COPD: Journal of Chronic Obstructive Pulmonary Disease

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/icop20

Exploring Tai Chi Exercise and Mind-Body

Breathing in Patients with COPD in a Randomized
Controlled Feasibility Trial

Kristen M. Kraemer, Daniel Litrownik, Marilyn L. Moy, Peter M. Wayne,

Douglas Beach, Elizabeth S. Klings, Harry Reyes Nieva, Adlin Pinheiro, Roger
B. Davis & Gloria Y. Yeh

To cite this article: Kristen M. Kraemer, Daniel Litrownik, Marilyn L. Moy, Peter M. Wayne,
Douglas Beach, Elizabeth S. Klings, Harry Reyes Nieva, Adlin Pinheiro, Roger B. Davis & Gloria
Y. Yeh (2021) Exploring Tai Chi Exercise and Mind-Body Breathing in Patients with COPD in a
Randomized Controlled Feasibility Trial, COPD: Journal of Chronic Obstructive Pulmonary Disease,
18:3, 288-298, DOI: 10.1080/15412555.2021.1928037

To link to this article: https://doi.org/10.1080/15412555.2021.1928037

Published online: 09 Jun 2021.

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 COPD: Journal of Chronic Obstructive Pulmonary Disease
2021, VOL. 18, NO. 3, 288–298
https://doi.org/10.1080/15412555.2021.1928037

Exploring Tai Chi Exercise and Mind-Body Breathing in Patients with COPD
in a Randomized Controlled Feasibility Trial
Kristen M. Kraemera,c, Daniel Litrownik a,b, Marilyn L. Moyc,d, Peter M. Wayneb, Douglas Beachc,e, Elizabeth
S. Klingsf, Harry Reyes Nievac , Adlin Pinheiroa, Roger B. Davisa,c and Gloria Y. Yeha,b
a
Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; bOsher Center
for Integrative Medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts, USA; cHarvard Medical School,
Boston, Massachusetts, USA; dPulmonary and Critical Care Medicine Section, Department of Medicine, Veterans Administration Boston
Healthcare System, Boston, Massachusetts, USA; eDivision of Pulmonary and Critical Care, Department of Medicine, Beth Israel Deaconess
Medical Center, Boston, Massachusetts, USA; fThe Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA

ABSTRACT ARTICLE HISTORY

In this pilot feasibility randomized controlled trial, participants with moderate to severe COPD Received 21 January 2021
were randomized to a 12-week tai chi or MBB intervention. Participants were assessed at baseline, Accepted 4 May 2021
12 weeks, and 24 weeks. Feasibility, as assessed by intervention adherence, was the primary outcome. KEYWORDS
We also estimated preliminary between-group differences in COPD symptoms and health-related Tai chi; mind-body breathing;
quality of life, cognitive-emotional function, and functional status across three timepoints: baseline, feasibility study; randomized
12, and 24 weeks. A total of 92 participants were randomized 2:1 to tai chi (n = 61) or MBB (n = 31). controlled trial
The overall group adherence in the first 12 weeks was 62% in tai chi and 75% in MBB. From
baseline to 12 weeks, tai chi demonstrated greater improvements in depressive symptoms (Cohen’s
d effect size (ES) = −.53; adj mean diff = −2.31 [-5.7, 1.07]), 6-minute walk test distance (ES = .47;
adj mean diff = 62.04 [2.85, 121.22]), social support (ES = .36; adj mean diff = .19 [-0.11, 0.49])
and chair stand (ES = .44; adj mean diff = .91 [-0.05, 1.86]). Only improvements in social support
were maintained at 24-week follow-up. Tai chi and MBB are feasible for individuals with COPD.
Preliminary effects suggest that while our mindful breathing intervention may not be sufficient
to impact outcomes, tai chi may result in short-term benefits in mood, social support and functional
capacity. More work is needed to better understand mindful breathing for COPD and to examine
methods for maintaining improvements from tai chi over time.

Introduction One common component to many mind-body interventions

Chronic obstructive pulmonary disease (COPD), a progres-
sive respiratory disease characterized by declines in lung
function, affects nearly 16 million adults in the USA and
is a leading cause of death [1]. Individuals with COPD
experience worsening dyspnea, exercise intolerance, and
subsequent reductions in physical activity. Notably, lower
levels of physical activity, independent of lung function, are
associated with a higher risk of hospital admissions and
readmissions, acute exacerbations, and death [2–7].
Complicating the clinical picture, individuals with COPD
have psychological comorbidities, including higher rates of
anxiety and depression than the general population, which
contribute to poor disease outcomes, lower levels of quality
of life, and poor self-care behaviors [8, 9]. There is a
well-described interaction between anxiety and dyspnea that
contributes to a spiral of disability and functional decline [10].
Mind-body interventions may be well-suited for address-
ing the complex biopsychosocial effects of COPD on patients.
is mindful breathing, which is particularly relevant to
patients with COPD. Conventional breathing retraining exer-
cises, which typically do not include an explicit mindfulness
focus, are incorporated into conventional pulmonary reha-
bilitation programs and may include pursed-lip breathing
and some elements of diaphragmatic breathing. Pursed lip
breathing may improve breathlessness, the mechanical func-
tion of the lungs, and exercise capacity [11–13]. However,
there is also inconsistent evidence, particularly for diaphrag-
matic breathing, in terms of benefits to dyspnea, quality of
life, and some pulmonary parameters (e.g. ventilation, chest
wall motion) [11–14]. Breathing techniques that integrate
mindfulness may be particularly helpful for patients with
COPD. These techniques include a nonjudgmental awareness
of the somatic and psychological processes associated with
the breath to help individuals breathe more efficiently. Few
studies have examined mindful breathing, specifically. Yogic
breathing was shown to be associated with improved exercise

