Authors: Danping Song, Hengyu Liu, Zhe Chen, Jing Du, Ping Lu
Categories: Original Article, Traditional Chinese exercise (TCE), postoperative, lung cancer, systematic review, meta-analysis
Source: Journal of Thoracic Disease
Efficacy of traditional Chinese exercise on postoperative rehabilitation in lung cancer a systematic review and meta-analysis
Authors: Danping Song, Hengyu Liu, Zhe Chen, Jing Du, Ping Lu
Abstract
Background
Pulmonary rehabilitation plays a crucial role in lung cancer patients after surgery. In this context, traditional Chinese exercises (TCEs) are being increasingly utilized. However, the existing studies are characterized by small sample sizes, inconsistent interventions, and diverse outcome measures, which result in high heterogeneity and limited clinical applicability. This meta-analysis systematically assessed the impacts of two common TCEs on postoperative lung cancer patients, aiming to provide a basis for evidence-based rehabilitation strategies.
Methods
A systematic search of nine electronic databases was conducted for randomized controlled trials (RCTs) from inception to November 3, 2025. After independent screening, data extraction, and risk-of-bias assessment, meta-analysis was performed.
Results
Twenty-five RCTs involving 1,834 participants were included. The meta-analysis demonstrated that TCE significantly improved pulmonary function outcomes, including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), FEV1/FVC ratio, and FEV1% predicted. Additionally, TCE increased the 6-minute walk distance (6MWD) and quality of life (QoL) score. Regarding psychological outcomes, TCE significantly alleviated symptoms of anxiety. TCE showed no statistically significant effect on postoperative fatigue, Borg dyspnea scores and depression in lung cancer patients. Subgroup analyses suggested that timing of intervention initiation and settings may account for the observed heterogeneity in respiratory function outcomes. Furthermore, subgroup showed that Liuzijue was more effective than Baduanjin in improving FEV1/FVC (mean 4.88 vs. 2.71), while Baduanjin was more effective than Liuzijue in alleviating anxiety (mean −7.45 vs. −2.20).
Conclusions
TCE appears to be a beneficial intervention for enhancing pulmonary function, QoL, and mental health in postoperative lung cancer patients. However, further-quality studies are warranted to confirm the robustness of these findings due to limitations in certain outcome measures.
Introduction
Lung cancer remains the world’s most common malignancy, with GLOBOCAN 2022 estimating 2.48 million new cases (1). In China alone, the National Cancer Center reported 1.06 million diagnoses and 733,300 deaths in 2022, ranking lung cancer first for both incidence and mortality (2). Surgery for stage I-II lung cancer achieves more than 80.0% 5-year survival and is the standard curative approach (3,4), yet parenchymal resection reduces forced expiratory volume in 1 second (FEV1) by 21.0% after lobectomy, 18.4% after segmentectomy and 8.6% after wedge resection (5). Consequently, 60.0% of survivors complain of dyspnoea or chest tightness, 37.0% report chronic cough and 50.0% experience persistent fatigue (6,7). Kyte* et al. (8) found that this symptom burden frustrates patients’ desire to resume normal life, while Huang et al. *(9) documented anxiety in 49.6% and depression in 38.3%, emotions that impair rehabilitation and long-term prognosis.
Robust evidence shows that structured pulmonary rehabilitation improves postoperative lung function and quality of life, with exercise training as its cornerstone (10-12). Traditional Chinese exercises (TCEs), such as Baduanjin, Tai Chi, Wuqinxi and Liuzijue and so on, deliver low to moderate intensity aerobic stimuli through slow, gentle, continuous movements synchronized with controlled breathing. Pursed-lip and diaphragmatic patterns strengthen respiratory muscles, expand tidal volume and alveolar ventilation, and relieve dyspnoea (13). Requiring no equipment and practicable indoors or outdoors, these routines are easily adopted and sustained.
In 2022 China’s National Health Commission mandated expanded use of traditional Chinese medicine in public health, explicitly promoting traditional exercise for population-wide wellness (14). These practices already improve both lung function and mood in chronic obstructive pulmonary disease and post coronavirus disease 2019 (COVID-19) cohorts (15-17), and are now being trialled after lung-cancer surgery (18,19). Evidence to date, however, rests on small, heterogeneous trials that vary in duration, frequency and outcome measures, yielding inconsistent conclusions. Therefore, we undertook a systematic review and meta-analysis to quantify the efficacy of TCE in postoperative lung cancer patients. We present this article in accordance with the PRISMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0500/rc) (20).
