Aldridge, D. and Reuther, I.

2001 A Single case Approach to Qigong

A Single Case Approach to Qigong Yangsheng as a Complementary Therapy in the Management of Asthma David Aldridge and Ingrid Reuther
Abstract Objectives Qigong Yangsheng, the healthpromoting method of Traditional Chinese Medicine combining movement, mental exercise and breathing technique, is used in China for the therapy of bronchial asthma and for some time now has been enjoying an ever-widening acceptance in the Western world as well. This pilot study investigates if Qigong Yangsheng could be used as complementary therapeutic measure to treat asthma patients in a Western industrialised country. Design Thirty asthma patients, with varying degrees illness severity, were taught Qigong Yangsheng under medical supervision. They were asked to exercise independently, if possible, on a daily basis and to keep a diary of their symptoms for half a year including peakflow measurements three times daily, use of medication, frequency and length of exercise as well as five asthma-relevant symptoms (sleeping through the night, coughing, expectoration, dyspnea and general well-being). The concept of this Qigong is an integral part of Traditional Chinese Medicine. The word "Qigong" incorporates two concepts: The first is "Qi" meaning breath, steam, mist, breeze, energy. In this study we are using it in the same sense as vital force or energy of life. A second concept is "Gong" meaning exercise in the sense of a permanent, diligent and persistent practice. It also means to "master a technique". "Qigong" can be translated as "training with the vital force", "persistent practice to increase the energy of life". "Yangsheng" means care of life 1 study was based on a single-case research design series with baseline, one teaching phase, a phase of self-practice and a refresher teaching course. A fourweek follow-up period was carried out in the same season as the original baseline phase 52 weeks later. Results An improvement was indicated if subjects showed a decrease of at least 10 percent in peak-flow variability between the first and the fifty-second week. This occurred more frequently in the group of the exercisers (n =17) than in the group of non-exercisers (n =13) (p<0.01 chisquare with Yates correction). When comparing the study year with the year before the study, there was improvement also in reduced hospitalisation rate, less sickness leave, reduced antibiotic use and fewer emergency consultations resulting in reduced treatment costs. Conclusion Qigong Yangsheng. is recommended for asthma patients with professional supervision. An improvement in airway capability and a decrease in illness severity can be achieved by regular selfconducted Qigong exercises. and further qualifies the use of practice as a gentle, therapeutic form of exercise. In modern China, the practice of Qigong is widespread and enjoys an everincreasing popularity. Approximately 7080 million Chinese practice Qigong on a regular basis, mostly in the mornings in the parks, in groups or alone, standing, walking or sitting. There include exercises utilising movement (donggong) and rest (jinggong). It is perhaps the gentle and harmonising approach of Qigong that has led it to be readily accepted in Western society as a health-

Aldridge, D. and Reuther, I. 2001 A Single case Approach to Qigong

promoting exercise in which Europeans are becoming increasingly interested 1, 2. However, Qigong is also used as a therapeutic method applicable to chronic diseases and there are hospitals in China specialising exclusively in this approach. Good results have been achieved in the treatment of high blood pressure, gastric ulcers and asthma 3, 4. A challenge to the adoption of Qigong as complementary medical approach is that it has yet to prove an efficacy that will satisfy a European culture of health care delivery 5, 6, 7, 8 For this reason a small pilot study on the effectiveness of Qigong and its appropriate delivery as an health care approach was started in 1994. Breath Ttraditional forms of medicine, Aryuveda and Unani (Greco-Arabian) have a vitalist epistemology based upon the physician as activator of the seven natural principles which adminster the body (elements, temperaments, humours, members, vital breaths, faculties and functions). In this sense, after Hippocrates, Nature heals; the physician is natures assistant. Breath is an important factor in activating the patient. Vitality itself derives from viva, Let him live. The breath carries such a living force. Breath and spirit share the same root, in Latin spirare, which later becomes spiritus, life breathed as the Holy Spirit. Life has the quality of inspiration and is heard in biblical texts as I am the Breath of Life. Similarly the Greek anemos and the Latin anima are translated as wind and breath. Thus we have the ideas of vitality and animation being achieved through the inspiration of the breath, or pneuma in Unani medicine, which is the conveyor of the spirit and activates, through its various parts, particular systems. It is Breath, in the Christian Bible Old Testament, that animates the dry bones with vitality such that they love. Today Aryuvedic medicine, yoga and some forms of Traditional Chinese medicine still utilise the regulation of breathing as an important factor in healing.

