Buffart et al, 2012
20
* Pan et al, 2015
27
*
Pan et al, 2015
27
* Cramer et al, 2012
21
* Wang et al, 2020
28
*
Liu et al, 2020
30
* Pan et al, 2015
27
* Liu et al, 2020
30
#
Carral et al, 2018
32
* Zeng et al, 2019
35
# Wayne et al, 2017
34
*
Zeng et al, 2014
33
* Lin et al, 2011
36
* Zeng et al, 2019
35
*
Wayne et al, 2017
34
* Wu et al, 2018
40
* Wu et al, 2018
40
#
Zeng et al, 2019
35
# Depression Zhang et al, 2012
19
# Fatigue Buffart et al, 2012
20
#
Pan et al, 2016
37
# Buffart et al, 2012
20
* Dong et al, 2019
22
*
Yan et al, 2013
38
# Cramer et al, 2012
21
* Pan et al, 2015
27
#
Wu et al,2018
40
* Pan et al, 2015
27
* Sadja et al, 2013
29
*
Distress Zhang et al, 2012
19
# Liu et al, 2020
30
# Liu et al, 2020
30
#
Buffart et al, 2012
20
* Zeng et al, 2014
33
# Espíndula et al, 2017
31
*
Lin et al, 2011
36
* Wayne et al, 2017
34
* Zeng et al, 2019
35
*
Lin et al, 2011
36
* Zhang et al, 2015
39
*
Wu et al, 2018
40
*
Note: *, Alternative exercise traditions are useful; #, Alternative exercise traditions are useless.
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a psychological impact as it may cause a patient to develop
anxiety, neuroticism, and anger.
44
A total of eight reports
analyzed the intervention effects of alternative exercise
traditions on anxiety, and six of them showed that alter-
native exercise traditions can improve anxiety in cancer
patients. A total of nine reports analyzed the intervention
effects of alternative exercise traditions on depression, and
six of them showed that alternative exercise traditions can
improve depression in cancer patients. A total of three
reports analyzed the intervention effects of alternative
exercise traditions on distress, and two of them showed
that alternative exercise traditions can improve distress in
cancer patients. In summary, alternative forms of exercise
can be used as a supplementary therapy to help cancer
patients with their social and psychological suffering. Tai
Chi, Qigong, yoga, and others encourage patients to pay
attention to their breathing, calm their mind, and
concentrate.
45,46
For anxiety or depression that affects
sleep, psychological counseling should be combined with
physical and mental exercise. A total of eight reports
analyzed the intervention effects of alternative exercise
traditions on sleep outcomes, and four of them showed
that alternative exercise traditions may not necessarily
improve the sleep outcomes of cancer patients. Sleep dis-
orders are known to be related to inammation.
47
Studies
have shown that exercise is an effective intervention to
Table 3 Quality Assessment of the Included Reviews Using the AMSTAR Tool (n = 26)
Authors, Year AMSTAR Items Total
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Y N C
Luo et al,2020
15
Y Y Y N Y Y Y Y Y Y N 9 2 0
Lee et al, 2010
16
N Y Y N Y Y Y Y Y N N 7 4 0
Pan et al, 2015
17
N Y N N Y Y Y Y Y N N 6 5 0
Yan et al, 2014
18
N N N N Y Y Y Y Y Y N 6 5 0
Zhang et al, 2012
19