CONTACT Kristen M. Kraemer kkraemer@bidmc.harvard.edu Division of General Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School,
330 Brookline Avenue, CO-1309, 2nd Floor, Boston, 02215 MA, USA.
Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1928037.
Trial Registration: This trial is registered in Clinical Trials.gov, ID number NCT01551953
© 2021 Taylor & Francis Group, LLC
 COPD: Journal of Chronic Obstructive Pulmonary Disease 289

tolerance and forced expiratory volume in one second overall study feasibility, are presented elsewhere [23]. A
(FEV1) in individuals with COPD [13, 15, 16], while two randomized subset of tai chi participants also received an
studies that combined mindful attention with breathing exer- additional 12 weeks of tai chi “maintenance” classes.
cises found no improvements across several physical (e.g. Participants in all groups were assessed at baseline, 12 weeks,
dyspnea, exercise tolerance) and psychological (e.g. emo- and 24 weeks. Research staff performing the assessments
tional function) outcomes [17, 18]. More rigorous research were blinded to treatment group.
is needed to understand the effects of mindful breathing
techniques for patients with COPD.
Tai chi is a multimodal mind-body approach that inte- Eligibility, recruitment, and randomization
grates several components relevant to COPD management,
Individuals with moderate-severe COPD were eligible to
including low-impact physical activity, strength training,
participate. Moderate-severe COPD was defined as: 1) GOLD
postural control training, and various mindful breathing
(Global Obstructive Lung Disease) stage 2, 3 or 4 with
techniques. Preliminary research suggests that tai chi may
symptoms of dyspnea (either FEV1 ≤ 80% and FEV1/FVC
improve both physiological and psychosocial symptoms
<0.70, or computed tomography [CT] evidence of emphy-
associated with COPD, including exercise tolerance, anxiety
sema) and 2) age ≥ 40 years. Individuals were excluded if
and depressive symptoms, and quality of life [19–21]. In
they had: 1) respiratory failure or GOLD stage 4 and were
one of the largest studies to date, Polkey and colleagues
unable to perform a six-minute walk test (6MWT); 2) a
[22] found that tai chi may be equivalent to pulmonary
COPD exacerbation in the past two weeks that required
rehabilitation for dyspnea, strength, and exercise capacity,
steroids, antibiotics, emergency department visit or hospi-
but not lung function (i.e. FEV 1, forced vital capacity
talization; 3) thoracic surgery within the subsequent
[FVC]). While tai chi appears promising for COPD man-
3 months; 4) hypoxemia on cardiopulmonary exercise test
agement, the value of the mindful breathing component is
or 6MWT (oxygen saturation < 88% on supplemental oxygen
not well understood.
at the end of the walk test); 5) vascular or other neuro-
Therefore, as a first step toward addressing this research
muscular conditions resulting in an inability to ambulate;
gap, and given the potential relevance of mindful breathing
6) indicators of unstable cardiovascular disease (i.e. electro-
for this pulmonary population, the current study compared
cardiogram [EKG] changes on cardiopulmonary exercise test
tai chi to an intervention comprising the mindful breathing
or chest pain on 6MWT); 7) severe cognitive problems (i.e.
component of tai chi only. Understanding the relative effects
Mini-Mental Status Exam ≤ 24); 8) current regular tai chi
of these two approaches may inform the application of
practice or participation in a pulmonary rehabilitation pro-
mind-body interventions as therapeutic options for COPD
gram; 9) unstable or untreated clinical depression; or 10)
management. Indeed, results may provide preliminary infor-
non-English speaking status.
mation regarding a simplified intervention focused on mind-
All study procedures were approved by each institution’s
ful breathing techniques as a potential stand-alone mind-body
human subjects review board (BIDMC 2010 P-000412; VA
approach for individuals with COPD. Moreover, this study
2540). Potential participants in primary care and pulmonary
may provide preliminary insights regarding active treatment
clinics were identified (August 2011–June 2015) through
components in tai chi, particularly the relevance of mindful
hospital databases at three large academic medical centers
breathing in an overall tai chi program. The aim of the
in Boston: Beth Israel Deaconess Medical Center, VABoston
current pilot study was to examine the feasibility (i.e. adher-
Healthcare System, and Boston Medical Center. Individuals
ence) and preliminary effect estimates of a mind-body
deemed potentially eligible through screening were sent a
breathing (MBB) intervention, compared to a tai chi pro-
recruitment letter and contacted via telephone. Participants
gram that includes MBB, with respect to COPD symptoms
provided written informed consent and were randomized
and health-related quality of life (HRQL), cognitive-emotional
in a 2:1:1 ratio after baseline testing to tai chi, MBB, or
function, and functional status. Findings from the current
education control (data not included here). After week 12
study will be used to inform hypotheses and guide the
testing, participants in the tai chi group were further ran-
development of a fully-powered randomized controlled trial
domized to an additional tai chi maintenance class or usual
(RCT) to understand the impact of these mind-body
care. A study biostatistician performed the randomization
approaches.
procedures; groups were assigned using a permuted blocks
method with randomly varying block sizes of 4 and 8.
Group assignments were sealed in sequentially numbered
Materials and method opaque envelopes and study staff randomized each partici-
pant by opening the next numbered envelope.
Study design
This analysis focuses on the exploratory comparison of tai Interventions
chi versus MBB, within a larger 3-arm pilot RCT examining
the effects of a 12-week tai chi program versus an The tai chi and MBB classes were held twice per week (1 h