We understand others, and are ourselves understood, by the way in which we breathe. At its simplest and coarsest, we know when another person is happy, sad or anxious through their breathing. Beyond that, there are levels of subtle understanding inherent in the projected breath. This has ramifications for counselling, therapy and for all medical encounters 5. Asthma Asthma was selected as target disease for this clinical study for several reasons. First, asthma is an illness in which any improvement or deterioration can be measured easily, the most simple method being with the aid of a peak-flow measuring device (PEFR = peak expiratory flow rate) 9, 10. Second, asthma is a very frequent disorder. At least 5 percent of Germans suffer from asthma and some authors even refer to asthma as a national disease 10, 11 . It was relatively easy to find enough patients willing to participate in a study. Recruitment to a study is often a stumbling block, particularly when an unconventional approach, within a health care delivery framework, is being introduced. Furthermore, Qigong is demanding in that it expects the patients to actively comply with his or her own treatment, it is as educative as it is curative. Indeed, both are inextricably linked. Third, there is currently no medication with which asthma can be cured 12. The German League for Respiratory Conditions offers a set of recommendations for the management of asthma 13 that follows a step-by-step plan with the intention of achieving the best possible pulmonary function values with the least possible side effects of medication. Despite this step-by-step plan, and proven effective pharmacological medicines, the degree of severity (mortality) and frequency (morbidity) of the disease are increasing.

Aldridge, D. and Reuther, I. 2001 A Single case Approach to Qigong

The situation is extremely unsatisfactory 4, 14, 15 . An approach that leads to an improvement in pulmonary function with the least possible side-effects needs to be urgently examined. Fourth, asthma is an expensive disease to manage. At the University of Hannover it was found that - depending on the severity of the disease - direct costs in the amount of between DM2.000,- and DM7.500 annually per adult asthmatic are incurred. If additional costs arising from the inability to work are included the we arrive at an annual figure of DM13.000 per person with severe asthma 16. At a time when fiscal considerations are an important part of health care delivery, the possibility of adopting a relatively inexpensive complementary therapy becomes attractive. Complementary forms of therapy can be assessed for efficacy including their cost-benefit ratio 5. Qigong is reported to be successfully employed in China for the treatment of asthma 17, yet what we needed to discover was how such an approach be readily incorporated into European practice while also remaining true to the peculiarities of the Qigong Yangsheng method 2, 18 It is important in the incorporation of approaches taken from another health care culture that we retain aspects of the therapy that are appropriate when we design our research method 19. Our hypothesis was that Qigong Yangsheng would have both a subjective and objective influence on patients suffering with chronic asthma leading to an cost-effective treatment that could be made available to community medicine. Method As the persons exercising Qigong are active in their treatment, they are knowledgeable and must be informed to master the method, then there was no opportunity for double-blinding. Furthermore, these patients were also responsible for making regular readings

of their own lung function, thus being aware of their own progress. Although a cross-over design is suggested for studies on acupuncture 20, this methodology is also problematic for our approach. A cross-over design assumes that once the active agent is removed then the patient will revert to a previous state. In Qigong Yangsheng, the assumption is that the person learns at each stage and that the learned abilities, however small, cannot revert. Once a patient has recognized the value of regular Qigong exercises it is debatable if he would be willing to omit those exercises in the second phase of a cross-over study. Another reason for not using a controlled trial was that we needed to know if teaching Qigong was acceptable to patients in a Westernised health care setting, the frequency and form of that teaching should take, if there were objective variables related to peak air flow, what subjective variables were available comparable with other studies, and what was the relevant treatment group in terms of asthma disease staging and current medication. Only when we had asked such preliminary questions as these could we begin to consider what treatment variables needed to be controlled and what needed to be assessed 19, 21. In simple terms we did not know the dose-response relationship and therefore we did not know what to control in a controlled study. For the present pilot study a single-case research design was chosen, although the difficulties related to learning still apply 22, 23, 24. In this study the respective patient at first is only compared with himself. Individual differences in learning capacity and implementation of learned matter, as well as duration, frequency and mastery of the exercise result in a different effectivity of the Qigong exercises and hence take widely varying courses. In a single case study one can take these aspects into account 25. What the single case design lends itself too is a structured series of