Methods
Protocol and registration
The study protocol has been registered with Prospective Register of Systematic Reviews (CRD420251246728).
Eligibility criteria
This study established qualifying criteria for inclusion based on population, intervention, comparison, outcome and study design (PICOS) criteria.
The inclusion criteria were as (I) the study participants were adults aged 18–90 years who had undergone lung cancer surgery; (II) the study applied TCE intervention, including Baduanjin, Liuzijue, Wuqinxi, and Tai-Chi, either as a single modality or in combination with each other; (III) pulmonary function, activity tolerance, quality of life, and mental health outcomes were reported; (IV) the study design was a randomized controlled trial (RCT).
Studies were excluded if they met any of the following (I) non-clinical studies (e.g., animal experiments); (II) published in languages other than English or Chinese; (III) duplicate publications, in which case the most recent version was retained; (IV) unavailable full-text articles; and (V) studies with missing key outcome data or insufficient details for meta-analysis (e.g., no standard deviation values, sample size ambiguity).
Search strategy
A comprehensive literature search was conducted across nine electronic databases, including Web of Science, Embase, PubMed, the Cochrane Library, Ovid Medline, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Database, and CQVIP. The search period covered from the inception of each database to November 3, 2025. The search strategies were developed using a combination of Medical Subject Headings (MeSH), Emtree terms, and free-text words. Two main concepts were combined using the Boolean operator “AND”: (I) lung cancer (e.g., “lung neoplasms”, “non-small cell lung carcinoma”, “pulmonary tumor”) and (II) traditional Chinese exercises (e.g., “Baduanjin”, “Liuzijue”, “Qigong”, “Tai Chi”, “Wuqinxi”). Corresponding Chinese search terms were used for the Chinese databases. In addition to electronic searching, the reference lists of included studies and relevant reviews were manually screened to identify potential eligible studies. The detailed search strategies for all databases are provided in Table S1.
Study selection and data extraction
Literature management was carried out using EndNote 21 software. Two researchers (D.S. and H.L.), independently conducted literature screening, data extraction, and cross-checking. In case of a disagreement, the third researcher (J.D.) was involved in the discussion to reach a consensus. Data extraction was carried out using a pre-designed standard form, which (I) basic information of the first author, publication year, title, and sample size; (II) participant age and gender; (III) intervention measures for the intervention group and control group, intervention period, frequency, and duration of each session; and (IV) outcome pulmonary function indicators, such as forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), FEV1/FVC ratio, and FEV1% predicted; 6-minute walk distance (6MWD); Borg dyspnea score; quality of life (QoL); fatigue score; anxiety and depression scores; and adverse reactions.
Study risk of bias assessment
Two investigators (D.S. and H.L.) independently assessed the methodological quality of the included studies using the version 2 of the Cochrane Risk of Bias instrument for RCT (RoB-2). Discrepancies were resolved by consensus or consultation with a third investigator (Z.C.). The RoB-2 consists of six (I) bias arising from the randomization process; (II) bias due to deviations from intended interventions; (III) bias due to missing outcome data; (IV) bias in measurement of the outcome; and (V) bias in selection of the reported result. Judgments regarding the risk of bias for each domain were categorized as “Low risk”, “Some concerns”, or “High risk”, following the signaling questions algorithm. The overall risk of bias for each result was determined as “Low” if all domains were low; “Some concerns” if at least one domain was raised but none were high; and “High” if any domain was high or multiple domains were raised. Disagreements were resolved through consensus or consultation with a third reviewer. Visualizations were generated using robvis 0.3.0 (R package).
Certainty assessment
Two reviewers (D.S. and H.L.) independently rated the certainty of evidence using the “Grades of Recommendation, Assessment, Development, and Evaluation” (GRADE) system. The GRADE approach uses five domains, including risk of bias, inconsistency, indirectness, imprecision, and publication bias, which are assessed to determine the degree of confidence in the estimate of effect or association derived from the meta-analysis. The quality of evidence was graded as high, moderate, low, or very low. Any discrepancy was resolved through discussion.