N Y Y Y Y Y Y Y Y Y Y 10 1 0
Buffart et al,2012
20
N N Y N Y Y Y Y Y Y Y 8 3 0
Cramer et al,2012
21
N Y N N Y Y Y Y Y Y Y 8 3 0
Dong et al, 2019
22
N Y Y N Y Y Y Y Y Y Y 9 2 0
Ford et al, 2020
23
N Y N Y Y Y Y Y Y Y Y 9 2 0
Hashimi et al,2019
24
N Y Y N Y Y Y Y Y N Y 8 3 0
Harder et al, 2012
25
N Y Y N Y Y Y Y Y N Y 8 3 0
Lee et al, 2007
26
N N Y N N Y Y Y Y N N 5 6 0
Pan et al, 2015
27
N Y N N Y Y Y Y Y N N 6 5 0
Wang et al, 2020
28
N Y N N Y Y Y Y Y Y Y 8 3 0
Sadja et al, 2013
29
N Y N N Y Y Y Y Y Y N 7 4 0
Liu et al, 2020
30
N Y Y N Y Y Y Y Y Y N 8 3 0
Espíndula et al,2017
31
Y Y N N Y Y Y Y Y Y N 8 3 0
Carral et al, 2018
32
Y Y N N Y Y Y Y Y Y Y 9 2 0
Zeng et al, 2014
33
N Y N N Y Y Y Y Y Y Y 8 3 0
Wayne et al, 2017
34
N Y N N Y Y Y Y Y Y Y 8 3 0
Zeng et al, 201935 N C N C N Y Y Y Y Y Y 6 3 2
Liu et al, 2011
36
N C N N Y Y Y Y Y N N 5 5 1
Pan et al, 2016
37
N Y Y N N Y N Y Y Y N 6 5 0
Yan et al, 2013
38
N Y Y N Y Y Y Y Y Y N 8 3 0
Zhang et al, 2015
39
N Y N Y Y Y Y Y Y Y N 8 3 0
Wu et al, 2018
40
N Y N N Y Y Y Y Y N N 6 5 0
Percentage of systematic reviews meeting
each criteria
11.5 80.8 42.3 11.5 88.5 100.0 96.2 100.0 100.0 69.2 46.2
Notes: AMSTAR items: Q1, a-priori design; Q2, duplicate study selection and data extraction; Q3, search comprehensiveness; Q4, status of publication (eg, non-English
articles or dissertations); Q5, listing included and excluded studies; Q6, characteristics of the primary studies provided; Q7, scientic quality of the primary studies assessed
and documented; Q8, scientic quality of the included data used appropriately in drawing conclusions; Q9, appropriateness of methods used to combine the ndings of the
primary studies; Q10, assessment of publication bias; and Q11, acknowledgement of conicts of interest and potential sources of support in both the systematic review and
the primary studies. Y, yes; N, no; C, cannot answer. We assigned 1 point to each “yes” item. The sub-column “Y”, the AMSTAR score, represents the quality of each
included study which is the most important column in the table. The last row in the table indicates the percentage of included studies which met each item in AMSTAR scale.
Bases on this, the methodological issues of included studies were identied.
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Table 4 PRISMA Statement Score/Point
Topic PRISMA Items Luo
et al,
2020
15
Lee et al,
2010
16
Pan
et al,
2015
17
Yan
et al, 2014
18
Zhang
et al,
2012
19
Buffart
et al,
2012
20
Cramer
et al,
2012
21
Dong
et al,
2019
22
Ford
et al,
2020
23
Hashimi
et al,
2019
24
Harder
et al,
2012
25
Lee et al,
2007
26
Pan
et al,
2015
27
Title 1 Title 1 1 1 1 1 1 1 1 1 1 1 1 1
Abstract 2 Structured
summary
1 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5
Introduction 3 Rationale 0.5 0.5 1 0.5 0.5 0.5 1 1 0.5 0.5 0.5 0.5 1
4 Objectives 1 1 1 1 1 1 1 1 1 1 1 1 1
Methods 5 Protocol and
registration
1 0 0 0 0 0 0 0 0 0 0 0 0
6 Eligibility criteria 1 1 1 1 1 1 1 1 1 1 1 1 1
