Hui Tan, and Long-Fan Piao

Abstract—Objective: To determine the effect of Baduanjin combined rehabilitation therapy on stroke patients through systematic review and Meta-analysis.Method: computer retrieval Embase and PubMed, Cochrane Library, Clonal,MBJ Journals, CNKI, Web of Science, China resources pool,Weipu Chinese science and technology journal (VIP), service system of Chinese biomedical literature database (CBM), a database of ten thousand Chinese and English in about Baduanjin to the rehabilitation effect of patients with cerebral apoplexy randomized controlled experiment (RCT),are built from library retrieval time until 31 December 2020.Two researchers independently screened the literature,extracted the data, and evaluated the risk of bias in the included studies.RevMan5.3 software and Pedro scale were used to conduct literature quality evaluation and statistical analysis of the study data.For indicators with significant heterogeneity, the heterogeneity was reduced by excluding some literature deviating from the forest map, and then the pooled analysis was performed.Meanwhile, funnel plots were drawn to analyze the publication bias of the included studies.Results: (1) A total of 114 literatures were obtained, and 27 studies, including 23 Chinese literatures and 4 English literatures, with a total of 2526 patients, were obtained after eliminating duplicates and those failing to meet the inclusion criteria.There were 12 outcome indicators involved.(2)Quality evaluation showed that 23 literatures were grade A, 4 literatures were grade B, 16 literatures used simple random method, 4 literatures used random number table method, and 4 literatures used hidden blind assignment method.No selective reporting was found in all the included literatures.(3) Meta-analysis results show that the daily life activities ability (MD = 10.10, 95% CI: 8.75-11.45, P ＜ 0.00001),treatment effectiveness (RR = 1.1, 95% CI: 0.99-1.23, P =0.07), depression (SMD = 1.34, 95% CI: 2.59-0.08, P = 0.04),(BBS MD = 8.58, 95% CI: 4.97-12.2, P ＜ 0.00001), defecate integral (MD = 0.65, 95% CI: 0.92-0.38, P ＜ 0.00001), mental health (SMD = 0.34, 95% CI: 1.6-0.93, P = 0.6), a balance(MD = 6.09, 95% CI: 5.76-6.43, P ＜ 0.00001), the ability to walk (MD = 0.7, 95% CI: 0.43-0.97, P ＜ 0.00001), lower limb FMA (MD = 5.69, 95% CI: 4.66-6.72, P ＜ 0.00001), upper limb FMA (MD = 3.42, 95% CI: 1.53-5.3, P ＜ 0.00004).SF-36(SMD = 0.65, 95% CI: 0.91-2.21, P = 0.41), and BERG (MD =10.43, 95% CI: 9.02-11.48, P ＜ 0.00001), the onset of FMA contrast (MD = 4.77, 95% CI: 3.45-6.1, P ＜ 0.00001).Conclusion: Baduanjin movement as a method of auxiliary and security can help stroke patients get the best curative effect, through the evidence-based analysis can be concluded that the Baduanjin combined rehabilitation therapy for cerebral apoplexy patients postoperative balance function,improved degree of depression, integral, defecate daily life activities ability and psychological health are greatly improved, and can significantly improve the quality of life of patients with clinically and promote patients recover.

Key words—Baduanjin, Rehabilitation treatment, Stroke,

Effect, Meta-analysis

INTRODUCTION

Stroke is one of the common vascular diseases, which is characterized by high morbidity, disability rate and mortality, and seriously endangers the health of the population [1].Stroke affects 15 million people every year and is also the major cause of death and disability worldwide [2].At present, the prevalence of stroke in my country is very severe, especially in rural areas, where the prevalence and incidence rates have risen sharply in recent years.Compared with comparable survey results 30 years ago, the prevalence of stroke in rural areas in my country rose by 155.0% in 2013, the prevalence of urban residents rose by 18.2%, and the incidence of stroke in rural areas increased.31.6%, but the incidence of urban residents dropped by 18.1% [3].The Global Burden of Disease(GBD) 2017 stroke analysis found that although the agestandardized death rate of stroke has decreased from 1990 to 2017 [4], the decline in age-standardized incidence rates was much smaller, indicating that prevention efforts are not as successful as treatment efforts.The results of GBD 2016[5] showed that 87.9% of ischemic stroke DALYs and 89.5% of hemorrhagic stroke DALYs are due to potentially changeable risk factors measured in GBD, suggesting that stroke reduction can be achieved by reducing exposure to risk factors.According to the World Health Organization,effective stroke prevention strategies include reducing related risks High systolic blood pressure, elevated blood lipids, high fasting blood sugar, smoking, low physical activity, unhealthy diet, high body mass index [6], similar to the results of GBD 2016 and GBD 2017 [7].