Statistical analysis
This study utilized RevMan 5.2 and Python 3.13.7 softwares for statistical analysis. All outcome measures were continuous variables, and the mean difference (MD) and its 95% confidence interval (CI) were used to combine effect sizes. Given that the included studies employed different quality of life assessment scales, standardized mean difference (SMD) was selected as the effect size measure to eliminate metric differences across instruments and ensure comparability of results.
Heterogeneity was evaluated using the P value and the I^2^ statistic. When heterogeneity was non-significant (P>0.1 and I^2^<50%), a fixed-effect model was adopted; when significant heterogeneity existed (P≤0.1 or I^2^≥50%), a random-effect model was used, and subgroup analysis was performed to explore the source of heterogeneity. To address the limitations of single-factor subgroup analysis, this study conducted subgroup analysis from six independent effect of TCE, traditional exercise type, intervention period, and evaluation scale, timing of intervention initiation and intervention setting. Sensitivity analysis was conducted by removing one study at a time to evaluate the stability of the results. Publication bias were assessed using Egger’s test, Begg’s test, trim-and-fill analysis, and Peters’ regression. In all statistical analyses, a P value of less than 0.05 was considered statistically significant.
Results
Study selection
A total of 1,183 studies were identified after searching all 9 databases. After removing 393 duplicates, 790 records were screened through the review of titles and abstracts. Subsequently, the remaining 44 full-text articles were retrieved and evaluated. Ultimately, 25 reports met our inclusion criteria and were included in the final analysis (21-45). The PRISMA flowchart provides a comprehensive overview of the selection process (Figure 1).
Study characteristics
The general characteristics of the included studies are summarized in Table 1. Our review included 1,834 participants from 25 studies. Among the identified articles, 24 were two-arm studies, and one was a three-arm study. However, considering the aim of our study is Qigong exercise, we only selected data from one intervention group and the control group in this three-arm study. These studies were published between 2016 and 2025, with sample sizes ranging from 40 to 205. Twenty-four studies were conducted in China, only one study was conducted in Turkey. The mean age of participants ranged from 51.26 to 68.32 years. The percentage of female participants ranged from 16.67% to 66.04%. The included studies had varying follow-up periods, with the longest being 48 weeks post-intervention (34) and the shortest being a week post-intervention (21,22,27,29,33). Most studies employed two measurement baseline and post-intervention, while only four studies utilized multiple measurement points (26,30,37,38). The data presented in five studies (21,24,27,31,33) were found to be incomplete in the original documents. We attempted to contact the authors via email, but we were unable to obtain the original data.
Characteristics of the interventions
In our review, nine included studies evaluated Liuzijue exercise (20-28). Sixteen studies evaluated Baduanjin exercise (30-45). Most interventions (11 studies) lasted about 12 weeks, with others lasted about 1 week (5 studies), 2 weeks (2 studies), 4 weeks (2 studies), and 8 weeks (3 studies). Only one intervention extended to a duration of 48 weeks (34). The implementation of these interventions involved a frequency ranging from once daily to six times daily, and three days a week to everyday. Session lengths typically ranged from 15 to 60 minutes, with the most common duration being 30 minutes. Some interventions were combined with Traditional Chinese Medicine therapies, such as Chinese herbal decoction, acupoint sticking therapy, and psychological nursing. The control group interventions included conventional treatment, routine respiratory rehabilitation training, simple respiratory trainers, and oral placebos. We outlined the implementation details of the intervention and control groups in Table 1.
Risk of bias assessment report
Figures 2,3 present the risk of bias assessment based on the five domains of RoB 2.0. Overall, 12.0% studies (n=3) were rated as high risk, 88.0% studies (n=22) were categorized as having “some concerns”.
Regarding specific domains, bias arising from the randomization process was the primary concern, with 88.0% (n=22) of studies rated as having “some concerns” due to unclear allocation concealment. In contrast, bias due to deviations from intended interventions was generally low, with 88.0% (n=22) of trials classifies as low risk. Bias due to missing outcome data and bias in selection of the reported result were also limited, with 96.0% (n=24) of the studies categorized as low risk in each domain. All included studies were judged to be at low risk of bias in measurement of the outcome. The certainty of evidence was rated as low to moderate, primarily due to risk of bias in study design and high heterogeneity (inconsistency) across studies (Table 2).