Aldridge, D. and Reuther, I. 2001 A Single case Approach to Qigong

interventions and observation phases (see Figure 1). Peak-flow measurement 26, use of prescribed medication, and diary entries of symptoms (sleeping through the night, coughing, expectoration, dyspnea and general well-being) and exercise were monitored during the successive phases. Peak flow measurement can be done by the patient using a small portable device

from the study during a no-therapy phase. There was then a six month phase (C2) where no treatment was offered, followed by a four-week follow-up phase comparable to the baseline period (see Figure 1). The follow-up period was initiated one year after the study began. This is especially advisable in the case of asthma since widely diverging seasonal fluctuations occur in the course of this

Figure 1: Phases of observation, exercise and self-practice in a single-case study design Daily peak flow and diary recording Baseline data
4 weeks
Peak flow and diary

Qigong course
8 weeks

Self-practice
8 weeks

Qigong refresher course

4 weeks

B2

Self-practice
Six months

C2

Follow -up
4 weeks

A2

* * comparative data points

week 1, week 10, week 20 and week 52 as seen in Figures 2-5

and the regular measurement of peak flow is recommended to monitor the efficacy of new forms of asthma treatment 11. An improvement may also be noticed by a decreased need of medication. In addition symptoms like coughing, expectoration and sleeping through the night may be assessed on an evaluation scale. There are then, a variety of parameters, quantitative and qualitative, available for evaluation. A four-week baseline phase (A) was important to assess the initial problem. An eight-week treatment phase (B) followed that included the instruction of Qigong in conjunction with a request to exercise daily if possible. The next phase (C), again for eight weeks, followed involving no instruction from a teacher (this phase was as long as the treatment/instruction period in phase B). A four-week treatment phase (B2) followed to avoid discharging the patient

disease. Therefore, disease activity was compared in each case before and after treatment in the same season. At the time of the follow-up, none of the study participants were enrolled in an active exercise course. As we will see later, from the structure of the study and the use of patient diaries, it was possible to make a distinction between patients that had been exercising independently and non-exercising ones. This point is not without importance, as there is a general concern about the non-compliance of medication by asthma sufferers 27 and such a study as this, which offers both treatment and health promotion, should offer those elements of negotiation and accommodation necessary for an improved provider-patient relationship 28 . Thirty adult asthmatics, 23 females and 7 males, of all degrees of asthma severity, completed the study.

Aldridge, D. and Reuther, I. 2001 A Single case Approach to Qigong

Exercises and exercisers The 15 expression forms of TaijiQigong developed by Professor Jiao Guorui were taught 29. These exercises can be done standing or sitting so that they can be adapted to the physical strength of the patient. They are easy to learn, may be modified with ease, are versatile and well-balanced and can be practised out of sequence. A definite exercise, from which a special effect would be derived, is of less importance than the positive effect brought about by the harmonious unity of physical movement, mental calm and naturally flowing breathing. For reasons of time, and to avoid overtaxing the participants by too great a variety, only three preparatory exercises, the first seven of the 15 expression forms and the five final exercises were selected. The Qi-Gong instructors were all physicians personally trained in this method. Instruction took place once a week for eight weeks on an out-patient basis. Patients still regularly exercising independently at follow-up are classified in this study as exercisers. Improvement To assess the responsiveness of the peak-flow measurements we calculated the amplitude of the peak flow values relative to the highest value as a percentage 12. This is known as variability. Variability correlates to the degree of severity of the disease and to the degree of inflammation in the respiratory tract 30. The normal range is below 10 percent 11. A successful therapy can be assessed from the diminishment of variability 31 In severe cases the variability may be 50 percent or higher 32. A good management of the disease is recognized when the variability is under 20 percent 31 or, even better, under 10 percent 11. In this study a patient was considered improved when a diminishment of 10

