744770

research-article2017
CNU0010.1177/1474515117744770European Journal of Cardiovascular NursingChen et al.

Original Article

European Journal of Cardiovascular Nursing

The effects of Baduanjin exercise

1­–11
© The European Society of Cardiology 2017
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DOI: 10.1177/1474515117744770
https://doi.org/10.1177/1474515117744770

patients with heart failure: A journals.sagepub.com/home/cnu

randomized controlled trial

Dai-Mei Chen1, Wen-Chung Yu2, Huei-Fong Hung3,

Jen-Chen Tsai4, Hsiao-Ying Wu4,5 and Ai-Fu Chiou4

Abstract
Aims: The purpose of this study was to examine the effects of Baduanjin exercise on fatigue and quality of life in patients
with heart failure.
Methods: The study was a randomized controlled trial. Participants diagnosed with heart failure were recruited from
two large medical centers in northern Taiwan. Participants were randomly assigned to the intervention (n=39) or
control (n=41) groups. Patients in the intervention group underwent a 12-week Baduanjin exercise program, which
included Baduanjin exercise three times per week for 12 weeks at home, a 35-minute Baduanjin exercise demonstration
video, a picture-based educational brochure, and a performance record form. The control group received usual care
and received no intervention. Fatigue and quality of life were assessed using a structural questionnaire at baseline, four
weeks, eight weeks, and 12 weeks after the intervention.
Results: Participants in the Baduanjin exercise group showed significant improvement in fatigue (F=5.08, p=0.009) and
quality of life (F=9.11, p=0.001) over time from baseline to week 12 after the intervention. Those in the control group
showed significantly worse fatigue (F=3.46, p=0.033) over time from baseline to week 12 and no significant changes in
quality of life (F=0.70, p=0.518). Compared to the control group, the exercise group demonstrated significantly greater
improvement in fatigue and quality of life at four weeks, eight weeks, and 12 weeks.
Conclusions: This simple traditional exercise is recommended for Taiwanese patients with heart failure in order to
improve their fatigue and quality of life.

Keywords
Baduanjin exercise, fatigue, heart failure, quality of life

Date received: 28 December 2016; accepted: 7 November 2017

Introduction 1SurgicalDepartment, National Taiwan University Hospital, Taiwan

Fatigue is a common problem reported by 54–96% of
patients with heart failure.1–3 Patients with heart failure
describe fatigue as "a pervasive and unignorable bodily
experience."4 Fatigue may cause limitations in performing
daily and social activities, increased dependency on oth-
2Divisionof Cardiology, Department of Medicine, Taipei Veterans
General Hospital and Faculty of Medicine, National Yang-Ming
University, Taiwan
3Cardiology Department, Shin Kong Wu Ho-Su Memorial Hospital, Taiwan
4School of Nursing, National Yang Ming University, Taiwan
5Department of Nursing, Taoyuan General Hospital, Taiwan