attention-matched education control or a 12-week MBB per class) for a total of 12 weeks. After the week-12 assess-
program. Results from the primary comparison (tai chi ver- ment period, tai chi participants randomized to “mainte-
sus education control), including a priori benchmarks for nance” tai chi attended one additional class per week for
290 K. M. KRAEMER ET AL.
12 more weeks. Three instructors led both the tai chi and
MBB classes to minimize the effects of instructor personality
and teaching style between groups. Each instructor had
previously completed a formal training program, had an
average of 19 years of experience teaching tai chi, had prior
experience working with medical populations, and were
trained (by PMW) in the tai chi and MBB protocols.
Treatment fidelity was tracked via an instructor checklist
for each class. Participants in each group continued to
receive their usual care, which included regularly scheduled
provider visits and medications according to American
Thoracic Society guidelines for managing COPD [24].
Tai Chi
Complete details regarding the development and content of
the tai chi intervention are published elsewhere [25]. Briefly,
the 12-week program was designed to meet the needs of
older, physically limited adults with COPD. Five core tai
chi movements, rooted in the traditional Cheng Man-Ch’ing’s
Yang-style short form, were included in the intervention -
“raising the power,” “withdraw and push,” “grasp the spar-
row’s tail,” “brush knee twist step,” and “cloud hands.” Four
mind-body breathing techniques were integrated throughout
the interventions: 1) “Renewing the Body with the Breath,”
which emphasizes relaxation, body and breath awareness,
and imagery to systematically scan the whole body and
release tension; 2) “Mindful Breathing,” which emphasizes
mental focus, interoception, and awareness of the mecha-
nisms of breathing; 3) “Dan Tien Breathing” or “Ocean
Breathing,” which combines diaphragmatic breathing with
imagery and simple arm movements mirroring movement
of the abdomen; and 4) “Balloon Breathing,” which extends
the previous practice by extending the period of exhalation.
Each class also included traditional tai chi warm-up and
cool-down exercises. Participants were encouraged to prac-
tice at home for an additional three times per week for
30 min; they were provided with a 45-minute DVD and
audio file to encourage this home practice.
Individuals randomized to receive additional “mainte-
nance” tai chi reviewed and practiced material from the
first 12 weeks; no new material was introduced at this time.
Mind-body breathing
The MBB intervention was designed to focus primarily on
the four breathing techniques described above, without inte-
grating them with the tai chi movements and warm-up and
cool-down exercises. Mindful awareness of breath was
emphasized in each of the techniques. The 12-week MBB
intervention was matched to tai chi in total class time (1 h
weekly); however, the time spent on breathing techniques
was relatively increased. In addition to seated practice of
the breathing techniques, participants practiced using the
techniques in the context of simulated activities of daily
living (e.g. having a phone conversation, washing the dishes).
Participants in the MBB group were also encouraged to
practice at home three additional times per week for 30 min;
they were provided with a 45-minute DVD and audio file
that mirrored the breathing exercises taught in class to facil-
itate home practice.
Outcome measures
Intervention feasibility and safety monitoring
The focus of this analysis was on intervention feasibility
once enrolled (i.e. class attendance and home practice com-
pletion). Results on the overall study feasibility (e.g. will-
ingness to participate, rates of recruitment) are presented
elsewhere [23]. Intervention feasibility was assessed via class
attendance and home practice. Class attendance in each
group was tracked by study staff. Based on class attendance,
the a priori benchmark for intervention feasibility was a
majority of participants with ≥ 70% class attendance. For
the first 12 weeks, adherence to home practice was assessed
using home practice logs that tracked the frequency and
duration of practice. For the second 12 weeks, home practice
continued to be assessed via logs at each class in the tai
chi maintenance group, and all other participants (i.e. par-
ticipants who only completed the first 12 weeks of tai chi
and MBB) reported their home practice once a month to
study staff via telephone calls.
Adverse events were systematically tracked in both
groups. Throughout the 12-week intervention period, par-
ticipants were asked about new symptoms and changes in
symptoms at each class. At the 12- and 24-week testing
visits, participants were asked about emergency department
visits, hospitalizations, and medical symptoms in the past
12 weeks. Queried medical symptoms included dizziness,
muscle strain, fatigue, shortness of breath or COPD exac-
erbation, palpitations, falls, and psychological stress. We
documented relatedness to the study, severity, change in
medications, and additional medical or hospital visits for
all events. If a serious adverse event occurred, which was
defined by the Institutional Review Board as life-threatening,
requiring hospitalization, or resulting in significant disabil-
ity/incapacity, we conducted medical record reviews to
obtain additional details.
Health-related quality of life and dyspnea
Chronic respiratory disease questionnaire (CRQ).  The CRQ
is a 20-item self-report measure that assesses disease-specific
HRQL. The total score and four subscales (i.e. dyspnea,
fatigue, emotional function, mastery) were used in the cur-
rent study [26, 27].
University of California, San Diego shortness of breath
questionnaire (USCD SOB).  The UCSD SOB is a 24-item
self-report measure that assesses perceived shortness of
breath while performing several activities of daily living [28].
Cognitive-emotional
COPD self-efficacy scale (CSES).  The CSES is a 34-item
self-report measure that assesses one’s confidence in man-
aging or avoiding breathing difficulties across several