percent points or more in variability from the first to the 52nd week was achieved, provided the average of the peak flow values remained constant or increased and the medication required either remained the same or could be reduced. Results Patient 1 In Figure 2 we show the peak flow measurements and the medication required by a male patient, 38 years old, who was classified as an exerciser at follow-up. His peak-flow variability improves and his use of medication diminishes. Three peak-flow values are obtained in one day. The vertical lines mark delineate one week. Week one was chosen from the baseline test phase A. Week 10 is a week during the Qigong course (Phase B). Week 20 is a week during the independent exercise (Phase C) and Week 52 occurs in the follow-up phase. We can observe the typical circadian fluctuations in peak-flow with the lowest values mostly in the mornings 32. The horizontal line in Figure 2 defines the average peak flow values from the first week and is meant to facilitate the visual recognition of a trend in variability. At enrolment, this patient had a variability of 40 percent despite the fact that he was under continuous care of a pulmonologist and took a number of medicines. From the beginning of the study he exercised regularly. Initial successes can be seen during the 10th week. His peak-flow variability reduced to 12 percent and can be described describe as good asthma management. This improvement carried on to the 52nd week. His use of medication decreased from 133 ingestions of 4 remedies a week to seven ingestions of a single remedy (once a day) at follow-up. The patient is thus classified as an exerciser and as improved. Patient 2 A 40 year old female patient suffered from a mild form of asthma (Figure 3).

Aldridge, D. and Reuther, I. 2001 A Single case Approach to Qigong

She used her only medication, a cortisone spray, at times of a respiratory infection. During the weeks depicted here there was no need for medication. Although she had an initial variability of 20 percent, her baseline assessment was better than most of the other subjects in the study. She complained of daily symptoms; pain during breathing and anxiety attacks. With Qigong she was able to decrease peak-flow variability to 3 percent. These findings are within the normal range. Subjectively, she expressed a feeling of control and the daily symptoms of pain and anxiety disappeared. She was classified as an exerciser and improved. Patient 3 This 30 year old male patient, in Figure 4, initially exercised diligently and with good results especially with regard to the stress-related component of his symptoms. By standing like a pine tree for five minutes he achieved the same effect with the exercise as by the inhalation of a beta-mimetic. However, he discontinued the exercises because of lack of time and the initially improved values revert to the base line range. He continued with the same doses of medication. He was classified as nonexerciser and unimproved. Patient 4 In Figure 5 we see the results of a 34 year old male patient who only exercised during the Qigong training. He typifies the majority of the non-exercisers in that peak flow values, and variability, remained in the same range for the entire year. He continued to use the same amount of medication throughout the year medication. He continued with the same doses of medication. He was classified as non-exerciser and unimproved. Results Exercisers and non-exercisers The graphic examples in Figures Two to Five are representative of the varying types of patient exercise responses illustrating the variability of peak-flow at varying stages. A benefit of single-case designs is that it is possible to see the

change in a given variable graphically. If we then calculate the significance of exercise related to improvement, according to our aforementioned criteria (see Table 1), then we obtain a statistically relevant description of exercise being related to clinical improvement (p<0.01 chi-square test with Yates correction). Short-term changes While our principal concern was to determine the long-term clinical changes associated with Qigong for the purposes of clinical trial design, we also found that a short-term effect was indicated. An immediate effect of the Qigong exercises was noted in broncho- spasmolytic action (Figure 6). Two subjects are shown here who were successful from the first hour of the course. This effect can be achieved by some patients after just a few minutes with the preparatory exercise Standing like a pine tree Such immediate effect motivates the patients to continue exercising. They see and feel an immediate improvement. Furthermore, the technique, when observed by the patient himself, can be used as a countermeasure in a situation of respiratory distress. Once patients gain confidence in the method, and experience a change in peak-flow activity, then it is possible for them to envision possible long-term benefits. Not all participants noticed this immediate effect. However, all of the exercising subjects improved their exercise capabilities to such extent that they could register this positive effect at the one year follow-up. We would also argue for the potential of Qigong Yangsheng for the relief of acute symptoms for experienced exercisers. Cost effect Qigong is not only clinically viable as a form of treatment, it is cost-effective (see Table 2). In 1995 a Qigong course with medical supervision in Bonn cost between DM 64,(non-profit organisation) and DM 200,- (private organisation). Thus, the annual maximum (3 Qigong courses) would amount to between DM 192,- and