ers, loss of self-esteem, and depression, thereby affecting

Corresponding author:
patients’ quality of life.1,4 In addition, fatigue is a signifi- Ai-Fu Chiou, School of Nursing, National Yang Ming University, No.
cant predictor for worsening heart failure.5 Greater fatigue 155, Sec. 2, Li-Nong Street, Taipei, Taiwan.
is associated with a higher risk of cardiovascular death or Email: afchiou@ym.edu.tw
2 European Journal of Cardiovascular Nursing 00(0)
hospitalization and all-cause mortality.6 Therefore, it is
important to identify effective interventions to manage
fatigue in patients with heart failure to improve their qual-
ity of life and prognosis.
The European Society of Cardiology guidelines rec-
ommend regular aerobic exercise in patients with heart
failure to improve functional capacity and symptoms.7
The American College of Cardiology and the American
Heart Association also suggest that exercise training is
beneficial as an adjunctive approach to improve clinical
status in ambulatory patients with current or prior symp-
toms of heart failure.8 However, the implementation of
exercise training requires appropriate patient selection,
optimal training protocols, and progression monitoring.9
Aerobic and resistance exercise training have been proven
to reduce symptoms such as fatigue in heart failure
patients, increase maximum oxygen uptake and muscle
strength, increase exercise tolerance, reduce hospital stays
and mortality, and improve psychological and social func-
tion.10–13 Studies have also reported that exercise training
may offer important improvements in patients’ health-
related quality of life.14,15 Other forms of exercise such as
Tai Chi and yoga were also found to improve the physical
and mental health and quality of life of patients with heart
failure.16,17 Most exercise training studies in heart failure
patients employ moderate- to high-intensity training 3–5
times per week for 8–12 weeks.18 Although exercise train-
ing in patients with heart failure is an accepted adjunctive
intervention, remaining challenges include maintaining
adherence to exercise and cost-effectiveness. Most exer-
cise programs are complicated and require supervision,
and they may even result in overload of the heart and
increased fatigue in patients with heart failure.19 A simple,
easy-to-learn, free-of-charge, and appropriate home-
based exercise program is necessary to improve adher-
ence to exercise and help patients with heart failure
maintain a physically active lifestyle.
Baduanjin (also called Eight-Section Brocades) is an
ancient Chinese Qigong exercise that involves eight sec-
tions of simple, slow, and relaxing movements.20 Previous
studies have reported that Baduanjin can improve
fatigue,21,22 sleep quality and quality of life,20,23,24 balance
and physical flexibility,25,26 symptoms of osteoarthritis27
and menopausal symptoms28 and can reduce blood
lipids29 and blood pressure.30 Chan et al.21 found that a
nine-week Baduanjin exercise program consisting of six-
teen 1.5-hour lessons significantly reduced fatigue in
patients with chronic fatigue syndrome-like illness. Liao
et al.22 also reported that practicing Baduanjin exercise
30 min twice a day for six weeks had an effect on reliev-
ing fatigue in people with fatigue-predominant subhealth
(FPSH). The diagnostic criteria for FPSH include the fol-
lowing: (a) the chief complaint is persistent or recurrent
fatigue lasting more than three months; (b) routine physi-
cal examination shows no obvious abnormalities, thereby
excluding fatigue caused by disease; (c) total scores on
the Chalder’s Fatigue Scale31 are three points or higher.
In addition, a systematic review showed that Baduanjin
exercise had significant benefits for quality of life.24
However, there is a paucity of literature to support the
effects of Baduanjin on fatigue and quality of life in
patients with heart failure.
Baduanjin exercise is a moderate-intensity movement
with low physical demand that is easy to learn and can be
performed at home without any assistive equipment. Thus,
it is suitable for patients with stable heart failure to per-
form at home. In addition, Baduanjin exercise has been
recommended by the Chinese Health Qigong Association
for exercise in the community.30 The purpose of this study
was to examine the level of fatigue and quality of life in
heart failure patients over time in response to a 12-week
Baduanjin exercise program.
Methods
Design
This study was a parallel, randomized controlled trial with
a longitudinal research design. Participants were randomly
assigned to either the Baduanjin exercise group or the con-
trol group. The Baduanjin exercise group received a
12-week Baduanjin exercise program. The control group
received usual care. Fatigue and quality of life were
assessed at baseline, four weeks, eight weeks, and 12
weeks after enrolment.
Participants, recruitment, and randomization
This study was conducted in accordance with the princi-
ples of the Declaration of Helsinki. This study was
approved by the Joint Institutional Review Board of
Medical Research Ethics Foundation (Approval
No.13-S-013). The study was further approved by the eth-
ics review board of each hospital in which the study was
conducted. Participants were recruited using convenience
sampling from two large medical centers in northern
Taiwan. The two medical centers have many specialty
departments for the treatment of a broad spectrum of dis-
eases including cardiovascular diseases and cancers.
Cardiovascular therapies are the leading specialties of both
medical centers. The inclusion criteria for participants
were as follows: (a) diagnosed with stable heart failure by
a physician according to New York Heart Association
(NYHA) class I and II; (b) aged 20 years or older; (c) able
to communicate and speak Chinese; and (d) have video
devices available for use at home. Piepoli et al. proposed
that exercise training is recommended for patients with
NYHA class I–III stable heart failure.9 Patients with
NYHA class IV stable heart failure have an increased risk
when exercise training (e.g. chest pain, dyspnea, and
Chen et al. 3
arrhythmia). Since our home-based Baduanjin exercise
program was designed to be practiced in patients’ homes,