different areas: times of negative affect, intense emotions,
physical exertion, at-risk behaviors, and adverse weather/
environment conditions. Items are rated on a 5-point Likert
scale (1 = very confident to 5 = not at all confident) with
higher scores reflecting lower confidence. The CSES has
demonstrated good psychometric properties [29].
Center of epidemiology studies – depression scale
(CES-D). The CES-D is a well-validated self-report measure
that assesses depressive symptoms [30]. Scores > 15 are
indicative of significant depressive symptoms. The CES-D
has demonstrated good psychometric properties [31, 32].
Multidimensional scale of perceived social support
(MSPSS).  The MSPSS is a well-validated 12-item self-
report measure that assesses one’s perceived social support
within their existing social network (i.e. family, friends,
significant others) [33].
Functional status
Six-minute walk test (6MWT).  The 6MWT is a standardized
measure of exercise capacity that assesses the maximum
distance walked in six minutes [34]. The test was performed
according to American Thoracic Society (ATS) guidelines,
with no practice test administered to minimize participant
burden [35]. Participants were able to stop when needed.
Participants who were prescribed oxygen with exercise uti-
lized their physician prescribed flow rate during the walk
test. The 6MWT is an independent predictor of COPD
prognosis and survival [36].
30-second chair stand test.  The chair stand test is a
validated assessment used to measure lower body strength
and endurance. Participants are instructed to fold their
arms, rise to a standing position, and return to a seated
position as many times as possible in 30 s [37].
Chair sit and reach.  Commonly used in older or
deconditioned populations, the chair sit and reach was used
to assess lower body flexibility, primarily in the hamstrings
(distance (inches) from toe to end of fingers) [38].
Patient-Reported Outcome Measurement Information
System Fatigue Short Form 7a (PROMIS-Fatigue).  The
PROMIS-Fatigue is a well-validated self-report measure
used to assess functional fatigue [39].
Community Health Activities Model Program for
Seniors Physical Activity Questionnaire for Older Adults
(CHAMPS).  The CHAMPS is a well-validated 41-item
self-report measure that assesses physical activity across
several domains (i.e. leisure, household, occupational)
[40]. Participants report weekly frequency and total time
spent in physical activities, which is used to estimate
caloric expenditure (in kilocalories per week).
COPD: Journal of Chronic Obstructive Pulmonary Disease 291
Other data collection
Sociodemographic information, spirometry, and lung vol-
umes were collected at baseline. The BODE index (FEV1%
predicted, 6MWT distance, modified Medical Research
Council dyspnea score, body mass index) [41] and multiple
comorbidities from the Charlson Comorbidity Index [42]
were calculated at baseline. Spirometry was performed using
rolling-seal volume displacement spirometers (Collins GS or
CPL) by respiratory therapists or physicians following
American Thoracic Society standards [43]. Participants per-
formed three acceptable spirometry efforts; each spirometry
effort was repeated after inhalation of two puffs (180 mcg)
of albuterol. FEV1 and FEV1/FVC were measured in the
current study. Lung volumes were measured via plethys-
mography, a pressure-based volume measurement technique
using Boyle’s law using pressure transducers and a pneu-
motachograph (Collins Box2). Expiratory reserve volume
(ERV), inspiratory capacity (IC), total lung capacity (TLC),
and IC/TLC were measured.
Statistical analysis
Adherence and safety
Given the pilot nature of this study, feasibility (i.e. adher-
ence) was the primary outcome. Adherence to each class
and home practice were assessed using descriptive statistics.
Safety was assessed via the number of reportable and
non-reportable adverse events per group.
Preliminary estimates of effects
As part of the larger trial with three arms (tai chi vs. edu-
cation vs. MBB), the tai chi vs. MBB comparison was a
prespecified exploratory comparison and was therefore not
fully powered to detect between-group differences. Therefore,
in line with guidelines for pilot trials, rather than assess
efficacy and statistical significance, analyses focused on effect
sizes and confidence intervals to inform the development
of future trials [44–47].
We estimated effect sizes (standardized differences
between groups) by comparing change scores between
groups (baseline to 12 weeks, 12 to 24 weeks) and calculating
Cohen’s d [48]. We calculated confidence intervals (95%)
for Cohen’s d using Hedges and Olkin’s [49] formula for
confidence intervals for standardized differences. For the
12- to 24-week effect sizes, analyses were separated for the
tai chi participants who received and did not receive addi-
tional maintenance classes. In these analyses, to match the
comparison of 12-week intervention, followed by 12-week
follow-up, we included participants who received only
12 weeks of tai chi total (n = 25). To further inform hypoth-
eses regarding the effects of additional tai chi maintenance
classes, we also estimated effect sizes by comparing change
scores from baseline to 24 weeks between those in the tai
chi group who also received additional maintenance classes
(i.e. received additional tai chi from 12 to 24 weeks; n = 27)
to those in the MBB group. Further, we used generalized
estimating equations to estimate the difference in mean
changes between groups from baseline and 12 weeks, 12 and
292 K. M. KRAEMER ET AL.
Figure 1.  CONSORT flow diagram.
24 weeks, and baseline and 24 weeks, adjusting for baseline
values that were imbalanced between the three treatment
groups (i.e. tai chi, MBB, education) at baseline: Charlson
comorbidity index, CES-D score, and BODE index. We
included treatment group assignment, time point, and their
interaction in each model as categorical variables. As
demonstrated in the CONSORT (Figure 1), we conducted
analyses in subjects with complete data at each of the 12-
and 24-week timepoints and we did not impute missing
data. We conducted all analyses using SAS statistical soft-
ware, version 9.4 (SAS Institute Inc., Cary, NC).
Results
Baseline characteristics
The trial CONSORT diagram focused on the tai chi and
MBB arms is presented in Figure 1. Baseline characteristics
of each group are presented in Table 1. A total of 92 par-
ticipants were randomized to tai chi (n = 61) or MBB
(n = 31). The mean age of participants was 68.2 (SD = 8.7)
and 66% were male. Participants had a mean FEV1% pre-
dicted of 58.4 (SD = 14.5) and mean tobacco pack years of
50.3 (SD = 37.6). Overall, 24% were GOLD stage 3-4 and
17% were on supplemental oxygen. Comorbidities included
coronary artery disease (32%), cancer (21%), chronic mus-
culoskeletal issues or back pain (51%), and significant lim-
itation of an extremity (weakness or paralysis: 21%).
Baseline values of FEV1% predicted, FEV1/FVC, ERV, IC,
TLC are included in Table 1 in each group. These lung
testing parameters were relatively balanced across groups.
Adherence and safety
The overall group adherence (i.e. class attendance) in the
first 12 weeks was 62% in the tai chi group and 75% in
the MBB group. The majority of participants in both groups
attended ≥ 70% of classes (59% in tai chi and 74% in
MBB). Class and home practice adherence among those
with available data (n = 50 in tai chi and n = 27 in MBB)
are presented in Table 2. Table 2 does not include
 COPD: Journal of Chronic Obstructive Pulmonary Disease 293