Aldridge, D. and Reuther, I. 2001 A Single case Approach to Qigong

DM 600,-. The peak flow measuring device was not included in this calculation since it should be a standard requirement for every asthmatic (cost according to model, approx. DM 50,-) Even when assessing the maximum possible costs for Qigong instruction at DM 600,- this means an annual savings of DM 2,500 per patient. In these calculations we have included all 30 subjects enrolled in the trial, not simply the improved exercisers. Conclusion Qigong Yangsheng can lower the cost of asthma treatment, brings no additional expenses and has a potential for long term savings in health care costs. For those countries where there is private health care insurance, where the costs are shared by the employer and patient, then employers, especially larger companies, may be interested in offering Qigong exercises at the workplace. If 5 percent of the population suffer with asthma, then health insurance companies should have a serious interest in Qigong Yangsheng as a means of curbing costs. The benefit for the exercising patient is that improved pulmonary function means better breathing and for some patients a feeling of control over their own illness. A diminished PEF-variability from the range of between 40 and 50 percent to under 20 percent means a diminution of potentially life-threatening attacks. Qigong Yangsheng enables the patient to take an active part in his recovery process, he is not just exclusively the inactive recipient of treatment but becomes now an active participant exerting influence on his condition. The learning element in Qigong is an important principle of prevention. What we see from this study is that motivation plays an important role and that 50% of those enrolled in the study failed to continue exercising once the second teaching course was concluded. This reflects the concern expressed in the literature related to asthma patient compliance and health-care beliefs about treatment and identity 27.

In terms of research trials design we see the benefit of a single case approach. First there is an graphic overview of a change in symptoms. Peak-flow values can be plotted and inspected to see if they make clinical sense for the patient concerned. Patient subjective diary reports, when confined to restricted data collection periods at strategic times during the treatment process, are valuable for feedback in terms of what the patient herself identifies as being clinically significant. Second, we can identify the potential problems for a bigger research study. It would be necessary to control for exercisers and non-exercisers. As the results at 20 weeks would have been different from those at the 52 weeks follow-up, it is important to assess the long terms benefits of complementary therapy approaches that include an element of prevention and a learned technique. Third, the clinicians participating in such a study, both as trainers and referrers, have the chance to experience the research process as applied to clinical practice. In pragmatic terms, while a large scale clinical study is delayed, this delay means that the appropriate treatment is indicated and the ramifications of the treatment approach fully understood. Researchers and clinicians in a further study are clear about what they need to know in terms of data collection and recruitment and the clinical relevance of the trial for the defined population being studied. A matched-control study could be planned but the element of exerciser/non-exercise will always be a thorny problem. This means that when a statistician is contacted, the dependent and independent variables can be recognised. For experienced clinicians, who may be novice researchers, there is an opportunity to become conversant with clinical research through practice. Finally, this research takes as its parameter of recovery those suggested by the patient too contributing that offers a relevance for this work to the population of sufferers. If thirty single-case designs like this were collected over the course of a year from five interested clinicians, then we

Aldridge, D. and Reuther, I. 2001 A Single case Approach to Qigong

would have had a clinical database of 150 asthma studies. Over a five-year period, we could have a collection of 750 singlecase studies with an agreed formal design structure. Such a process could be repeated for other complementary therapies or other diseases. While this approach may not rival the large-scale

trials for complementary therapies that are impressing the established medical journals, for the clinician in practice it would be a valuable resource that is within his or her own capability. For a group of practitioners interested in beginning research this would be an ideal starting point for researching by doing.

1. Hildenbrand, G. Qigong Gesundheitsfrdernde bungen der traditionellen chinesischen Medizin. Therapeutikon 1989; 3(9): 483-489. 2. Jiao, G. Qigong Yangsheng, Gesundheitsfrdernde bungen der Traditionellen Chinesischen Medizin . Uelzen: Medizinisch Literarische Verlagsgesellschaft, 1994. 3. Hua, H, Shao-bai, G, Jie-mei, W, Wanchun, C, Wen-yan, W and Wen-yuan, S. Volkskrankenhaus Nr. 6 der Stadt Shanghai, Follow-up-Beobachtung des Therapieeffekts einer integrierten Behandlung mit Schwerpunkt auf Qigong von 107 Patienten mit schwerem Asthma bronchiale, (bersetzung von Michael Hammer). Shanghai-zhong-yi-yao-za-zhi 1962; 2: 34-36. 4. Sly, RM. Mortality from asthma. J Allerg Clin Immunol 1989; 84(4 pt 1): 421-434. 5. Aldridge, D. Spirituality, healing and medicine. London Jessica: Kingsley Publishers 2000. 6. Fisher, P and Ward, A. Complementary medicine in Europe. BMJ 1994; 309: 107110. 7. Hege, H. Das Lannoye-Papier: Alternativmedizin im Europischen Parlament. Deutsches rzteblatt 1995; 92: 2312-14. 8. Lane, DJ and Lane, TV. Alternative and complementary medicine for asthma. Thorax 1991; 46: 787-797. 9. Magnussen, H and Wettengel, R. Das PeakFlow-Meter. Med. Klin 1993; 88: 720723. 10.Editorial. Internationaler Konsensusbericht zur Diagnose und Behandlung des Asthma bronchiale. National Heart, Lung and Blood