we selected patients with NYHA class I–II stable heart
failure to reduce the risk of exercise training and to ensure
patients’ safety.
Participants were excluded if they had (a) impaired
mobility, defined as a limitation in independent, purpose-
ful physical movement of the body or of one or more
extremities; (b) unstable angina or myocardial infarction,
unstable serious arrhythmia, unstable structural valvular
disease, open-heart surgery, or chronic obstructive pulmo-
nary disease (COPD); (c) diagnosis of major depression
and cognitive disorders; or (d) unstable vital signs (defined
as blood pressure >180/110 mm Hg or <90/60 mm Hg and
resting heart rate >100 beats/min). These exclusion criteria
were based on recommendations from the European
Society of Cardiology9 and the American College of Sports
Medicine.32 In addition, patients with heart failure or
COPD have similar prevalent symptoms including dysp-
nea and fatigue33 and, because heart failure patients with
COPD might have more severe fatigue which could lead to
overestimation of the levels of fatigue, this study excluded
patients who were diagnosed with COPD.
During the study period from December 2013–November
2014, a total of 171 patients were recruited from the outpa-
tient department of the study hospitals according to the
inclusion criteria. Of these patients, 73 refused to partici-
pate, 16 were not accessible, and two were unable to play
videos at home. Most participants who refused to partici-
pate in this study did so for personal reasons, including
being too busy, having no motivation or interest, and feel-
ing inconvenienced or uncomfortable.
Eighty patients were randomly assigned to either the
intervention group (n=39) or the control group (n=41).
Seventeen patients withdrew due to personal reasons (n=9),
loss of contact (n=4), admission (n=3), and death (n=1).
Of the 80 participants, 63 total patients completed the entire
study, yielding an attrition rate of 21.25% (Figure 1). Each
participant was assigned a number from 1–80. A block ran-
domization method was used to generate the sequence of
the intervention and control groups in blocks of four at a
1:1 ratio.34 The blocks were chosen randomly to determine
patients’ assignment to the groups using simple random
sampling with a random number table. The allocation was
kept in sequentially numbered, opaque envelopes. A post-
hoc statistical power analysis was calculated using the
G-Power procedure35 with an alpha of 0.05 and showed
sufficient power (>0.8) with a sample size of 80.
Intervention
Patients in the intervention group underwent a 12-week
Baduanjin exercise program consisting of 12 weeks of
Baduanjin exercise, a 35-minute Baduanjin exercise dem-
onstration video, a picture-based educational brochure,
and a performance record form. The 35-minute Baduanjin
exercise demonstration video was produced by the Chinese
Traditional Exercise Association for use by patients with
heart failure in this study. The educational brochure was
produced by the researcher with pictures based on the
demonstration video and comprised an introduction to the
Baduanjin exercise, guidelines for performing the exer-
cise, and all movements of the Baduanjin exercise. In the
educational brochure, patients were advised to stop exer-
cise and seek medical attention immediately if they expe-
rienced warning signs such as chest pain, shortness of
breath, dizziness, cold sweats, nausea, and vomiting.
The researcher, a trained Baduanjin instructor, pro-
vided individualized Baduanjin exercise training to the
intervention group in their homes three times per week
for two weeks using the demonstration video and the
educational brochure they had at home. The researcher
needed to ensure the accuracy of the participants’ perfor-
mance of the Baduanjin exercise. The participants were
led by the demonstration video to perform the Baduanjin
exercise at home three times per week for 10 weeks.
Participants were asked to record their daily Baduanjin
exercise schedule on a performance record form for 12
weeks. Weekly telephone follow-up was performed by
the researcher to monitor the participants’ Baduanjin
exercise performance.
The Baduanjin exercise included three phases: warm-
up, exercise, and cool-down. During the warm-up and
cool-down phases, the participants performed deep breath-
ing and stretching exercises to improve range of motion in
their joints and flexibility and reduce muscle and bone
injuries. During the exercise phase, the participants per-
formed eight sections of movements led by the Baduanjin
exercise video, including (a) supporting the heavens with
both hands to regulate the three visceral cavities housing
the internal organs, (b) drawing a bow to each side, resem-
bling shooting an eagle, (c) holding up a single hand to
regulate the spleen and the stomach, (d) looking backward,
relieving exhaustion, (e) shaking the head and wagging the
tail to remove excess heat from the heart, (f) touching the
feet with both hands to rid the heart of its illness, (g)
clenching fists and glaring to increase physical strength,
and (h) shaking the body to ward off all illnesses.20
Through regulation of breathing and movement of differ-
ent joints and muscles, Baduanjin can promote the func-
tions of multiple organs and systems such as the nervous
and cardiorespiratory systems, and it can improve mental
health.36–38
Control group
The control group received usual care and underwent no
intervention. Participants in the control group were advised
to maintain their usual lifestyle and completed no exercise
programs.
4 European Journal of Cardiovascular Nursing 00(0)
Figure 1.  Flow diagram of the study.
Measurements
All participants completed a structured questionnaire that
included demographic and clinical information, the mod-
ified Piper Fatigue Scale (PFS),2 and the Minnesota
Living with Heart Failure Questionnaire (MLHFQ)39 at
baseline, four weeks, eight weeks, and 12 weeks after the
intervention. Physiological measurements included blood
pressure, heart rate, respiration rate, hemoglobin, and
oxygen saturation. Demographic and clinical data
included age, gender, marital status, education, religion,
work status, NYHA class, ejection fraction, use of medi-