Meta-analysis outcome
Pulmonary function
FVC
Thirteen RCTs with 905 patients were included to assess the effect of TCE on FVC in postoperative lung cancer patients. Meta-analysis showed TCE significantly improved FVC compared to controls (MD =0.24, 95% CI: 0.15 to 0.34; P<0.001, random-effects model), as shown in Figure 4. Subgroup analyses confirmed an independent beneficial effect of TCE on postoperative FVC in lung cancer patients (MD =0.25, 95% CI: 0.12 to 0.37; P<0.001, random-effects model). Substantial heterogeneity was observed across studies. And the timing of intervention initiation and the environmental setting may be potential sources of heterogeneity, as shown in Table 3.
FEV1
Fifteen RCTs with 1,005 patients evaluated FEV1 changes. TCE significantly improved FEV1 compared to controls (MD =0.32, 95% CI: 0.22 to 0.42; P<0.001, random-effects model), as shown in Figure 5. In subgroup analyses, TCE showed an independent positive effect on postoperative FEV1 in lung cancer patients (MD =0.34, 95% CI: 0.22 to 0.47; P<0.001, random-effects model). Subgroup analyses indicated that the timing of intervention initiation and the environmental setting may be potential sources of heterogeneity, and FEV1 improvement was significantly greater when intervention was initiated within one week versus one week or later postoperatively, as shown in Table 3.
FEV1%
Five RCTs involving 520 patients assessed changes in FEV1%. TCE improved FEV1% more than the control group (MD =4.11, 95% CI: 0.99 to 7.23; P=0.01, random-effects model), as shown in Figure 6. In subgroup analyses, TCE showed an independent beneficial effect on postoperative FEV1% in lung cancer patients (MD =4.61, 95% CI: 0.18 to 9.04; P=0.04, random-effects model). Subgroup analyses failed to identify sources of heterogeneity, see details in Table 3.
FEV1/FVC
Eleven RCTs assessed FEV1/FVC changes in 721 patients. TCE improved FEV1/FVC more effectively than the control group (MD =4.88, 95% CI: 3.21 to 6.54; P<0.001, random-effects model), as shown in Figure 7. Subgroup analysis demonstrated that TCE independently contributed to better postoperative FEV1/FVC in patients undergoing lung cancer surgery (MD =6.44, 95% CI: 4.39 to 8.49; P<0.001, random-effects model). Subgroup analysis indicated that Liuzijue showing greater improvement in FEV1/FVC than Baduanjin. The timing of intervention initiation may be a potential source of heterogeneity, and FEV1 improvement was significantly greater when intervention was initiated within one week versus one week or later postoperatively, see details in Table 3.
Activity tolerance and quality of life
6MWD
Fourteen RCTs including 1,116 patients assessed changes in 6MWD. TCE showed greater improvement than control group (MD =28.58, 95% CI: 14.05 to 43.11; P<0.001, random effects model), as shown in Figure 8. Subgroup analysis demonstrated that TCE independently contributed to greater postoperative 6MWD in patients undergoing lung cancer surgery (MD =29.18, 95% CI: 9.32 to 49.04; P=0.004, random effects model). Subgroup analysis found that intervention settings may be a potential source of heterogeneity, see details in Table 3.
Borg dyspnea score
Eight RCTs evaluated the alterations in Borg dyspnea scores, encompassing 698 patients. The findings indicated that TCE was effective in reducing Borg dyspnea scores (MD =−0.29, 95% CI: −0.45 to −0.12; P<0.001, random-effects model), as shown in Figure 9. However, subgroup analysis revealed that TCE alone showed no significant effect on reducing postoperative Borg dyspnea scores (MD =−0.20, 95% CI: −0.40 to 0.01; P=0.06, random-effects model). Substantial heterogeneity was observed across studies, but subgroup analyses failed to fully explain its sources, see details in Table 3.
Fatigue
Three RCTs involving 329 patients assessed Baduanjin’s effect on fatigue using the Piper Fatigue Scale. Results showed no significant difference between Baduanjin and control groups in reducing fatigue (MD =−1.86, 95% CI: −4.01 to 0.29; P=0.09, random-effects model), as shown in Figure 10.