Table 1. Baseline sociodemographic and clinical characteristics. participants who were further randomized to tai chi main-
Characteristic Tai Chi (N = 61)* MBB (N = 31)* tenance in the second 12 weeks. In the first 12 weeks, the
Age (mean, SD) 68.6 (9.2) 67.5 (7.7) tai chi group endorsed an average of 94.4 (SD = 75.8) min-
Male sex 43 (71) 18 (58) utes of home practice per week and the MBB endorsed
Race    
 White 48 (79) 24 (77) 116.4 (SD = 117.7) minutes. In the follow-up period, those
 Black 7 (12) 6 (19) in the tai chi group logged an average of 68.8 (SD = 58.6)
 Other 6 (10) 1 (3) minutes of home practice per week and the MBB logged
Annual income <$35 K 37 (61) 11 (35)
Functional Comorbidity 4.5 (2.4) 4.1 (1.9)
88.0 (SD = 72.8) minutes. Those in the tai chi maintenance
Index (mean ± SD) classes endorsed an average of 52.1 (SD = 50.4) minutes of
GOLD stage (mean, SD) 2.3 (0.6) 2.2 (0.5) home practice per week.
 Stage I-II 45 (74) 25 (81) Reportable adverse events are summarized in Supplemental
 Stage III-IV 16 (26) 6 (19)
BODE index (mean, SD) 2.8 (1.8) 2.5 (1.6) Table 1. During the 12-week intervention period, a total of
 0-2 27 (44) 18 (58) 16 reportable adverse events occurred in the tai chi group
 3-4 23 (38) 9 (29) and none occurred in the MBB group. In the tai chi group,
  5 or greater 11 (18.0) 4 (13)
Baseline max VO2 13.8 (5.1) 13.8 (4.4)
these included 7 COPD exacerbations and 12/16 (75%) were
(mean ± SD) deemed unrelated to the study. Events that were possibly
Regular oxygen use 11 (18) 5 (16) related in the tai chi group included musculoskeletal flares
Smoking pack years (mean, 57.6 (38.2) 35.5 (32.3) among those with a prior history of chronic pain and/or
SD)
Completed pulmonary 12 (20) 7 (23) osteoarthritis. In the follow-up period, there were three
rehabilitation reportable events in the MBB and 21 in the tai chi group.
Comorbidities    
  CVD (CAD, Angina, 23 (38) 6 (19)
In the MBB group, these included 3 COPD exacerbations.
Angioplasty, MI) In the tai chi group, these included 11 COPD exacerbations,
 Heart Failure 7 (12) 3 (10) 1 musculoskeletal flare, and 10 other events (see Supplemental
 Cancer 14 (23) 5 (16) Table 1). No events were deemed related in the tai chi or
 Hypertension 42 (69) 19 (61)
 Limitation of limb 14 (23) 5 (16.1) MBB groups in the follow-up period. Common expected
(weakness, paralysis) symptoms that did not meet criteria for reporting to our
  OA, Sciatica, Chronic back 31 (51) 16 (52) IRB, including muscle soreness, dizziness/fainting, shortness
pain
  Peripheral vascular 4 (7) 1 (3) of breath, fatigue, falls, palpitations, and psychological stress,
disease were reported by 55/61(90%) subjects in tai chi and 28/31
 Stroke or cerebrovascular 7 (12) 1 (3) (90%) in MBB.
disease
  Connective tissue disease 9 (15) 1 (3)
  Obstructive sleep apnea 14 (23) 4 (13)
6-Minute Walk Test (ft) 1210.6 (283.9) 1333.7 (300.2) Preliminary effect estimates
(mean ± SD)
Calorie Expenditure 1469.1 (2514.5) 2141.5 (3268.1) MBB vs. Tai Chi post-intervention (baseline to 12 weeks)
- Moderate Exercise Results on the effects of tai chi and MBB on HRQL,
(mean ± SD)
Frequency - Moderate 5.6 (7) 6.9 (7.9) cognitive-emotional measures, and functional status from
Exercise (mean ± SD) baseline to 12 weeks are presented in Table 3. Overall, there
CES-D (mean ± SD) 14.9 (11.7) 10.0 (10.7) were moderate between-group differences favoring tai chi
Spirometry (mean ± SD)
 FEV1 % predicted NHANES 57.8 (14.3) 59.6 (14.8) in CES-D and the 6MWT distance, and small-moderate
 FEV1/FVC 0.46 (0.11) 0.47 (0.12) between-group differences favoring tai chi in chair stand
Lung Volume/Capacity and MSPSS. Calorie expenditure in moderate intensity exer-
(mean ± SD)
 ERV (L) 0.89 (0.40) 0.83 (0.45) cises decreased in both groups, but less so in the tai
 IC (L) 2.25 (0.79) 2.24 (0.60) chi group.
 TLC (L) 5.90 (1.30) 5.96 (1.16)
Note.
*N(%) unless otherwise noted; CAD: coronary artery disease; CES-D: Center for MBB vs. Tai Chi follow-up (12-24 weeks)
Epidemiological Studies-Depression; CVD: cardiovascular disease; ERV: expi- Follow-up effects from 12 to 24 weeks are presented in Table 4,
ratory reserve volume; FEV1: forced expiratory volume in one second; FVC:
forced vital capacity; IC: inspiratory capacity; MI: myocardial infarction; OA:
including participants who only received the first 12 weeks
osteoarthritis; TLC: total lung capacity. of tai chi (n = 25). Tai chi continued to demonstrate