cations, chronic diseases, and regular exercise within the
past six months.
Outcome measures
The primary outcome was fatigue. Fatigue was measured
using the Chinese version of the shortened PFS.2 The short-
ened PFS is composed of 15 items that measure two domains
of fatigue: severity and temporality. Each item is scored from
0–3, with a total possible score of 0-45. Higher scores indi-
cate greater fatigue. The content validity index of the short-
ened PFS was reported as 0.83 in patients with heart failure.2
The Cronbach’s α of this scale in this study was 0.91.
The secondary outcome was quality of life. Quality of
life was measured by the Chinese version of the MLHFQ.39
The MLHFQ contains 21 items to assess the impact of
heart failure on patients’ physical, emotional, and general
Chen et al. 5
dimensions within the past month. Each item score ranges
from 0–5. The total possible score ranges from 0–105,
with higher scores indicating a lower quality of life. The
content validity index of the MLHFQ was 0.98.39 In this
study, the Cronbach’s α of the MLHFQ was 0.92.
With regard to physiological measurements, blood
pressure and heart rate were measured using the "Heart
Rate Master ANSWatch Wrist Physiological Monitor
TS-0411Deluxe Advanced" (made in Taiwan). Oxygen
saturation was measured using “NONIN 9550 Onyx II”
(made in Germany). The level of hemoglobin was assessed
by drawing blood samples from the participants at baseline
and after 12 weeks.
Procedures
A pilot study was conducted in 10 patients with heart failure
to examine the feasibility of the research and the interven-
tion. The researcher explained the study purpose, methods,
procedure, and right to voluntarily withdraw to all partici-
pants in an education room of the outpatient department of
the study hospitals. After obtaining informed consent, all
participants were asked to complete the questionnaire for
baseline data. The research assistant then took the partici-
pants’ blood pressure, heart rate, respiration rate, and oxy-
gen saturation and drew a blood sample. Clinical data
including NYHA classification, ejection fraction, and medi-
cations were obtained from medical charts by the research
assistant. The levels of fatigue and quality of life were
assessed again at four, eight and 12 weeks after enrolment
through telephone interviews between the research assistant
and participants at home. Blood pressure, heart rate, respira-
tory rate, oxygen saturation, and hemoglobin were meas-
ured at week 12 after enrolment. The research assistant was
blinded to the participants’ intervention allocation.
Data analysis
Data were analyzed using SPSS (version 19.0, Chicago,
Illinois, USA). Independent t-tests and chi-square (χ2) tests
were used to examine the homogeneity of demographic
and clinical information, fatigue, and quality of life
between the two groups at baseline.
Repeated measures analysis of variance (ANOVA) was
used to test for change over time (i.e. baseline, four weeks,
eight weeks, and 12 weeks) in fatigue and quality of life for
the intervention and control groups. ANOVA uses F-tests to
statistically test the equality of means. Generalized estimat-
ing equations (GEEs) were used to compare differences in
fatigue and quality of life over the 12 weeks between the
intervention and control groups. GEEs were proposed
by Liang and Zeger40 to provide consistent population-
averaged estimates of the regression parameters and their
variance under mild assumptions about time dependence.
It has been commonly applied to longitudinal data analysis
in clinical trials. Effect size is the magnitude of the differ-
ence between groups; a greater effect size indicates a larger
difference between experimental and control groups.41,42
Effect size (Cohen’s d) was calculated as mean (group 1)–
mean (group 2)/standard deviation. A p-value of 0.05 was
considered statistically significant.
Results
Characteristics, fatigue, and quality of life at
baseline between the two groups
The mean age of all participants was 70.29 years (standard
deviation (SD)=13.53). The majority of participants were
male, married, retired, Buddhists or Taoists, and had an
elementary level education. In all, 68.8% of patients per-
formed regular exercise such as slow walking. Most
patients had NYHA class II stable heart failure and a mean
oxygen saturation of 97.09% (SD=1.32). The mean fatigue
score was 10.69 (SD=8.32), and 77.6% of heart failure
patients had mild to severe fatigue. There were no signifi-
cant differences between the Baduanjin exercise and the
control group at baseline in demographic and clinical char-
acteristics, fatigue, and quality of life, except for the use of
β-blockers (Table 1). Significantly more patients in the
control group used β-blockers than those in the interven-
tion group (70.7% vs 43.6%, p=0.014).
The effects of Baduanjin exercise on fatigue and
quality of life at different time points by group
Table 2 shows the results of the within-group effects of
fatigue and quality of life over time from baseline to the
twelfth week for each group using repeated measures
ANOVA. The mean fatigue score in the Baduanjin exer-
cise group significantly decreased from baseline to the
12th week by 3.4 points (11.30 vs 7.90, F=5.08, p=0.009),
indicating significant improvement in fatigue after 12
weeks of the intervention. In the control group, the mean
fatigue score significantly increased from baseline to the
12th week by 2.21 points (9.00 vs 11.21, F=3.46, p=0.033),
indicating significant worsening of fatigue over time.
With regard to overall quality of life, the mean score
for the Baduanjin exercise group significantly decreased
from baseline to 12 weeks by 7.57 points (22.97 vs 15.40,
F=9.11, p=0.001), indicating significant improvement in
their overall quality of life. In addition, participants in the
Baduanjin exercise group also showed significant
improvement in the physical (F=4.55, p=0.021), general
(F=10.52, p<0.001) and emotional (F=3.63, p=0.027)
subscales of quality of life. In the control group, there
were no significant differences at different time points in
overall quality of life or its subscales.
6 European Journal of Cardiovascular Nursing 00(0)