The age-standardized death rates and prevalence of stroke have decreased over time, but the overall burden of stroke has remained high [8], estimates of disease burden for stroke have been produced by other research groups by meta-analyzing data in the literature on incidence and death,using the literature, administrative hospital records, and cause of death records [9-11].

Although the age-standardized mortality rate for stroke has decreased worldwide over the past two decades, the absolute number of stroke patients is increasing, and the impact is likely to increase dramatically in the future due to the population aging and health transition observed in developing countries [12, 13].Cerebrovascular dysfunction leads to cell death, which is caused by occlusion of cerebral blood flow and cerebrovascular (ischemic stroke)or rupture of the cerebrovascular (hemorrhagic stroke) [14].Sensorimotor disorders (e.g., changes in body sensation and patterns of coordination and balance) are directly related to the inability to initiate voluntary movement or hemiplegia [15].In addition, depressive symptoms are a common complication in post-stroke survivors; About 30%of the survivors will suffer from depression, which may be related to their despair about the future life [16].This greatly affects the daily living activities of patients and reduces the quality of life [17, 18].The number of stroke cases in China has exceeded 7 million; About 70-80% of the surviving individuals lose functional ability and need treatment to improve [19].In the United States, more than 700,000 people suffer from stroke every year [20].Although there are a lot of rehabilitation technology and high-tech equipment for the rehabilitation of stroke patients,but due to the high price, most people cannot pay, and although these equipment and rehabilitation technology can solve part of the physical pain, but for the patient’s mental rehabilitation did not meet the requirements.The Baduanjin Exercise emphasizes the combination of symmetrical body postures, meditative mind and harmonious breathing techniques, and is one of the most common forms of Qigong practiced in China for over 1000 years [21].Compared with Tai Chi and other complex and lengthy forms of exercise, Baduanjin is only composed of eight independent and smooth movements, which has low physical and cognitive requirements and is easier to learn and practice [22, 23].Baduanjin training can not only improve musculoskeletal and neuromuscular functions, but also its unique functions (physical and mental relaxation,mental concentration and breathing control) can also enhance their adherence to Baduanjin exercise, so as to promote mental health [24].Although at present a large number of tests are carried out to investigate eight brocade exercise on the influence of the curative effect after stroke[25-51], but there is no Baduanjin joint rehabilitation therapy for cerebral apoplexy patient’s application effect of system evaluation, therefore, we in order to objectively evaluate the existing about Baduanjin with rehabilitation therapy for cerebral apoplexy application effect of system evaluation on the literature and meta-analysis.The latest information from this study will enable future researchers and clinicians to design and develop effective mind-body exercise programs to accelerate the physical and mental recovery of stroke patients.The information provided by this systematic review can help clinicians and nurses make evidence-based decisions on the use of Baduanjin training for stroke patients through this study.

MATERIAL AND METHODS

Literature Retrieval Strategies

Search Terms(“Baduanjin” OR “Baduanjin exercise”)AND ( “stroke” OR “cerebrovascular disease” OR“cerebral infarction” OR “cerebral hemorrhage”) AND(“curative effect” OR “effect”) AND (“Randomized controlled trial” OR “RCT”) as the English search term;The Chinese search terms were (“Baduanjin” OR“Baduanjin Sports”) AND (“stroke” OR “cerebrovascular disease” OR “stroke” OR “cerebral infarction” OR“cerebral hemorrhage”) AND (“curative effect” OR“effect”) AND “randomized controlled trial”.