Table 2. Tai Chi and Mind-Body Breathing intervention adherence.

  Intervention period (Baseline-12 weeks) Follow-up period (12-24 weeks)
Mean (SD)
  Tai Chi (n = 50) MBB (n = 27) Tai Chi (n = 25) MBB (n = 27)
Classes Attended 17.3 (6.9) 19.7 (4.9) - -
Class Time (mins/wk) 86.7 (34.7) 98.7 (24.4) - -
Home Practice Time (mins/wk) 94.4 (75.8) 116.4 (117.7) 68.8 (58.6) 88.0 (72.8)
Home Practice Frequency (sessions/wk) 2.9 (1.6) 4.4 (4.8) 0.6 (0.4) 0.9 (0.7)
Total Minutes of Practice (minutes/wk) 181.1 (98.3) 210.8 (126.6) 68.8 (58.6) 88.0 (72.8)
294 K. M. KRAEMER ET AL.

Table 3. Mean changes in health-related quality of life, cognitive-emotional measures, and functional status from baseline to 12 weeks in the Tai Chi and
Mind-Body Breathing groups.
  Intervention period (Baseline-12 weeks)
Between group
Outcome Measure Tai Chi* MBB* effect size** Adjusted mean difference‡
Symptoms and health-related      
quality of life
  CRQ Dyspnea 0.29 (1.31) 0.11 (0.99) 0.15 (-.32, .61)a 0.06 (-0.40, 0.53)
  CRQ Emotion 0.25 (0.75) 0.02 (0.86) 0.28 (-.19, .75)a 0.19 (-0.18, 0.55)
  CRQ Fatigue 0.20 (1.23) −0.01 (1.21) 0.17 (-.29, .64)a 0.19 (-0.31, 0.69)
  CRQ Mastery 0.27 (0.94) 0.06 (0.86) 0.24 (-.22, .71)a 0.11 (-0.25, 0.48)
  CRQ Total 0.25 (0.74) 0.05 (0.71) 0.29 (-.18, .75)a 0.14 (-0.19, 0.46)
 UCSD Shortness of Breath −1.70 (11.73) −1.86 (11.21) 0.01 (-.45, .48)b 0.53 (-4.82, 5.88)
Cognitive-emotional measures
  COPD Self-Efficacy 0.13 (0.58) −0.03 (0.69) 0.24 (-0.23, 0.71)b 0.15 (-0.12, 0.43)
 CES-D −2.57 (7.73) 1.42 (7.23) -.53 (-1.01, −0.06)a −2.31 (-5.7, 1.07)
 MSPSS 0.14 (1.00) −0.15 (0.49) 0.36 (-0.10, 0.83)a 0.19 (-0.11, 0.49)
Functional status
  6-Minute Walk Test (ft) 35.27 (118.63) −25.48 (138.04) 0.47 (0, 0.94)a 62.04 (2.85, 121.22)
  Chair Stand 0.63 (1.74) −0.26 (2.26) 0.44 (-0.03, 0.91)a 0.91 (-0.05, 1.86)
  Chair Sit and Reach (in) 0.28 (3.18) 0.33 (3.29) −0.02 (-0.48, 0.45)b −0.01 (-1.42, 1.41)
 PROMIS-Fatigue −0.13 (0.40) −0.05 (0.52) −0.17 (-0.63, 0.30)a −0.06 (-0.28, 0.15)
Calorie Expenditure - Moderate −216.06 (2310.65) −960.56 (2456.02) 0.31 (-0.16, 0.78)a 386.33 (-415.04, 1187.69)
Exercises†
 Frequency of Moderate Intensity −1.26 (6.52) 0.11 (10.21) -.16 (-0.62, 0.30)b −1.98 (-5.87, 1.90)
Exercises
Note.
*
Mean change (±SD).
**
Standardized difference (95% CI).
†
kcal/week.
‡
Adjusted mean difference at week 12, adjusted for baseline value, and baseline BODE, CESD, Charlson.
a
Between group effect size favors Tai Chi.
b
Between group effect size favoring MBB; CES-D: Center for Epidemiological Studies-Depression; CRQ: Chronic Respiratory Disease Questionnaire; MSPSS:
Multidimensional Scale of Perceived Social Support; PROMIS-Fatigue: Patient-Reported Outcome Measurement Information System Fatigue Short Form 7a;
UCSD: University of California, San Diego Shortness of Breath Questionnaire.

Table 4. Mean changes in health-related quality of life, cognitive-emotional measures, and functional status from 12 to 24 weeks in the Tai Chi and Mind-Body
Breathing groups.
Follow-up period (12-24 Weeks)
Outcome Measure Tai Chi (n = 25)* MBB (n = 27)* Between-group effect size** Adjusted mean difference‡
Symptoms and health-related        
quality of life
  CRQ Dyspnea −0.24 (1.33) 0.08 (1.05) −0.26 (-0.81, 0.29) b
−0.35 (-0.97, 0.27)
  CRQ Emotion −0.17 (1.03) −0.12 (0.76) −0.06 (-0.61, 0.49)a −0.23 (-0.75, 0.29)
  CRQ Fatigue −0.40 (1.17) 0.13 (1.00) −0.48 (-1.04, 0.07)b −0.45 (-1.05, 0.15)
  CRQ Mastery 0.16 (0.90) −0.19 (1.08) 0.35 (-0.20, 0.91)a 0.31 (-0.23, 0.84)
  CRQ Total −0.17 (0.94) −0.03 (0.70) −0.16 (-0.71, 0.39)b −0.18 (-0.66, 0.29)
 UCSD Shortness of Breath 2.72 (11.94) 0.77 (8.32) 0.19 (-0.36, 0.74)b 2.61 (-3.78, 9.00)
Cognitive-emotional measures        
  COPD Self-Efficacy 0.27 (0.68) −0.05 (0.38) 0.59 (0.03, 1.15)b 0.24 (-0.08, 0.56)
  CES-D Score 0.47 (9.69) −0.12 (6.78) 0.07 (-0.48, 0.62)b 2.75 (-1.17, 6.68)
 MSPSS 0.37 (0.86) −0.08 (0.59) 0.61 (0.05, 1.17)a 0.45 (0.04, 0.86)
Functional status        
  6-Minute Walk Test (ft) −50.64 (77.45) 32.08 (139.99) −0.73 (-1.32, −0.14)b −73.75 (-151.07, 3.57)
  Chair Stand −0.52 (1.97) 0.19 (2.77) −0.30 (-0.86, 0.27)b -.59 (-2.19, 1.01)
  Chair Sit and Reach (in) 0.57 (2.71) 0.35 (3.04) 0.08 (-0.49, 0.64)a 0.1 (-1.76, 1.96)
  PROMIS Fatigue 0.24 (0.71) 0.02 (0.54) 0.35 (-0.20, 0.91)b 0.28 (-0.06, 0.62)
  Calorie Expenditure - Moderate −39.38 (2309.38) 32.31 (1701.98) −0.04 (-0.59, 0.52)b 26.33 (-985.37, 1038.03)
Exercises †

 Frequency of Moderate Intensity 7.34 (27.99) −1.71 (11.14) 0.42 (-0.13, 0.98)a 5.6 (-6.26, 17.46)
Exercises
Note. Tai chi group only includes participants who received the first 12 weeks of Tai Chi.
*
Mean change (±SD).
**
Standardized difference (95% CI).
†
kcal/week.
‡
Adjusted mean difference at week 24, adjusted for week 12 value, and baseline BODE, CESD, Charlson.
a
Between group effect size favors Tai Chi.
b
Between group effect size favoring MBB; CES-D: Center for Epidemiological Studies-Depression; CRQ: Chronic Respiratory Disease Questionnaire; MSPSS:
Multidimensional Scale of Perceived Social Support; PROMIS-Fatigue: Patient-Reported Outcome Measurement Information System Fatigue Short Form 7a;
UCSD: University of California, San Diego Shortness of Breath Questionnaire.