Table 1.  Homogeneity of participants’ characteristics at baseline between the two groups (n=80).

Characteristics All Control Intervention χ2 p

(n=80) (n=41) (n=39)
n (%) n (%) n (%)
Gender
 Male 42 (52.5) 24 (58.5) 18 (46.2) 1.23 0.268
 Female 38 (47.5) 17 (41.5) 21 (53.8)  
Marital status
 Single 3 (3.8) 2 (4.9) 1 (2.6) 0.71 0.700
 Married 63 (78.8) 33 (80.5) 30 (76.9)  
 Widowed/divorced 14 (17.6) 6 (14.6) 8 (20.5)  
Religion
 None 11 (13.8) 6 (14.6) 5 (12.8) 2.75 0.432
 Taoism 37 (46.3) 22 (53.7) 15 (38.5)  
 Buddhism 26 (32.5) 10 (24.4) 16 (41.0)  
 Christianity 6 (7.6) 3 (7.3) 3 (7.7)  
Education
 Illiterate 5 (6.3) 2 (4.9) 3 (7.7) 2.47 0.651
 Elementary 27 (33.8) 13 (31.7) 14 (35.9)  
  Junior high 12 (15.0) 7 (17.1) 5 (12.8)  
  Senior high 17 (21.3) 11 (26.8) 6 (15.4)  
 College/university 19 (23.8) 8 (19.5) 11 (28.2)  
Living arrangement
  Live alone 3 (3.8) 1 (2.4) 2 (5.1) 0.40 0.817
  Live with family 75 (93.8) 39 (95.1) 36 (92.3)  
  Live with others 2 (2.5) 1 (2.4) 1 (2.6)  
Work status
 Unemployed 65 (81.3) 33 (80.5) 32 (82.1) 0.03 0.858
 Employed 15 (18.8) 8 (19.5) 7 (17.9)  
Exercise
 Yes 55 (68.8) 27 (65.8) 28 (71.8) 2.85 0.241
 No 25 (31.3) 14 (34.1) 11 (28.2)  
NYHA
  I 21 (26.3) 9 (22.0) 12 (30.8) 1.58 0.455
  II 59 (73.8) 32 (78.0) 27 (69.2)  
Use of β-blockers 6.03 0.014
 Yes 46 (57.5) 29 (70.7) 17 (43.6)  
 No 34 (42.5) 12 (29.3) 22 (56.4)  
  Mean (SD) Mean (SD) Mean (SD) t p
Age (years) 70.29 (13.53) 71.44 (13.65) 69.08 (13.48) 0.78 0.439
Number of comorbidities 3.56 (1.47) 3.66 (1.56) 3.46 (1.37) 0.60 0.551
Ejection fraction (%) 58.61 (15.56) 60.44 (13.35) 56.68 (17.56) 1.08 0.282
Systolic blood pressure 118.90 (14.38) 118.00 (12.62) 119.84 (16.15) –0.57 0.570
Diastolic blood pressure 72.30 (5.88) 72.32 (5.48) 72.29 (6.35) 0.02 0.984
Heart rate 77.59 (12.43) 78.37 (13.43) 76.76 (11.37) 0.57 0.570
Oxygen saturation 97.09 (1.32) 97.09 (1.49) 97.09 (1.13) 0.00 1.000
Hemoglobin 12.61 (1.69) 12.37 (1.74) 12.86 (1.61) −1.32 0.191
Fatigue 10.69 (8.32) 10.66 (8.53) 10.72 (8.20) −0.03 0.975
Overall quality of life 23.74 (16.61) 23.39 (15.53) 24.10 (17.87) −0.19 0.849
 Physical 12.36 (8.26) 12.59 (8.91) 12.13 (7.63) 0.25 0.806
 General 6.92 (6.18) 6.34 (5.13) 7.54 (7.13) −0.87 0.390
 Emotional 4.45 (4.58) 4.46 (4.18) 4.44 (5.02) 0.03 0.979