7 Information sources 1 0.5 1 0.5 0.5 0.5 1 1 0.5 0.5 0.5 0.5 1
8 Search 0 0 0 0 0.5 0 1 1 1 0 0 0 1
9 Study selection 1 0.5 1 0.5 1 0.5 1 0.5 0.5 0.5 0.5 0.5 1
10 Data collection
process
0.5 0.5 1 0.5 1 0.5 0.5 1 1 0.5 0 0 1
11 Data items 1 1 1 1 1 1 1 1 1 1 1 1 1
12 Risk of bias in
individual studies
0.5 0.5 0.5 0.5 0.5 0 0.5 0.5 0.5 0.5 0.5 0.5 0.5
13 Summary measures 1 1 1 1 1 1 1 1 1 1 1 1 1
14 Synthesis of results 1 1 1 1 1 1 1 1 1 1 1 1 1
15 Risk of bias across
studies
1 0.5 0.5 1 0.5 0.5 0.5 1 1 0.5 0 0 0.5
16 Additional analyses 1 0 0.5 0 0 0 0 0 0 0 0 0 0
Results 17 Study selection 1 1 1 0.5 1 1 1 0.5 1 0.5 1 0.5 1
18Study characteristics 1 1 1 1 1 1 1 1 1 1 1 1 1
19 Risk of bias within
studies
1 0.5 0.5 0.5 0.5 0 1 1 1 0.5 0.5 0.5 0.5
20 Results of individual
studies
1 1 1 1 1 0.5 1 1 1 1 0.5 0 1
21Synthesis of results 1 1 1 1 1 0.5 1 1 1 1 0.5 0 1
22 Risk of bias across
studies
0.5 0.5 0.5 0.5 0.5 0 1 1 0.5 0.5 0.5 0 0.5
23 Additional analysis 1 0 0 0 0 0 0 0 0 0 0 0 0
Discussion 24 Summary of evidence 1 1 1 1 1 0.5 1 1 1 1 1 0.5 1
25 Limitations 1 0.5 1 0.5 1 1 0.5 0.5 1 1 0.5 1 1
26 Conclusions 1 1 1 1 1 1 1 1 1 1 1 1 1
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Funding 27 Funding 1 0 0 1 0 0 1 1 1 1 0 0 0
Topic PRISMA Items Wang
et al,
2020
28
Sadja
et al,
2013
29
Liu et al,
2020
30
Espíndula
et al, 2017
31
Carral
et al,
2018
32
Zeng et al,
2014
33
Wayne
et al,
2017
34
Zeng
et al,
2019
35
Liu et al,
2011
36
Pan et al,
2016
37
Yan et al,
2013
38
Zhang
et al,
2015
39
Wu
et al,
2018
40
Title 1 Title 1 1 1 1 1 1 1 1 1 1 1 1 1
Abstract 2 Structured summary 0.5 0.5 0.5 0.5 1 0.5 0.5 0.5 0.5 0.5 0 0.5 0.5
Introduction 3 Rationale 1 0.5 0.5 0.5 0.5 0.5 0.5 0.5 1 1 1 0.5 1
4 Objectives 1 1 1 1 1 1 1 1 1 1 1 1 1
Methods 5 Protocol and
registration
0 0 0 1 1 0 0 0 0 0 0 0 0
6 Eligibility criteria 1 1 1 1 1 1 1 1 1 1 1 1 1
7 Information sources 0.5 1 1 0.5 0.5 0.5 0.5 0.5 1 0.5 0.5 1 1
8 Search 1 0.5 0 0 0 1 1 0 0 0 0 0.5 0
9 Study selection 1 0.5 0.5 0.5 0.5 0.5 1 0 1 0 0.5 1 0.5
10 Data collection
process
1 0 1 1 0.5 1 1 0.5 1 0 0.5 0.5 0.5
11 Data items 1 1 1 1 1 1 1 1 1 1 1 1 1
12 Risk of bias in
individual Studies
1 0.5 1 0.5 0.5 1 1 1 0.5 0.5 0.5 0.5 0.5
13 Summary measures 1 1 1 1 1 1 1 1 1 1 1 1 1
14 Synthesis of results 1 1 1 1 1 1 1 1 1 1 1 1 1
15 Risk of bias across
studies
0 1 0.5 1 1 1 1 1 0.5 0.5 0.5 0.5 0.5
16 Additional analyses 1 0 1 0 0 1 0 0 0 0 0 0 0
Results 17 Study selection 1 1 1 1 1 0.5 1 0 1 0 1 1 0.5
18 Study characteristics 1 1 1 1 1 1 1 1 1 1 1 1 1
19 Risk of bias within
studies
0.5 0.5 1 0.5 1 1 1 0.5 0.5 0.5 0.5 0.5 0
20 Results of individual
studies
1 0.5 1 1 1 1 1 1 1 1 1 1 1
21 Synthesis of results 1 1 1 1 1 1 1 1 1 1 1 1 1
22 Risk of bias across
studies
1 0.5 0.5 1 1 1 0.5 0.5 0 0.5 0.5 0.5 0
23 Additional analysis 1 0 1 0 0 1 0 0 0 0 0 0 0
Discussion 24 Summary of evidence 1 1 1 1 1 1 1 1 1 1 1 1 1
25 Limitations 1 0.5 1 0.5 1 0.5 1 0.5 1 0.5 1 1 1
(Continued)
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control inammation,