improvements in MSPSS compared to MBB. However, com-
pared to MBB, after the intervention ended, both COPD
self-efficacy and the 6MWT distance declined in the tai chi
group. There were small effects of improved CRQ-mastery
and an increase in physical activity frequency
(moderate-intensity exercise) in tai chi, while small
between-group effects favored MBB in measures of fatigue
(CRQ-fatigue and PROMIS-fatigue) and lower extremity
strength (chair stand).
MBB vs. Tai Chi maintenance (baseline to 24 weeks)
Comparing those who received additional tai chi mainte-
nance (24-week intervention total, n = 27) to those who
received MBB (12-week intervention, 12-week follow up)
from baseline to 24 weeks, there were moderate-large
between-group effects favoring tai chi maintenance in
CRQ-mastery (ES = 0.74; adjusted mean difference = 0.56)
and chair stand (ES = 0.56; adjusted mean difference = 1.38).
Discussion
In the current pilot RCT, we aimed to estimate the feasibility
(i.e. adherence) and preliminary effects of time- and
attention-matched 12-week tai chi and MBB programs on
COPD symptoms and HRQL, cognitive-emotional, and func-
tional outcomes among individuals with moderate-severe
COPD. As discussed elsewhere [23], overall study feasibility
(e.g. willingness to participate, recruitment rates) was sub-
optimal due to potential inefficiencies in our recruitment
process. Once enrolled, however, class attendance and home
practice rates suggest that both interventions were feasible,
but overall class adherence and home practice were slightly
higher in MBB than the tai chi group. These findings are
consistent with previous work, which suggests that once
participants are enrolled, tai chi programs adapted for indi-
viduals with respiratory diseases are feasible [50, 51].
Excellent adherence rates for MBB also suggests that a mind-
ful breathing program is feasible for individuals with COPD.
Both interventions were safe with few reportable adverse
events deemed related to the study. The four events deemed
related or possibly related to tai chi included musculoskeletal
flares. The overall percentage of participants reporting com-
mon expected symptoms was equal in both groups, which
underscores the relatively debilitated and co-morbid popu-
lation we studied. However, a higher percentage of partic-
ipants in the tai chi group endorsed common symptoms
related to exercise (e.g. muscle soreness, shortness of breath).
Therefore, it is possible that class and home practice adher-
ence was slightly lower in tai chi due to musculoskeletal
flares and other common and expected symptoms related
to exercise. While some symptoms are expected and unavoid-
able with any form of exercise, future work may consider
further adapting tai chi for COPD to minimize uncomfort-
able exercise-related symptoms.
Nonetheless, at 12 weeks, there were modest improve-
ments in depressive symptoms, exercise capacity, chair stand,
and social support for tai chi compared to MBB. We
observed minimal within-group improvements across most
COPD: Journal of Chronic Obstructive Pulmonary Disease 295
outcomes in the MBB group, including psychosocial out-
comes, which is surprising. Further, there was an apparent
small increase in depressive symptoms at 12 weeks. This
suggests that mindful breathing alone may not be sufficient
to impact these outcomes in 12 weeks among individuals
with moderate-severe COPD. Indeed, extant work has
demonstrated inconsistent findings on the effects that
mind-body breathing interventions or mindfulness interven-
tions with breathing components have in this population
[17, 18]. It is unclear if the specific breathing techniques
chosen were not effective, the incorporation of breathing
practice into activities of daily living was not helpful, or
the time dedicated to certain exercises was sub-optimal. For
example, it is possible that one-hour of breathing exercises
was too long or even counterproductive. In contrast to the
quantitative results from this analysis, results from qualita-
tive analysis of exit interviews from this same study [52]
suggest that those in the tai chi and MBB groups equally
endorsed themes related to improved internal locus of con-
trol and self-efficacy toward managing anxiety and dyspnea,
greater emotion regulation and decreased reactivity, less
emotional distress, improved physical function, and greater
valuing of social interactions. Therefore, it is also possible
that the quantitative outcomes in the current analysis did
not effectively capture participants’ experience with the MBB
group. Further, other mind-body interventions with a focus
on breathing have been shown to be beneficial among indi-
viduals with COPD [53]. Given these mixed findings, future
work should continue to evaluate mindful and other
mind-body breathing programs for individuals with COPD
and might consider variables such as intervention dosage,
the type of breathing exercises, and the ratio of various
breathing exercises.
Once the classes ended, many of the positive effects of
tai chi were not maintained in the follow-up period (12
to 24 weeks). Both exercise capacity and chair stand waned
in the follow-up period in the tai chi group compared to
MBB, suggesting that continued exercise is needed to main-
tain functional gains. Initial improvements in depressive
symptoms for tai chi also did not appear to be maintained
over the follow-up period. Of note, COPD self-efficacy
and fatigue worsened from 12 to 24 weeks in the tai chi
group, whereas there was no change in the MBB group.
It is possible that the MBB intervention, while not pro-
ducing positive gains in the first 12 weeks, acted as a buffer
toward progressive declines in self-efficacy and fatigue
typically seen in patients with COPD. However, compared
to MBB, social support continued to improve in tai chi
and there were small trends toward improvements in the
mastery subscale of HRQL and the frequency of moderate
intensity exercise in the follow-up period (12 to 24 weeks)
that were not evident at post-intervention. Together, these
results suggest that more than 12 weeks of tai chi may be
needed to produce long-term changes in physical and psy-
chosocial outcomes among individuals with moderate-severe
COPD. Indeed, results from a separate analysis of data
from the current pilot RCT (comparing tai chi with the
education control) [23], suggest that tai chi with additional
booster or maintenance classes may be protective against
296 K. M. KRAEMER ET AL.
decreases in exercise capacity and associated with increases
in COPD self-efficacy compared to tai chi with no addi-
tional maintenance classes. Furthermore, results from the
current analysis demonstrated that those who received an
additional 12 weeks of tai chi maintenance improved in
HRQL (CRQ-Mastery) and lower extremity strength over
24 weeks with potential improvements in other indices (e.g.
depression, exercise capacity) compared to MBB. However,
these results may simply be due to the extra time and