Search DatabaseThe Journals were searched by EMBASE, PubMed, Cochrane Library, CLNAHL, MBJ Journals, Web of Science (December 2020), CNKI, VIP,CBM, Wanfang Database and other Chinese and English databases.

Retrieval time rangeRandomized controlled trials(RCTs) on the effect of Baduanjin on stroke were searched from the database establishment to December 2020, with the last retrieval time being December 31, 2020.

Retrieval strategyTake PubMed as an example, the specific retrieval strategy is shown in Table 1.

Inclusion and exclusion criteria

Literature inclusion criteriaThe research Type:published in both English and Chinese RCT, published time for libraries to December 2020.

The object of study: (1) The age of 18 years old or more cerebral apoplexy patients, conforms to the Chinese medical association of the fourth national cerebrovascular disease conference by the criteria for the diagnosis of cerebral apoplexy or the WHO diagnostic criteria set by the 1978, and by skull CT or MRI confirmed; (2) Patients without consciousness disorder; (3) Postmortem survival and observation time were ≥ 1 w; (3) Patients complicated with severe heart, liver and kidney diseases, endocrine and metabolic diseases, tumors, severe malnutrition and severe stroke were excluded.

Intervention measures: the experimental group was given Baduanjin and rehabilitation treatment, and the control group was given routine rehabilitation treatment.

Exclusion criteria(1) Case reports, systematic reviews and reviews of related studies; (2) Clinical studies with incomplete or duplicated data reports; (3) Clinical studies with high loss of follow-up rate or follow-up time inconsistent with study design; (4) In clear description of intervention methods and inability to obtain full-text literature; (4) Clinical studies with incomplete or duplicated data report; (5) Clinical studies with high loss of follow-up rate or follow-up time inconsistent with studydesign.

Literature selection

Using NoteExpress duplication of literature, the two researchers independent review on the topic of each article and abstract, according to include and exclude standards independently selected literature, independent extract data(including year of literature, the author, the object of study baseline characteristics and outcome indicators, etc.), then compare to the extraction of information.If data is missing,contact the author of the literature as much as possible for relevant information.The two reviewers extracted, entered and checked the data according to the predetermined path,resolved the differences through discussion, and contacted the literature author or corresponding author to supplement the missing data.In case of disagreement, the two parties may discuss it or refer it to a third researcher for decision.

Data quality evaluation

The data quality evaluation was performed independently by two people according to Cochrane 5.1.0.From the selected deviation, the implementation deviation,the measurement deviation, the missing bias, the report deviation, and the other deviation.The evaluation and discussion were conducted according to the above criteria,and the final decision on inclusion or exclusion of the literature was made after consensus was reached.If the opinions were not unanimous, the inclusion or exclusion would be decided by a third party.Using physical therapy evaluation evidence database [52] (Physiotherapy Evidence Database, Pedro) for methodological quality evaluation into the literature.0-3 is of low quality, 4-7 is of medium quality, and 8-11 is of high quality [53-54].

Statistical analysis

The software RevMan5.3 was used for statistical analysis.Chi-square test was used for heterogeneity among studies.If I2＜ 50% andP≥ 0.1, there was no heterogeneity among studies, and a fixed-effect model was used for Meta-analysis.If I2≥ 50% andP＜ 0.1, there was heterogeneity between studies, and random-effects model was used for Meta-analysis.Risk ratio (RR) analysis was used for the dichotomous variables, and continuity variables were used.Mean difference (MD) was selected as the effect size.Each effect size was represented by 95%confidence interval (CI), andP＜ 0.05 was considered statistically significant.Sensitivity analysis was conducted by removing references one by one to verify the stability of the results.If the mean or standard deviation difference between included studies is more than 10 times, the standard mean difference (SMD) and 95% confidence interval CI (95% CI) are used.Report statistical results with a 95% CI.Heterogeneity was reduced by excluding some references deviating from the forest map and then combined analysis was performed.IfP＜ 0.05, the difference was significant.Funnel plots were drawn to analyze the publication bias of the included studies.Significant clinical heterogeneity was treated by subgroup analysis or sensitivity analysis, or descriptive analysis only.