48
but the mechanism of how exer-
cise affects sleep is still unclear. At the same time, due to
insufcient intensity, exercise may not trigger changes that
promote better sleep (such as body changes, melatonin
release, and reduction of inammation). A total of six
reports included in this study analyzed the intervention
effects of alternative exercise traditions on BMI. Of these
reports, ve showed that alternative exercise traditions
cannot reduce the BMI of cancer patients. This result
may be related to differences in race, region, and
age.
49–51
A proper extension of exercise time may be
effective in reducing the BMI of cancer patients.
52
At the
same time, BMI reects the overall body weight and does
not distinguish between adipose tissue and nonfat
tissue.
53,54
In the future, other physical measurement indi-
cators for evaluating obesity are expected. A total of eight
reports analyzed the intervention effects of alternative
exercise traditions on fatigue, and ve of them showed
that alternative exercise traditions can improve fatigue in
cancer patients. Alternative exercise traditions integrate
exercise (body posture), meditation (concentration), and
breathing to achieve a state of mental calm and relaxation
to reduce fatigue.
55–57
In summary, alternative exercise traditions have the
potential to improve the negative psychological conditions
of cancer patients and improve their QOL. However,
whether or not they are more advantageous than conven-
tional rehabilitation training still needs to be supported by
a large sample size and strict standardized trials. At the
same time, Tai Chi, yoga, and Qigong cannot be used as
intervention methods in general without distinguishing the
characteristics of different schools and movements. Future
research should incorporate a large number of samples (in
the baseline and follow-up phases), long-term follow-up
evaluations (eg, 6 months or more), and clearly dened
targeted measurement indicators into the design.
Alternative Exercise Traditions in the
Context of the COVID-19 Pandemic may
be an Effective Intervention That is Easy
to Promote
COVID-19 is the most widespread global pandemic to
affect humans in the last 100 years.
58
In the early stage
of the epidemic, academician Zhong Nanshan spoke
highly of Tai Chi for strengthening one’s body and
tness.
59
In particular, Tai Chi has been regarded as cap-
able of improving cardiopulmonary function, thereby
Table 4 (Continued).
Topic PRISMA Items Luo
et al,
2020
15
Lee et al,
2010
16
Pan
et al,
2015
17
Yan
et al, 2014
18
Zhang
et al,
2012
19
Buffart
et al,
2012
20
Cramer
et al,
2012
21
Dong
et al,
2019
22
Ford
et al,
2020
23
Hashimi
et al,
2019
24
Harder
et al,
2012
25
Lee et al,
2007
26
Pan
et al,
2015
27
26 Conclusions 1 1 1 1 1 1 1 1 1 1 1 1 1
Funding 27 Funding 1 0 1 0 1 1 1 0 0 1 1 0 0
Notes: PRISMA statement from Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of
clinical epidemiology. 2009;62(10). Creative Commons.