attention the tai chi maintenance participants received
compared to those in MBB (24 weeks vs. 12 weeks inter-
vention). More research is needed to understand the most
effective dose of tai chi to sustain effects and to examine
whether a longer MBB intervention is needed to detect
meaningful change.
One obvious difference between our two interventions is
that the tai chi included integrated physical movement with
mindful breathing and other mind-body strategies. While
preliminary effects should be interpreted with caution due
to the pilot nature of the current study, our results suggest
that perhaps multimodal mind-body exercise approaches,
which include physical movement, may offer short-term
physical and psychosocial benefits for individuals with
COPD over a more simplified intervention that focuses
mainly on mindful breathing. While mindful breathing is
theoretically relevant and promising, the mixed findings
point to a more complex picture. Given the effects of inter-
related biopsychosocial factors on morbidity in COPD [8–
10], integrated approaches (e.g. tai chi) that simultaneously
target these factors (e.g. exercise capacity and depressive
symptoms) may be particularly valuable. This is in line with
research suggesting that other integrated mind-body move-
ment interventions may confer physical and psychosocial
benefits for individuals with respiratory diseases (e.g. yoga,
dance) [54–56]. Moreover, integrated mind-body exercise
approaches may confer advantages over non-movement
mind-body interventions for health behavior promotion,
particularly physical activity promotion, which is crucial for
individuals with COPD. Low-to-moderate intensity activity,
combined with other mind-body strategies, may improve
exercise capacity, increase self-efficacy for exercise, remove
psychosocial barriers to exercise (e.g. depressive symptoms),
enhance other self-regulatory processes (e.g. emotion regu-
lation), and ultimately improve downstream physical activity
levels [57]. Results from the current study demonstrated
potential improvements in the frequency of moderate inten-
sity exercise in tai chi over the course of the 24 weeks.
Larger, fully-powered studies are needed to assess the dif-
ferential effects of mind-body exercise interventions and
non-movement mind-body programs for health behavior
promotion.
Findings from the current study offer tentative insights
regarding active therapeutic ingredients in tai chi. Mindful
breathing is one component in a multimodal tai chi inter-
vention. Given the absence of substantive within-group
change in the MBB group across most outcomes, it is
possible that mindful breathing does not drive change in
tai chi interventions. On the other hand, mindful breath-
ing combined with physical activity may additively or
synergistically influence outcomes. Consistent with this
line of thinking, in studies that compare tai chi to physical
activity control conditions, results suggest that tai chi may
lead to more improvement across several outcomes (e.g.
exercise capacity, positive affect) [58–61]. Future research
should further elucidate which components drive change
in mind-body exercise interventions, and whether there
are additive or synergistic effects of components (e.g.
physical activity, mind-body breathing, mindfulness).
Multiphase Optimization Strategy (MOST) study designs,
which aim to identify active treatment components in
multimodal interventions, may be particularly useful in
this regard [62].
The primary limitation of the current study was the
small sample size. Since the publication of our protocol
paper [25], there has been a greater appreciation for the
limitations of pilot studies and new guidelines for appro-
priately reporting results have been issued [44–47]. We
acknowledge we may have been underpowered to detect
significant differences across multiple outcomes. In addi-
tion, the current study included a relatively short follow-up
period. It is possible that MBB effects emerge gradually
over longer periods of time. Indeed, we observed slightly
higher home and total practice in the MBB group, sug-
gesting that MBB is feasible to implement and sustain,
which may confer longer-term benefits that were not cap-
tured in this study. Further, individuals with moderate-severe
COPD without a severe exacerbation in the past two weeks
were eligible for the study. Given the relatively short time-
frame of two weeks, it is possible that individuals with
more unstable disease were enrolled in the study, which
may have impacted our results. Lastly, participants did not
complete a practice 6MWT at baseline, which may have
led to an overestimation of the treatment effect in both
groups. However, given that the same 6MWT procedures
were used across all participants, the lack of a practice
test would not have contributed to differences between
group. Despite these limitations, the current study provides
rigorous preliminary data to guide future study develop-
ment and informs hypotheses regarding the differential
effects of integrated mind-body exercise and mindful
bre at h i ng i nte r ve nt i ons for i nd iv i du a ls w it h
moderate-severe COPD.
Disclosure statement
Dr. Wayne reports grants from NIH (K24AT009282) during the
conduct of the study. Dr. Yeh reports grants from NIH (R01AT005436;
K24AT009465) during the conduct of the study; Dr. Kraemer reports
support from NIH (T32AT000051) during the conduct of this study;
This work was conducted with support from Harvard Catalyst |
The Harvard Clinical and Translational Science Center (National
Center for Advancing Translational Sciences, National Institutes of
Health Award UL 1TR002541) and financial contributions from
Harvard University and its affiliated academic healthcare centers.
The content is solely the responsibility of the authors and does not
necessarily represent the official views of Harvard Catalyst, Harvard
University and its affiliated academic healthcare centers, or the
National Institutes of Health; All other authors report no conflicts
of interest.

Funding
This work was supported by an award from the National Center for
Complementary and Integrative Health (NCCIH) at the National
Institutes of Health (NIH) (R01AT005436). Dr. Kraemer was supported
by T32AT000051. Dr. Yeh was supported by K24AT009465. Dr. Wayne
was supported by K24AT009282. This work was conducted with sup-
port from Harvard Catalyst | The Harvard Clinical and Translational
Science Center (National Center for Advancing Translational Sciences,
National Institutes of Health Award UL 1TR002541) and financial
contributions from Harvard University and its affiliated academic
healthcare centers. The content is solely the responsibility of the authors
and does not necessarily represent the official views of Harvard
Catalyst, Harvard University and its affiliated academic healthcare
centers, or the National Institutes of Health.
ORCID
Harry Reyes Nieva http://orcid.org/0000-0001-7774-2561
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