χ2: Chi-square test; NYHA: New York Heart Association: SD: standard deviation; t: independent t-tests. Both χ2 and t tests were used to examine
the homogeneity of participants’ characteristics at baseline between two groups.
Chen et al. 7

Table 2.  Comparisons of fatigue and quality of life at different time points in each group (n=63).

Variables Baseline Week 4 Week 8 Week 12 F p

Mean (SD) Mean (SD) Mean (SD) Mean (SD)  

Fatigue
Control 9.00 (7.49) 10.15 (6.55) 11.45 (7.55) 11.21 (7.10) 3.46 0.033
Intervention 11.30 (8.91) 9.67 (7.20) 8.20 (5.77) 7.90 (5.35) 5.08 0.009
Overall quality of life
Control 19.21 (13.47) 21.18 (12.99) 21.55 (13.56) 20.33 (12.35) 0.70 0.518
Intervention 22.97 (17.86) 19.40 (14.46) 15.70 (9.75) 15.40 (11.74) 9.11 0.001
Physical quality of life
Control 10.55 (8.13) 11.73 (7.70) 11.88 (7.47) 11.39 (6.65) 0.83 0.455
Intervention 11.40 (7.72) 10.07 (6.41) 8.97 (4.94) 8.63 (4.99) 4.55 0.021
General quality of life
Control 5.27 (4.51) 4.94 (3.73) 4.82 (3.95) 4.58 (4.00) 0.43 0.663
Intervention 7.10 (6.77) 5.17 (5.33) 3.37 (2.93) 3.40 (4.31) 10.52 <0.001
Emotional quality of life
Control 3.39 (3.46) 4.52 (3.75) 4.85 (3.57) 4.36 (3.25) 2.19 0.113
Intervention 4.47 (5.05) 4.17 (4.38) 3.37 (2.95) 3.37 (3.53) 3.63 0.027

SD: standard deviation.

F-tests were used in the repeated measures analysis of variance to statistically test the equality of means.