Quality of life
Among the 18 RCTs evaluating quality of life changes, 1,193 patients were included. Among them, seven studies utilized the 36-Item Short Form Health Survey scale(SF-36) as the assessment tool, five employed Functional Assessment of Cancer Therapy-Lung Cancer scale (FACT-L), four used European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 scale (QLQ-C30) , one used European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scale (EORTCQLQ-C30), and one used World Health Organization Quality of Life Assessment-Brief Version scale (WHOQOL-BREF). Chen* et al. *(34) used reverse scoring, to ensure consistent directionality across all scales, quality of life score was multiplied by -1. The results showed that TCE was associated with improved quality of life in lung cancer patients following surgery (SMD =1.64, 95% CI: 1.13 to 2.16; P<0.001, random-effects model), as shown in Figure 11. Subgroup analysis demonstrated that TCE independently contributed to better postoperative quality of life in patients undergoing lung cancer surgery (SMD =1.88, 95% CI: 1.06 to 2.70; P<0.001, random-effects model), however, the sources of heterogeneity remained unidentified. Refer to Table 3 for detailed information.
Negative emotions
Anxiety
Eight RCTs involving 499 patients assessed changes in anxiety scores. Yue Dong (29) used the Hamilton Anxiety Scale, while the other seven studies used the Self-Rating Anxiety Scale (SAS). Results showed that TCE significantly reduced anxiety scores (MD =−6.31, 95% CI: −9.28 to −3.35; P<0.001, random-effects model), as shown in Figure 12. Subgroup analysis demonstrated that TCE independently contributed to lower postoperative anxiety levels in patients undergoing lung cancer surgery (MD =−9.58, 95% CI: −10.58 to −8.58; P<0.001, random-effects model). Subgroup analysis indicated exercise type maybe a source of heterogeneity (P=0.001, I^2^=90.2%, random-effects model), with Baduanjin more effective than Liuzijue in reducing anxiety, see details in Table 3.
Depression
Eight RCTs encompassing 499 patients evaluated alterations in depression scores. Dong (29) employed the Hamilton Depression Scale, whereas the remaining seven studies utilized the Self-Rating Depression Scale (SDS). The findings demonstrated that TCE led to a significant reduction in depression scores (MD =−4.93, 95% CI: −6.70 to −3.16; P<0.001, random-effects model), as depicted in Figure 13. Subgroup analysis demonstrated that the independent effect of TCE was not significantly associated with improved postoperative depressive symptoms in patients undergoing lung cancer surgery (MD =−4.44, 95% CI: −9.97 to 1.09; P=0.12, random-effects model). See details in Table 3.
Adverse events
Six studies (26,35-37,41,45) reported no adverse events, two studies (22,42) reported no serious adverse events, and seventeen studies (21,23-25,27-34,38-40,43,44) did not provide any information about adverse events.
Sensitivity analysis
To assess the stability and reliability of the meta-analysis results, sensitivity analyses were conducted using the leave-one-out method. Excluding Zhao (25) reduced the I^2^ from 71.0% to 15.0% in FVC-related studies. Removing Pan (44) decreased the I^2^ from 77.0% to 38.0% in FEV1% studies. Omitting Xie (37) lowered the I^2^ from 92.0% to 72.0% in 6MWD studies. Excluding Han (35) reduced the I^2^ from 86.0% to 68.0% in depression score studies. These findings suggested that results for FVC, FEV1, FEV1%, 6MWD, and depression scores were less robust, whereas those for FEV1/FVC, Borg dyspnea score, fatigue, quality of life, and anxiety score are more robust, as evidenced by minimal fluctuations in their I^2^ values upon the removal of individual studies.
Publication bias analysis
Publication bias and small-study effects were assessed using Egger’s test, Begg’s test, trim-and-fill analysis and Peters’ regression. Egger’s test revealed statistically significant funnel plot asymmetry for 6MWD (intercept =−3.40, P=0.02) and QoL (intercept =15.85, P<0.001), whereas no significant asymmetry was detected for the remaining five outcomes (all P>0.30). However, trim-and-fill analysis estimated zero missing studies (k0=0) for all outcomes, and the pooled effect sizes remained unchanged after adjustment, indicating that the observed asymmetry was unlikely to reflect suppression of unfavorable results, see details in Figure 14. Rather, the extreme between-study heterogeneity (I^2^ ranging from 71% to 95%) was the most plausible explanation for funnel plot asymmetry, as substantial variation in true effect sizes inherently distorts funnel symmetry regardless of publication bias. This interpretation is further supported by Peters’ regression (Figure 15), in which no significant association between effect size and total sample size was identified for any outcome (all P>0.30), suggesting the absence of meaningful small-study effects. Taken together, these findings indicate that the pooled estimates reported in this meta-analysis are robust and unlikely to be materially biased by selective publication, details in Table 4.