Institute, Bethesda. Pneumonologie 1993; 47(Special issue 2): 245-288. 11.Nolte, D. Asthma, das Krankheitsbild, der Asthmapatient, die Therapie . Mnchen: Urban & Schwarzenberg, 1995. 12.Boulet, L-P, Turcotte, H and Brochu, A. Persistence of airway obstruction and hyperresponsiveness in subjects with asthma remission. Chest 1994; 105: 1024-1031. 13.Atemwegsliga, D. Empfehlungen zum Asthmamamagement bei Erwachsenen und Kindern. Pneumonologie 1994; 48: 270277. 14.Crane, J, Pearce, N, Beasley, R and Burgess, C. Worldwide worsening wheezing - is the cure the cause? Lancet 1992; 339: 814. 15.Niggemann, B. Nehmen Todesflle durch Asthma bronchiale zu? Eine aktuelle bersicht. Atemw Lungenkrkh 1991; 17(9): 435-452. 16.Schulenburg, J-M. Kongrebericht, Asthma und seine Folgen. Medical Tribune 1995; 46: 9. 17.Wersche, K. Klinische Studien aus China ber den Effekt von Qigong bei Asthma bronchiale, Ulcus ventriculi et duodeni und Hypertonus. Jahresheft fr Qigong Yangsheng 1994; : 42-49. 18.Reuther, I. Qigong Yangsheng als komplementre Therapie bei Asthma: eine Pilotstudie. Witten Herdecke, 1997. 19.Aldridge, D and Pietroni, P. The clinical assessment of acupuncture for asthma therapy. J R Soc Med 1987; 80: 222-224. 20.Linde, K. Randomized clinical trials of acupuncture for asthma - a systemic review. Forsch Komplementrmed 1996; 3: 148155.

Aldridge, D. and Reuther, I. 2001 A Single case Approach to Qigong

21.Aldridge, D and Pietroni, P. Research trials in general practice: towards a focus on clinical practice. Family Practice 1987; 4: 311-315. 22.Aldridge, D. The needs of individual patients in clinical research. Advances 1992; 8(4): 58-65. 23.Aldridge, D. Single-case research designs for the clinician,. J R Soc Med 1991; 84: 249252. 24.Aldridge, D. The single case in clinical research. In: Hoskyns S ed. Proceedings of the Fourth Music Therapy Research Conference. London: City University, 1988: 3-10. 25.Aldridge, D. Single case designs - an extended bibliography. Complementary Medical research 1991; 5(2): 99-109. 26.Enright, PL, Lebowitz, MD and Cockroft, DW. Physiologic measures: Pulmonary Function Tests in Asthma Outcome Measures. Resp Crit Care Med 1994; : S9S18.

27.Adams, S, Pill, R and Jones, A. Medication, chronic illness and identity: the perspective of perople with asthma. Soc. Sci. Med. 1997; 45(2): 189-201. 28.Lerner, B. From careless consumptives to recalcitrant patients: the historical construction of noncompliance. Soc. Sci. Med. 1997; 45(9): 1423-1431. 29.Jiao, G. Die 15 Ausdrucksformen des TaijiQigong . Uelzen: Medizinisch Literarische Verlagsgesellschaft, 1995. 30.Higgins, BG, Britton, JR, Chinn, S, Cooper, S, Burney, PGJ and Tattersfield, AE. Comparison of bronchial reactivity and peak expiratory flow variability measurements for epidemiologic studies. Am Rev Resp Dis 1992; 145: 588-593. 31.Geisler, LS. Der Asthmakranke - ein schwieriger Patient? . Mnchen: Medikon Verlag, 1990. 32.Hetzel, MR and Clark, THJ. Comparison of normal and asthmatic circadian rhythms in peak expiratory flow rate. Thorax 1980; 35: 732-738.