RESULTS

Study Selection

A total of 114 literatures were obtained by preliminary search, and 27 literatures were included in the study after eliminating duplicate literatures and non-conforming literatures.The relevant process of literature screening is shown in Figure 1.

Figure 1 Literature screening flow chart

Study characteristics and literature quality were included

Study characteristicsA total of 27 literatures wereincluded in this study [25-51], including 23 literatures in Chinese and 4 literatures in English.A total of 2526 patients with stroke were included in the 27 literatures, all of which were RCT studies.The basic characteristics of the included literatures in this study are shown in Table 2.

Table 2 Quality assessment of included studies (Cochrane Handbook -5.1.0).

Study QualityOf the 27 included literatures, 20 were Grade A and 7 were Grade B.The results are shown in Table 3.Simple random method was used in 16 literatures,random number table method was used in 4 literatures, and hidden blind assignment method was used in 4 literatures.No selective reporting was found in all the included literatures.The results of bias risk assessment are shown in Figure 2 and Figure 3.The evaluation results of the Pedro scale showed that there were 5 included literatures of high quality, 22 included literatures of medium quality and no literatures of low quality, as shown in Table 4.

Figure 2 Risk of bias

Figure 3 Risk of bias project

Table 4 Score of Pedro Scale for included studies

Effects of Baduanjin on stroke-related outcomes

Ability to perform activities of daily livingThree studies compared the activities of daily living of the two groups, and no heterogeneity was found in each study (I2=0%,P= 0.68).The fixed effect model was used to analyze the activities of daily living of the Baduanjin combined rehabilitation treatment group was better than the rehabilitation treatment group (MD = 10.1, 95% CI: 8.75-11.45,P＜ 0.00001), as shown in Figure 4.

Figure 4 Forest chart comparing the abilities of the two groups in activities of daily living

Therapeutic efficiencyFour studies compared the effective rate of the two groups, and no heterogeneity was found in each study (I2= 0%,P= 0.39).Based on the fixed effect model analysis, the effective rate of Baduanjin combined rehabilitation treatment was better than that of the rehabilitation treatment group (RR = 1.1, 95% CI: 0.99-1.23,P= 0.07), as shown in Figure 5.

Figure 5 Comparison of treatment efficiency between the two groups.

The degree of depressionThree studies compared depression between the two groups, the study of heterogeneity analysis shows in between a largerheterogeneity, (P＜ 0.00001, I2= 95%) by using the random effects model analysis, according to the forest figure, heterogeneous sources may be part of the forest figure literature and departures, after eliminating some literature Meta-analysis, heterogeneity analysis showed no big difference, Baduanjin joint rehabilitation treatment and rehabilitation treatment group (SMD = 1.34, 95% CI: 2.59-0.081,P= 0.04) compared to relieve depression in terms of the difference is smaller, as shown in Figure 6.

Figure 6 The depression degree of the two groups was compared in forest plot

BBSFour studies compared BBS between the two groups, the study of heterogeneity analysis shows in between a larger heterogeneity, (P= 0.0002, I2= 95%) by using the random effects model analysis, according to the forest figure, heterogeneous sources may be part of the forest figure literature and departures, eliminate some Meta-analysis literature after the remaining 2 documents,heterogeneity analysis showed (P= 0.83, I2= 0%)Baduanjin joint rehabilitation treatment and rehabilitation treatment group (MD = 8.55, 95% CI: 6.67-10.43,P＜0.00001), as shown in Figure 7.

Figure 7 Comparison of forest maps between two BBS groups

Defecation integralThe two studies compared the defecation scores of the two groups, and no heterogeneity

Figure 7 Comparison of forest maps between two BBS groups was found in each study (I2= 0%,P= 0.48).The fixed effect model was used to analyze the defecation scores of Baduanjin combined rehabilitation treatment was better than that of the rehabilitation treatment group (MD = -0.65,95% CI: -0.92--0.38,P＜ 0.00001), as shown in Figure 8.