Discussion
TCE is rooted in traditional Chinese culture, integrating philosophical concepts such as Yin-Yang, the Five Elements, and essence, qi, blood, and spirit. Through long-term practice, it has evolved into a therapeutic exercise with rehabilitative and curative benefits and is now a key component of traditional Chinese rehabilitation medicine (46). The present meta-analysis integrated 25 RCTs to evaluate the efficacy of TCE in postoperative lung cancer rehabilitation. The results demonstrated that TCE significantly improved pulmonary function (FVC, FEV1, FEV1/FVC, FEV1%), exercise tolerance (6MWD), and quality of life, and reduced, anxiety, with statistically significant differences. However, no clear benefit was observed for fatigue, Borg dyspnea score and depression, highlighting the need for further high-quality research in this area. These findings suggest that TCE may serve as a valuable adjunctive therapy for patients recovering from lung cancer surgery.
Previous meta-analyses have confirmed that Baduanjin positively affected FVC, FEV1, 6MWD, anxiety, depression, and quality of life in postoperative lung cancer patients, consistent with this study’s findings (20,47,48). Zhang (48) found no significant improvement in FEV1/FVC or Borg dyspnea score with Baduanjin. Their analysis included only 6 RCTs, while this one integrated 15 studies with a larger sample size, improving reliability. This review also assessed additional outcomes such as FEV1% and included other traditional exercises like Liuzijue, enabling a more comprehensive evaluation.
The evidence on Baduanjin’s effect on fatigue remains inconsistent. While a review by Liu (49) suggested potential benefits, which might depend on factors such as population, age, training environment, and fatigue degree. In contrast, Wen (50) found no significant effect in breast cancer patients. This study also found no clear benefit of TCE for post-surgical fatigue in lung cancer patients, likely due to limited sample size and variability in intervention protocols.
Significant heterogeneity was observed across the studies, and current subgroup analysis has not yet fully explained its sources, suggesting the involvement of other contributing factors. Furthermore, most studies had suboptimal randomization designs (e.g., lack of blinding) and high heterogeneity across outcome measures (FVC, FEV1, FEV1%, 6MWD, Borg dyspnea score, fatigue, quality of life, and depressive), resulting in downgraded certainty of evidence that warrants cautious interpretation. Within the first month after lung cancer surgery, patients commonly experience five interrelated symptom cluster-respiratory symptoms, pain-fatigue-sleep disturbances, psychological and emotional issues, digestive disorders, and neurological problems, each inversely associated with quality of life (51). Postoperative decline in pulmonary function, which is influenced by factors such as gender, age, and the type of surgery, stands as the primary cause of respiratory symptoms (6,52-54). Research results have demonstrated that segmentectomy is more efficient in preserving pulmonary function. The loss of pulmonary function following video-assisted thoracoscopic lobectomy and segmentectomy is approximately 10.0% and 5.0% per segment, respectively (6,55). However, only seven of the included studies provided information on the extent of surgical resection. Among these, four exclusively involved patients who underwent lobectomy, one focused on wedge resection, and two included a mix of lobectomy, segmentectomy, and wedge resection without conducting stratified analyses. The remaining 18 studies did not explicitly report the surgical extent. The control group protocols in the included studies predominantly received conventional care, including health education, condition monitoring, and psychological support, with one study employing conventional care plus placebo. Given that the control intervention may also influence outcomes, future studies should standardize control protocols. In addition, the incidence and severity of psychological symptoms, such as anxiety and depression, fluctuate continuously during the treatment process (56). Nevertheless, sixteen studies extended the intervention from the inpatient setting to the post-discharge period, using remote supervision methods such as patient diaries, WeChat, or telephone. However, the reliability of the data and the fidelity of exercise performance were difficult to evaluate. Moreover, the inconsistency in supervision frequency across studies may partly explain the high heterogeneity. Furthermore, existing studies have small samples and lack systematic control or analysis of confounding factors. Larger, more rigorous studies are needed to confirm the rehabilitation effects of traditional exercise across different surgical scopes and age groups and to identify the optimal intervention in the future.