Group differences in the effect of Baduanjin Table 3.  Group differences in the effect of Baduanjin exercise
exercise on fatigue and quality of life over time on fatigue and quality of life over time using generalized
estimating equations (GEEs) analysis (n=80).
Because the use of β-blockers in the two groups was sig-
Variables B SE 95% CI p
nificantly different at baseline, the use of β-blockers was
included as a covariate to be adjusted in the GEE analysis. Time×group Lower Upper  
Table 3 shows the GEE analysis of the between-group Fatigue  
effects of fatigue and quality of life between the two Baseline Reference  
groups over time after adjustment for the use of β-blockers. Week 4 −3.00 0.98 −4.92 −1.08 0.002
Participants in the Baduanjin exercise group had signifi- Week 8 −5.30 1.32 −7.89 −2.70 <0.001
cantly greater improvement in fatigue than the control Week 12 −5.37 1.59 −8.48 −2.26 0.001
group at four weeks (B=−3.00, p=0.002), eight weeks Quality of life
(B=−5.30, p<0.001) and 12 weeks (B=−5.37, p=0.001) Baseline Reference  
after the intervention. Figure 2 displays the fatigue scores Week 4 −6.63 2.39 −11.31 −1.95 0.005
in the two groups at baseline, four weeks, eight weeks, Week 8 −9.83 3.03 −15.76 −3.90 0.001
and 12 weeks. It shows that the mean fatigue score for the Week 12 −8.69 2.87 −14.32 −3.07 0.002
Baduanjin exercise group gradually decreased over time, CI: confidence interval; SE: standard error.
whereas that for the control group gradually increased. A GEEs model was used to test for differences between the interven-
These results indicated that Baduanjin exercise can effec- tion group and the control group with respect to changes from baseline
to post-intervention, adjusted for the covariate, the use of β-blockers.
tively reduce patient fatigue.
Compared with the control group, participants in the
Baduanjin exercise group exhibited significantly greater Adverse events
improvement in the overall quality of life at four weeks
(B=−6.63, p=0.005), eight weeks (B=−9.83, p=0.001) and No serious cardiac events were detected during the
12 weeks (B=−8.69, p=0.002) after the intervention (Table Baduanjin exercise intervention.
3). Figure 3 displays the quality of life scores in the two
groups at baseline, four weeks, eight weeks, and 12 weeks.
Discussion
It shows that the mean score of overall quality of life
for the Baduanjin exercise group gradually decreased The results of this study showed that the 12-week Baduanjin
over time, whereas that for the control group gradually exercise program was effective for improving fatigue and
increased. These results indicated that Baduanjin exercise quality of life in patients with heart failure. Participants in
can effectively improve patients’ overall quality of life. the Baduanjin exercise group had significantly greater
8 European Journal of Cardiovascular Nursing 00(0)
Figure 2.  Comparison of the modified Piper Fatigue Scale scores
between the two groups over the 12-week follow-up period.
Figure 3.  Comparison of Minnesota Living with Heart Failure
Questionnaire scores between the two groups over the 12-
week follow-up period.
improvement in fatigue and quality of life than the control
group at four weeks, eight weeks and 12 weeks after the
intervention. The effect size index (Cohen’s d) between the
intervention and control groups was medium for fatigue
(d=0.53) and small for quality of life (d=0.41), indicating
that the intervention had a small to moderate positive
effect.41 To the best of our knowledge, this study is the first
randomized controlled trial to investigate the effect of
Baduanjin exercise in patients with heart failure. Therefore,
it is difficult to compare our results with other studies
because of different measurements and study populations.
However, these results are consistent with previous studies
that examined the effects of similar intensities of aerobic
exercise such as walking,11,43–45 cardiac rehabilitation
training,46 or Tai Chi16 on the fatigue and quality of life of
patients with heart failure. A meta-analysis of six studies
also showed a significant benefit of Baduanjin exercise on
quality of life in various populations (standardized mean
difference −0.75, 95% confidence interval (CI) −1.26 to
−0.24, p=0.004).24 Our study also showed that 77.6% of
heart failure patients had mild to severe fatigue, which was
similar to the findings of previous studies. Overall, 50–96%
of heart failure patients experienced fatigue.1–3
Most patients with heart failure reported that the
Baduanjin exercise was able to refresh their spirits and
reduce their fatigue. The beneficial effects of the Baduanjin
exercise on fatigue may be attributed to the combination of
movements and breathing techniques. The movements of the
Baduanjin exercise can systematically mobilize movable
joints and muscles, stimulate metabolism and blood circula-
tion, and relieve stress; thus, it has the effect of refreshing the
spirit and relaxing the mind.22 In addition, previous studies
found that abdominal breathing can modulate parasympa-
thetic activity and heart rate variability, improve respiratory
functions, fatigue, and quality of life.47–49
Other similar forms of exercise, such as Tai Chi, that
emphasize the balance of body and mind were also found to