41
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attracting people’s attention.
60
The National Health
Commission of the People’s Republic of China issued
the “Rehabilitation Plan for Discharged COVID-19
Patients (Trial)” on March 4, 2020.
61
The section on
“Rehabilitation treatment methods” pointed out that
a series of aerobic prescriptions have been formulated for
patients with combined underlying diseases and residual
dysfunction. These prescriptions include Tai Chi and
Baduan Jin. According to the plan, patients are encouraged
to begin with low-intensity exercise and progress gradu-
ally, engaging in exercise for 20–30 min each time and 3–5
times a week. The appropriate exercise intensity is one that
does not cause fatigue the next day.
COVID-19 is not only a public health incident but
also a psychological crisis.
62
The UK Household
Longitudinal Study (UKHLS) revealed that 1 month
after the implementation of the British football ban, the
prevalence of people with clinically signicant mental
pain rose from 18.9% in 2018–2019 to 27.3% in
April 2020.
63
In cancer patients, reduced parasympathetic
tone may also be related to a long disease course and
short survival.
64,65
Yoga, Tai Chi, Qigong, and others can
change the structure of the brain, regulate physiological
activities, help alleviate psychological pressure, improve
autonomic nervous system balance,
66,67
and regulate
sympathy by improving central activity under the
stress–parasympathetic nerve output. Practicing Tai Chi
and Qigong may reduce the sympathetic nerve tension,
increase the parasympathetic nerve tension, and improve
the peripheral autonomic nerve activity.
68,69
In addition,
the training content of alternative exercise traditions is
simple and requires minimal equipment and venues. In
the context of the COVID-19 pandemic, these forms of
exercise are safer and more natural than other sports
activities. Moreover, they may be easy to promote and
can alleviate the subhealth of the public.
In summary, this study re-evaluated the published SR/
MAs of alternative exercise traditions for cancer treatment
and provided an important reference for the application of
alternative forms of exercise in the eld of cancer treat-
ment. However, as this study only included Chinese and
English literature, the research conclusions obtained may
have certain limitations. Moreover, the methodological
quality and standardized treatment reporting of the SR/
MAs included in this study need to be improved.
Researchers are recommended to strictly follow the
AMSTAR scale and PRISMA statement when writing
SR/MAs so as to provide high-quality research and
provide a scientic and reliable reference for clinical diag-
nosis and treatment decisions. The topic of alternative
exercise tradition for cancer intervention is still a hotspot
in international research. Researchers can pay close atten-
tion to the improvement of the preliminary design plan,
publication status, literature search, conict of interest, etc.
Conclusions
In conclusion, the methodological quality of the systematic
evaluations of the intervention effects of alternative exer-
cise traditions on cancer patients is not highly satisfactory.
Therefore, we suggest that focus should be directed to the
improvement of the preliminary design scheme, publica-
tion status, literature retrieval, conict of interest, and
other aspects. Under the current situation of strict preven-
tion and control of the epidemic and the promotion of self-
isolation at home, alternative exercise traditions should be
encouraged and promoted as early as possible.
Professionals can develop appropriate exercise alternatives
to ensure the expected effect of exercise while ensuring the
safety of patients. At the same time, the application of
alternative exercise traditions to the prevention of COVID-
19, its auxiliary treatment, and the rehabilitation of
affected patients should be strengthened so as to continu-
ously optimize the program.
Acknowledgments
This study was supported by Zhangjiagang City Science
and Technology Support Program (Social Development)
[ZKS1924]; Zhangjiagang City Health Youth Science and
Technology Program [ZJGQNKJ202009]; Hospital-level
Program of Zhangjiagang Hospital Afliated to Nanjing
University of Chinese Medicine[zzyq1905].
Disclosure
The authors have declared that they have no competing
interests.
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