TCE incorporates “body adjustment”, “breath adjustment”, and “mind adjustment” as core components. “Breath adjustment” involves optimizing respiratory function through specific breathing techniques. Liuzijue exercise combines reverse abdominal breathing and pursed-lip breathing, enhancing diaphragmatic activity. This prolongs exhalation, reduces lung residual volume, slows exhalation flow, and increases intrapulmonary pressure, helping prevent premature collapse of small airways and improving ventilation/perfusion ratio. During this process, respiratory muscles, including intercostal, rectus abdominis, and pectoralis major muscles, work synergistically to enhance pulmonary ventilation, gas exchange efficiency, and correct abnormal breathing patterns (57). Baduanjin emphasizes gradual progress in breathing regulation. Initially, practitioners use natural breathing. As movements become more proficient, they transition to abdominal breathing. In exercises like “Lifting the Heavens with Both Hands to Regulate the Triple Burner” and “Left and Right Drawing the Bow Like Shooting an Eagle”, deep and prolonged breaths help expand the chest cavity and enhance diaphragm movement, improving respiratory function (58).
Postoperative lung cancer patients often have limited activity due to shortness of breath, creating a cycle of “breathlessness-reduced activity”. TCE is a low to moderate intensity aerobic exercise, which can improve cardiopulmonary endurance. Its deep, slow, and rhythmic breathing pattern reduces the respiratory rate and oxygen consumption. For example, the oxygen consumption during Baduanjin is only 9.91±2.79 mL/(kg·min) (59). This helps relieve breathlessness and enhance activity tolerance, making TCE suitable for respiratory patients and those in the early stage of rehabilitation.
The therapeutic effects of TCE on anxiety and depression in postoperative lung cancer patients can be explained as (I) according to traditional Chinese medicine theory, “body adjustment” and “mind adjustment” are central to traditional exercise. “Body adjustment” involves maintaining mental relaxation and focus during practice, promoting smooth and controlled breathing, thereby enhancing physical strength and mental calm (60). “Mind adjustment” refers to the conscious regulation of awareness and thought processes, helping achieve emotional balance and overall well-being. (II) Research in modern medicine suggests that Baduanjin practice increases serum levels of 5-hydroxytryptamine (5-HT) and norepinephrine (NE) in maintenance hemodialysis patients, helping alleviate anxiety and depression symptoms (61). In addition, deep and slow breathing in TCE optimizes acetylcholine dynamics, activates the parasympathetic nervous system, and reduces sympathetic overactivity during stress, improving emotional well-being (62,63). The Liuzijue exercise also lowers IL-4, IL-13, and IL-17 levels, alleviating inflammation, enhancing immunity, reducing stress, and relieving negative emotions (64).
Limitations
Despite the significant contributions of this study, many studies in this article have methodological limitations. Due to the nature of exercise interventions, achieving double-blinding for both participants and researchers is difficult. Only two studies used in Ruqi Xie’s study (21), researchers were blinded but not participants; Jia Wang’s study (24) was conducted across two wards, both researchers and participants were blinded. Allocation concealment was reported in only three studies (21,24,37), potentially introducing selection bias. Blinding of outcome assessors can reduce measurement bias, but was implemented in only three studies (21,23,37). Three studies (28,32,44) mentioned randomization without specifying the methods. Only five (21-23,30,31) were prospectively registered and reported outcomes as planned; the remaining 20 lacked registration details. One study (45) noted negative results but did not provide data, raising concerns about publication bias. Given these limitations, results should be interpreted with caution.
Conclusions
The findings of this systematic review indicated that TCEs are potentially capable of exerting a positive impact on improving the lung function and activity tolerance, enhancing the quality of life, and alleviating negative emotions in patients after lung cancer surgery. However, only eight studies reported on adverse events, whereas the other seventeen did not address this issue. As a result, evidence regarding the safety of TCE training remains inadequate. The overall strength of the existing research evidence is affected by methodological limitations, and the reliability of the conclusions requires further verification through more large-sample RCTs with rigorous design and standardized operation.