have positive effects on balance control, cardiovascular fit-
ness, fatigue and quality of life in patients with heart fail-
ure.50 However, Tai Chi is complicated and difficult to learn,
which can limit participants’ adherence to the exercise.
Piepoli et al. suggested that stable and well-treated patients
could initiate a home-based program with guidance and
instructions.9 Frequent follow-up could help assess the ben-
efits of the home-based exercise program, determine any
unforeseen problems, and monitor patients’ performance.
Thus, our Baduanjin exercise program was designed to be
practiced in the patients’ homes with guidance and instruc-
tions from a Baduanjin exercise demonstration video, an
educational brochure, and regular follow-up. This may
improve patients’ confidence and adherence to the Baduanjin
exercise program. In our study, most patients with heart fail-
ure were satisfied with the Baduanjin exercise and reported
no adverse effects during the 12-week exercise program. In
addition, the Baduanjin exercise was able to quickly improve
fatigue and quality of life at four weeks after the interven-
tion. Thus, this simple, moderate-intensity Baduanjin exer-
cise is safe and suitable for patients with heart failure and
can be practiced as a home-based exercise by following the
video and instructions.
Limitations
This study had some limitations. First, only 80 participants
were recruited from two medical centers in northern Taiwan
and were limited to NYHA functional classes I and II. In
addition, the effects of Baduanjin exercise have not yet to be
examined in non-Chinese patients with heart failure and may
not have the same potential benefit for non-Chinese popula-
tions. Therefore, the results of this small, localized sample
may not be generalizable to non-Chinese patients with heart
failure or patients with low functional ability. This interven-
tion should be tested within a larger, more general popula-
tion. Second, our study design is not placebo-controlled.
Without a placebo control, improvements in patients in the
exercise group may not have been due to the effect of exer-
cise, but it could have been the effects of having a person
Chen et al. 9
visit six times in two weeks. In addition, our results showed
benefits in the initial phases of the exercise that then leveled
off. One explanation could be that the patients were no longer
receiving home visits from a trainer during the later stages.
Thus, a placebo-controlled study design is suggested for
future research. Third, our study did not compare Baduanjin
exercise to other forms of exercise. Therefore, it is still
unclear whether Baduanjin exercise is more effective than
other forms of exercise. In addition, our home-based
Baduanjin exercise that sent a trainer to the patient six times
might be costlier than group class programs. Future studies
may compare the effects of Baduanjin exercise to other
forms of exercise and compare the costs of home-based exer-
cise to group Baduanjin exercise classes. Fourth, the effects
of Baduanjin exercise on fatigue and quality of life were
measured for only 12 weeks of follow up. The long-term
effects of the exercise program were not examined. Although
Baduanjin exercise significantly improved participants’
fatigue and quality of life after 12 weeks, future research is
suggested to assess the long-term effects of this type of exer-
cise for patients with heart failure over 6–12 months. Finally,
we only used a daily exercise performance record form and
weekly follow-up telephone call to monitor participants’
compliance with exercise. There was a lack of objective
monitoring to examine participants’ exercise performance;
thus, future studies could use an Actiwatch or other monitor-
ing instrument to accurately assess adherence to exercise in
patients with heart failure.
Conclusion
This study indicates that Baduanjin exercise is an accept-
able, safe and feasible intervention that can effectively
improve fatigue and quality of life in community dwelling
Taiwanese patients with heart failure. Application of this
simple, traditional Baduanjin exercise is recommended for
patients with heart failure as an alternative method for
managing their fatigue and improving their quality of life.
Implications for practice
•• Heart failure patients who participated in the
12-week Baduanjin exercise program had sig-
nificant improvements in their fatigue and qual-
ity of life.
•• The Baduanjin exercise is safe, effective, and
feasible for patients with heart failure as an alter-
native method for managing patients’ fatigue and
promoting their quality of life.
•• A home-based Baduanjin exercise program for
patients with heart failure should consist of a
well-developed Baduanjin exercise program
with guidance and instructions from a Baduanjin
exercise demonstration video, an educational
brochure, and regular follow-up.
Acknowledgements
The authors would like to thank all the subjects who participate
in our study and all experts and hospitals for supporting this
study. They also thank Chen-Tse Chang for his help in producing
the Baduanjin exercise demonstration video.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This study was supported by the Ministry of Science and
Technology, Taiwan (MOST 102-2410-H-010-017).
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