Figure 8 Comparison of two groups of defecation scores in forest chart

Mental healthFour studies compared the mental health of the two groups, Between heterogeneity analysis showed that included in the study has great heterogeneity, (P＜0.00001, I2= 97%) by using the random effects model analysis, according to the forest figure, heterogeneous sources may be part of the forest figure literature and departures, after eliminating some literature Meta-analysis,heterogeneity analysis showed (P= 0.24, I2= 0%)Baduanjin joint rehabilitation treatment for mental health is better than the rehabilitation group (MD = 10.09, 95% CI:5.81-14.38,P＜ 0.00001), as shown in Figure 9.

Figure 9 Forest chart comparing mental health of the two groups

Positional balance abilityThree studies compared the orthostatic balance ability of the two groups, and the heterogeneity of each study was relatively low (I2= 39%,P= 0.2).The fixed effect model was used to analyze the orthostatic balance ability of Baduanjin combined rehabilitation treatment was better than that of the rehabilitation treatment group (MD = 6.09, 95% CI: 5.76-6.43,P＜ 0.00001), as shown in Figure 10.

Ability to walkFour studies compared the walking ability of the two groups, and there was no heterogeneity among the studies (I2= 0%,P= 0.62).The fixed effect model was used to analyze the walking ability of Baduanjin combined rehabilitation treatment was better than that of the rehabilitation treatment group (MD = 0.7,95% CI: 0.43-0.97,P＜ 0.00001), as shown in Figure 11.

Figure 11 The walking ability of the two groups is compared in forest map

FMA of lower limbsFive studies compared the lower extremity FMA of the two groups, and there was no heterogeneity among the studies (I2= 0%,P= 0.98).The fixed effect model was used to analyze the lower extremity FMA ability of Baduanjin combined rehabilitation group was better than that of rehabilitation group (MD = 5.69,95% CI: 4.66-6.72,P＜ 0.00001), as shown in Figure 12.

Figure 12 Forest map of lower limb FMA comparison between the two groups

FMA of upper limbThree studies compared the upper limb FMA ability of the two groups, and heterogeneity existed in each study (I2= 71%,P= 0.03).The randomeffect model was used to analyze the upper limb FMA ability of the Baduanjin combined rehabilitation group and the rehabilitation group showed no difference (MD = 3.42,95% CI: 1.53-5.3,P= 0.0004), as shown in Figure 13.

Figure 13 Forest map of upper limb FMA comparison between the two groups

SF-36Five studies compared the SF-36 of the two groups, and the heterogeneity of each study was high(I2=97%, P ＜ 0.00001).Random-effect model analysis showed that there was no difference between SF-36 in Baduanjin combined rehabilitation treatment and rehabilitation treatment group (SMD=0.65, 95%CI -0.91-2.21, P=0.41), as shown in Figure 14.

Figure 14 Comparison of two groups of SF-36 forest map

BergThe Berg ability of the two groups was compared in four studies with low heterogeneity (I2= 6%,P= 0.36).The fixed effect model was used to analyze the Berg ability of the Baduanjin combined rehabilitation group (MD =10.43, 95% CI: 9.02-11.48,P＜ 0.00001), as shown in Figure 15.

Figure 15 The two Berg groups compare forest maps

Comparison of upper and lower limb FMAEight studies compared upper and lower limb FMA capacity between the two groups, there was heterogeneity among the studies (I2= 66%,P= 0.004).The random effect model was used to analyze the FMA ability of upper and lower limbs in Baduanjin combined rehabilitation treatment group and the FMA ability of upper and lower limbs.The recovery of lower limbs was better than that of upper limbs,which may be related to the blood perfusion of upper and lower limbs, and the effect was significant (MD = 4.77, 95%CI: 3.45-6.1,P＜ 0.00001).As shown in Figure 16.

Figure 16 Forest diagram of FMA comparison between two groups of upper and lower limbs

Sensitivity analysisMD is chosen as the effect of the amount.Found that daily life activities ability, efficient treatment, depression, BBS, defecate integral, mental health, establish a balance, ability to walk, lower limb FMA, upper limb FMA, SF-36, Berg’s effect with 95% CI said that the results betweenP＜ 0.00001, the difference was statistically significant.After one by one, remove the literature, the results are consistent with prior to removal of literature, the results are stable.

