Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2020-046188 on 21 April 2021. Downloaded from Effects of traditional qigong exercise on ankylosing spondylitis: a protocol for systematic reviews and meta- analysis Wei Liu ,1,2 Yihua Fan ,1,2 Renhong Wan ,3 Longmei Zhao,1 Hang Lu,1 Rongjun Liao,1 Zhining Zhuang,1 Xiaoping Guo1 To cite: Liu W, Fan Y, Wan R, ABSTRACT Strengths and limitations of this study et al. Effects of traditional Introduction Ankylosing spondylitis (AS) is a recurrent qigong exercise on ankylosing autoimmune disease that is associated with a high ► This study will present, for the first time, a compre- spondylitis: a protocol for disability rate, which has a profound negative impact on systematic reviews and hensive systematic evaluation and meta- analysis of daily life. It has been clinically reported that traditional meta- analysis. BMJ Open traditional functional therapy in treating ankylosing qigong exercise has certain therapeutic advantages in 2021;11:e046188. doi:10.1136/ spondylitis (AS). treating AS; however, this postulation is not evidence- bmjopen-2020-046188 ► We will offer an evidence-based framework for using based. Therefore, this study will aim at systematically traditional methods to treat AS in a clinical setting. ► Prepublication history and appraising the validity and safety of traditional qigong ► Due to the diverse range of functional exercises, additional supplemental material exercise in treating AS. for this paper are available heterogeneity risk may increase. Methods and analysis We searched the English online. To view these files, ► We only included studies in Chinese and English lan- (PubMed, Embase, Web of Science and the Cochrane please visit the journal online guages, which may increase the risk of bias. (http:// dx. doi. org/ 10. 1136/ Library) and Chinese databases (China National Knowledge bmjopen- 2020- 046188). Infrastructure, Wan fang, VIP and Chinese biomedical database) for relevant information. Additionally, the Baidu WL and YF contributed equally. Academic and Google Academic databases were manually 5–6 years.23 It presents with various clinical searched to mine relevant information. Randomised features in its clinical course, with a third of WL and YF are joint first authors. controlled clinical trials of traditional qigong exercise in the patients developing severe disabilities. Received 25 October 2020 treating AS were searched from the establishment of Back pain, ankylosis, limited chest expansion Revised 27 March 2021 the database to September 2020. Quality articles were and limited spinal activity often occur in the http://bmjopen.bmj.com/ Accepted 09 April 2021 extracted and independently evaluated by two researchers early stages of the disease, resulting in occu- before inclusion in this study. Meta- analysis of the included pational disability and economic burden.5 articles was performed using the RevMan V.5.3 software. Ethics and dissemination This study will not involve Currently, non- steroidal anti- inflammatory primary data collection, and formal ethics approval agents are the main therapeutic options for will, therefore, not be required. We aim to publish this symptomatic AS. However, these medica- systematic review in a peer- reviewed journal. tions exert various side effects to the cardio- Trial registration number CRD42020207057. vascular system, gastrointestinal tract and kidney. Besides, the anti- tumour necrosis on September 28, 2021 by guest. Protected copyright. © Author(s) (or their employer(s)) 2021. Re- use factor (TNF) biologics used to treat AS are permitted under CC BY- NC. No INTRODUCTION associated with adverse side effects and are commercial re- use. See rights Ankylosing spondylitis (AS) is a chronic expensive.6 Exercise is the main scheme for and permissions. Published by systemic autoimmune disease that affects the non- drug treatment of AS. Appropriate exer- BMJ. sacroiliac joints, axial skeleton, peripheral cise relieves pain and relaxes joints, which 1Department of Rheumatism joints, tendon–ligament attachment points improves health and life quality.6 Reason- and Immunology, First Teaching 1 2 Hospital of Tianjin University of and other bony organisations. It is often able exercise programmes can promote the 7 Traditional Chinese Medicine, accompanied by finger inflammation (25%– recovery of body functions in AS. Tianjin, China 50%), uveitis (25%–40%), inflammatory Traditional qigong exercises, including 2 National Clinical Research bowel disease (26%) and psoriasis (10%), all qigong, Tai Chi, Baduanjin, represent one Center for Chinese Medicine 3 Acupuncture and Moxibustion, of which affect the patients’ quality of life. of the preventive and healthcare methods Tianjin, China The average prevalence