Figure 2: A male exerciser with improved peak flow variability and diminished medication. Peak-Expiratory-Flow-Rate (3 values/day)
l/min
500 450 400 350 300 250 200 150 100 50 0

week 1 week 10 peak flow average week one

week 20

week 52

Week 1 : PEF min: 280 l/min, PEF max: 480 l/min, PEF med: 390 l/min, PEF variability: 40% Week 20: PEF min: 380 l/min, PEF max: 440 l/min, PEF med: 400 l/min, PEF variability: 14% Week 52: PEF min: 390 l/min, PEF max: 440 l/min, PEF med: 420 l/min, PEF variability: 12%

Use of Medication
Applications/week
45 40 35 30 25 20 15 10 5 0

med 1 med 2 med 3 med 4 med 5 med 6 med 1 med 2 med 3 med 4 med 5 med 6 med 1 med 2 med 3 med 4 med 5 med 6 med 1 med 2 med 3 med 4 med 5 med 6

week 1

week 10

week 20

week 52

Medication 1: ForadilDA = Formeterol 12mcg Medication 2: ApsomolDA = Salbutamol 0,1 mg Medication 3: Cromohexal DA = Cromoglicinsure 1mg Medication 4: PulmicortDA = Budesonid 0,2 mg

Figure 3: A female exerciser with improved peak flow variability. Peak-Expiratory-Flow-Rate (3 values/day)
l/min
350

300

250

200

150

100

50

week 1 week 10 peak flow average week one

week 20

week 52

Week 1 : PEF min 250 l/min, PEF max 310 l/min, PEF average 295 l/min, PEF variability 20% Week 20: PEF min 280 l/min, PEF max 305 l/min, PEF average 305 l/min, PEF variability 13% Week 52 : PEF min 330 l/min, PEF max 340 l/min, PEF average 334 l/min, PEF variability 3%

Figure 4: An initial male exerciser with peak flow variability that reverts to base levels when he ceases to exercise (classified as non-exerciser). Peak-Flow-Measurement (3 values/day)
l/min
700

600

500

400

300

200

100

week 1

week 10

week 20

week 52

peak flow average week one Week 1: PEF min: 400 l/min, PEF max: 640 l/min, PEF average: 504 l/min, PEF variability 38% Week 20: PEF min: 490 l/min, PEF max: 670 l/min, PEF average: 588 l/min, PEF variability 27% Week 52: PEF min: 390 l/min, PEF max: 610 l/min, PEF average: 502 l/min, PEF variability 36%

Figure 5: A male non-exerciser with no-change in peak flow variability. Peak-Flow-Measurement (3 values/day)
l/min
450 400 350 300 250 200 150 100 50 0

week 1

week 10

week 20

week 52

peak flow average week one Week 1: PEF min: 200 l/min, PEF max: 440 l/min, PEF average: 313 l/min, PEF variability: 55% Week 10: PEF min: 230 l/min, PEF max: 440 l/min, PEF average: 315 l/min, PEF variability: 48% Week 52: PEF min: 200 l/min, PEF max: 450 l/min, PEF average: 291 l/min, PEF variability: 56%

Table 1: A 2x2 table comparison of exercisers and non-exercisers by clinical improvement. exercisers * improved ** not improved total 14 3 17 non-exercisers 1 12 13 total 15 15 30

* Exercisers: Patients still regularly exercising independently at follow-up. ** Improved is a diminishment of 10 percent points or more in peak-flow variability from the first to the 52nd week, provided that the average of the peak-flow values remained constant or increased and the medication required either remained the same or could be reduced.

Table 2: Cost reduction for all patients during the year of the study. before the study days unfit to work hospitalisation days emergency consultations antibiotic series for respiratory tract infection TOTAL Number of participants = 30 382 100 14 40 during the study 183 0 4 25 comparative reduction 199 days 100 days 10 consultations 15 series cost reduction in DM 51,740 40,000 500 750 92,990 Average cost reduction DM3,100 per patient

Figure 6: Peak-Flow (before and after Qigong training) Female, 49 years.

l/min
450 400 350 300 250 200 150 100 50 0

before Qigong

after Qigong

week 1

week 10

week 20

week 52

Male, 52 years.
l/min
450 400 350 300 250 200 150 100 50 0

before Qigong

after Qigong

week 1

week 10

week 20

week 52