DISCUSSIONS

Baduanjin application population and rehabilitation effect

The top 10 diseases of Baduanjin application are diabetes, chronic obstructive pulmonary disease,hypertension, coronary heart disease, stroke, cervical spondylosis, hyperlipidemia, lumbar disc herniation,perimenopausal syndrome and knee joint bones.Arthritis.As a traditional Chinese medicine guiding technique,Baduanjin mainly regulates yin and yang, regulates qi and blood, and clears the meridians through physical activities of the upper and lower limbs and trunk to adjust the shape of the body and breathe out [55].

Effect of Baduanjin on cerebral apoplexy patients

An English systematic review only conducted metaanalysis on balance function [56], a Chinese systematic review [57] only compared the results of ADL and neurological function after conventional rehabilitation combined with Baduanjin, and a systematic review assessed the risk factors of acute fatigue in stroke patients[58].A meta-analysis of risk factors related to fatigue after stroke [59].A meta-analysis of the epidemiological characteristics of post-stroke shoulder pain (PSSP) [60].In this study, the ability of daily living of patients was significantly improved compared with that before conventional rehabilitation treatment, and the effective rate of treatment was improved.Although there was no significant difference in the degree of depression, which may be related to the small sample size of the included literature, it also played a certain role in the improvement of patients' depression.On the BBS, defecate integral,mental health, have greatly facilitated patients defecation capacity improvement and recovery of mental health recovery in patients with cerebral apoplexy were green lights, in Baduanjin joint rehabilitation patients after stand balance ability increase, walking ability strengthen, lower limb FMA and upper limb FMA in under the action of the combined intervention makes be modified to improve the quality of life (SF-36), BERG outcome indexes such as upper and lower limbs FMA contrast and found in the lower extremities FMA ability is better than upper limbs FMA ability, may be related to the onset of blood circulation ability is different.

Research Limitations

A few of the 27 studies included in this study did not blind the subjects and researchers, and there may be bias in selection, measurement and implementation.Small sample studies are also greatly influenced by bias, which may lead to low reliability of the results.Only original studies published in Chinese and English up to December 31, 2020 were included in the study.Language and time constraints may introduce selectivity bias, this may affect the reliability of the combined results.

INNOVATION AND INSPIRATION

After fully reading a large number of relevant literatures,this study made a systematic review of the combined rehabilitation treatment for stroke patients compared with rehabilitation treatment alone.It was found that the combined intervention measures of the two improved the defecation ability of patients with mild stroke, increased the function of the patient's urinary system, and promoted the recovery of the body.In this study, we conducted a systematic evidence-based medicine review of studies that have not yet been conducted, including walking ability,daily living ability, upper and lower limb FMA and comparison of upper and lower limb FMA.

It is suggested that a more reasonable design should be carried out in future studies, and the required sample size should be estimated before the experiment and the blind method should be implemented for both subjects and researchers.Observe the clinical effects of Baduanjin combined rehabilitation therapy in patients with different intervention cycles and different age stages, so that the conclusions obtained have enough credibility, and confirm the research conclusions, making Baduanjin combined rehabilitation therapy become the intervention mode of stroke patients.

As mentioned in the review, although this systematic review has its own limitations, most of the included studies have a small sample size, and some RCTs are biased in terms of quality methodology.However, compared with rehabilitation treatment, Baduanjin combined rehabilitation treatment for stroke patients has no adverse events and is safe and feasible.Therefore, the conclusion that Baduanjin combined rehabilitation has obvious effect on stroke patients and is better than conventional rehabilitation treatment is well documented.

ACKNOWLEDGMENT

The authors did not receive any funding for this study.

Competing interests:The authors declare that they have no conflict of interest.

Citation:Tan H, Piao LF.The efficacy of Baduanjin combined rehabilitation therapy on stroke patients: A Meta-analysis.2021;4(4):20.doi: 10.53388/TMRND 20211004001.

Executive editor:Jin-Feng Liu.

Submitted:04 October 2021,Accepted:17 November 2021,Online:23 November 2021

? 2021 By Authors.Published by TMR Publishing Group Limited.This is an open access article under the CC-BY license (http://creativecommons.org/licenses/BY/4.0/)