of AS per 10 000 with the characteristics of traditional Chinese 3Graduate School, Tianjin is 23.8 in Europe, 16.7 in Asia, 31.9 in North medicine, which have been widely used to University of Traditional Chinese America, 10.2 in Latin America and 7.4 in treat Parkinson’s disease, non- specific low Medicine, Tianjin, China Africa.4 This disease is prevalent among those back pain, cancer and other conditions.8–10 Correspondence to aged between 20 and 30 years and affects Its curative effect has been proven to play 11 Dr Wei Liu; more males than females. At its onset, AS is a complementary and alternative role in fengshiliuwei@ 163. com asymptomatic, thus its diagnosis is delayed by some bone and joint diseases, among other Liu W, et al. BMJ Open 2021;11:e046188. doi:10.1136/bmjopen-2020-046188 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-046188 on 21 April 2021. Downloaded from diseases. Moreover, qigong exercise has potential values nationality, race, age, gender and disease duration among in the rehabilitation of patients with COVID-19.12 This others. exercise can increase muscle flexibility, improve cardio- pulmonary functions, enhance joint flexibility, increase Types of interventions muscle strength and relieve joint pain, which are bene- Treatment groups were subjected to traditional qigong ficial for AS.13 exercise (including Tai Chi, Baduanjin, Shi'erduanjin, Traditional qigong exercises, including Tai Chi, Wu changing tendon exercise, five mimic- animal exercises, six- Qin Xi, Liu Zi Jue and Yi Jin Jing, among others have character formula, five elements balance work, Longmen been developed in China for more than 1000 years. These five elements skill, gymnastic qigong, Mawangdui guiding exercises aim at integrating breathing exercises into body technique and qigong) combined with western medicine. movements,14 mental activities, limb movements and There were no restrictions regarding the type of tradi- self- massage to promote blood circulation, regulate the tional qigong exercise, the type of western medicine, immune system, reduce interleukin 6 levels and regu- treatment frequency and treatment course, among other late the inflammatory process.15 16 Clinical studies have factors. The control group was only administered with the confirmed that traditional qigong exercises can improve drug used in the treatment group. the body’s balance and flexibility, improve life quality, as Outcome measures well as alleviate depression and anxiety.17–19 Regular exer- Primary outcomes: cise enhances immunity by improving T cell subset distri- 1. Overall efficiency (we refer to the clinical efficacy eval- bution in human peripheral blood.20 Baduanjin could uation of AS in guiding principles for clinical research fully relax muscles, tendons and ligaments in the whole of new Chinese medicine.27 Clinical cure: ≥75% overall body and to effectively relieve muscle spasm, and to relieve improvement in the main symptoms and signs, with nor- pain.21 It improves morning stiffness of the waist and spine mal or significantly improved or close to normal eryth- in patients with AS21 and relieves body fatigue.22 Tai Chi rocyte sedimentation rate (ESR) and C reactive protein can promote patients’ flexibility, improve the function of (CPR); significant effect: ≥50% overall improvement cardiovascular system, enhance muscle strength, increase in main symptoms and signs with improved ESR and joint flexibility, reduce joint pain and facilitate patient CPR; effective: ≥30% overall improvement in major with AS recovery.10 23 Mawangdui guidance can influence symptoms and signs, with improved or non-improved the structure and function of anterior insula and anterior ESR and CPR; inefficacy: <30% overall improvement in cingulate cortex to regulate emotions,15 improve mood, main symptoms and signs with unimproved ESR and improve physical flexibility and relieve pain in patients CPR. Overall efficiency was defined as clinical cure+sig- with AS.24 nificant effect+effective/total number×100%). Randomised controlled trials (RCTs) have confirmed http://bmjopen.bmj.com/ 2. Bath Ankylosing Spondylitis Disease Activity Index.28 the effectiveness22 25 26 of traditional qigong exercises in Secondary outcomes: treating AS. However, discrepancies among study designs 1. Functional ability (measured using the Bath Ankylosing and curative effects reported in different clinical trials Spondylitis Functional Index.29 have inhibited establishment of its curative effect. There- 2. Ankylosing Spondylitis Metrology Index.29 fore, this systematic review and meta-analysis will aim at 3. Chest expansion (cm). evaluating the efficacy and safety of traditional qigong 4. Nocturnal spinal pain. exercise in the treatment of AS and to provide evidence-