The effect of an evidence-based Tai chi intervention on the fatigue-sleep disturbance-depression symptom cluster in breast cancer patients: A preliminary randomised controlled trial

Published:September 27, 2022DOI:


      • The fatigue-sleep disturbance-depression symptom cluster (FSDSC) is the most commonly seen symptom cluster in breast cancer (BC) patients.
      • Current research evidence on the effects of Tai chi for FSDSC alleviation remains unclear.
      • This study aimed to explore the potential effect of an evidence-based Tai chi intervention on the FSDSC in BC patients.
      • This study provided preliminary evidence that Tai chi could be a promising intervention for FSDSC management in BC patients.



      To explore the potential effects of Tai chi on the fatigue-sleep disturbance-depression symptom cluster (FSDSC) among breast cancer (BC) patients.


      This study was conducted as a preliminary randomized controlled trial among 72 BC patients (36 Tai chi and 36 control participants). All the participants were provided with routine care, while participants in the Tai chi group received an additional 8-week Tai chi intervention. Participants' fatigue, sleep disturbance and depression were assessed by the Brief Fatigue Inventory, the Pittsburgh Sleep Quality Index, and the Hospital Anxiety and Depression Scale-Depression. Participants’ quality of life (QoL) was assessed by the Functional Assessment of Cancer Therapy-Breast. Both covariates-unadjusted and adjusted GEE models were run to assess the effects of Tai chi intervention on the FSDSC and QoL and the relevant impacts of the covariates.


      Sixty-nine participants completed this study. In the unadjusted GEE model, compared with the control group and baseline, participants in the Tai chi group showed significant reductions in fatigue (p < 0.001), sleep disturbance (p < 0.001) and depression (p = 0.006), as well as a significant improvement in QoL (p = 0.032) at immediately post-intervention and four-week follow-up. The positive regression coefficients of the adjusted GEE model showed fatigue, sleep disturbance and depression can have impacts on each other (all at p < 0.05).


      Tai chi as an adjuvant intervention to routine care could relieve the symptom cluster of fatigue, sleep disturbance and depression and improve QoL among BC patients.


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        • Achterberg F.B.
        • Deken M.M.
        • Meijer R.
        • Mieog J.
        • Burggraaf J.
        • van de Velde C.
        • Swijnenburg R.J.
        • Vahrmeijer A.L.
        Clinical translation and implementation of optical imaging agents for precision image-guided cancer surgery.
        Eur. J. Nucl. Med. Mol. Imag. 2021; 48: 332-339
        • Akoglu H.
        User's guide to correlation coefficients.
        Turk J Emerg Med. 2018; 18: 91-93
        • Berger A.M.
        • Mooney K.
        • Alvarez-Perez A.
        • Breitbart W.S.
        • Carpenter K.M.
        • Cella D.
        • Cleeland C.
        • Dotan E.
        • Eisenberger M.A.
        • Escalante C.P.
        • Jacobsen P.B.
        • Jankowski C.
        • LeBlanc T.
        • Ligibel J.A.
        • Loggers E.T.
        • Mandrell B.
        • Murphy B.A.
        • Palesh O.
        • Pirl W.F.
        • Plaxe S.C.
        • National comprehensive cancer network
        Cancer-related fatigue, version 2.2015.
        J. Natl. Compr. Cancer Netw. 2015; 13: 1012-1039
        • Bower J.E.
        Cancer-related fatigue--mechanisms, risk factors, and treatments.
        Nat. Rev. Clin. Oncol. 2014; 11: 597-609
        • Brady M.J.
        • Cella D.F.
        • Mo F.
        • Bonomi A.E.
        • Tulsky D.S.
        • Lloyd S.R.
        • Deasy S.
        • Cobleigh M.
        • Shiomoto G.
        Reliability and validity of the functional assessment of cancer therapy-breast quality-of-life instrument.
        J. Clin. Oncol. 1997; 15: 974-986
        • Buysse D.J.
        • Reynolds 3rd, C.F.
        • Monk T.H.
        • Berman S.R.
        • Kupfer D.J.
        The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research.
        Psychiatr. Res. 1989; 28: 193-213
        • Cai Q.
        • Cai S.B.
        • Chen J.K.
        • Bai X.H.
        • Jing C.X.
        • Zhang X.
        • Li J.Q.
        Tai Chi for anxiety and depression symptoms in cancer, stroke, heart failure, and chronic obstructive pulmonary disease: a systematic review and meta-analysis.
        Compl. Ther. Clin. Pract. 2022; 46101510
        • Cheng L.
        • Qian L.
        • Chang S.
        • He B.
        Effect of Tai Chi on depression symptoms and sleep quality among older adult women after exercise cessation.
        Res. Sports Med. 2021; 29: 395-405
        • Cheng D.
        • Wang X.
        • Hu J.
        • Dai L.L.
        • Lv Y.
        • Feng H.
        • Zhang Y.
        • Guo Y.
        • Wang L.
        Effect of tai chi and resistance training on cancer-related fatigue and quality of life in middle-aged and elderly cancer patients.
        Chin. J. Integr. Med. 2021; 27: 265-272
        • Cheung D.
        • Takemura N.
        • Smith R.
        • Yeung W.F.
        • Xu X.
        • Ng A.
        • Lee S.F.
        • Lin C.C.
        Effect of qigong for sleep disturbance-related symptom clusters in cancer: a systematic review and meta-analysis.
        Sleep Med. 2021; 85: 108-122
        • Cheung D.S.T.
        • Chau P.H.
        • Yeung W.F.
        • Deng W.
        • Hong A.W.L.
        • Tiwari A.F.
        Assessing the effect of a mind-body exercise, qigong Baduanjin, on sleep disturbance among women experiencing intimate partner violence and possible mediating factors: a randomized-controlled trial.
        J. Clin. Sleep Med. 2021; 17: 993-1003
        • Chuang T.Y.
        • Yeh M.L.
        • Chung Y.C.
        A nurse facilitated mind-body interactive exercise (Chan-Chuang qigong) improves the health status of non-Hodgkin lymphoma patients receiving chemotherapy: randomised controlled trial.
        Int. J. Nurs. Stud. 2017; 69: 25-33
        • Cohen J.
        A power primer.
        Psychol. Bull. 1992; 112: 155-159
        • Eton D.T.
        • Cella D.
        • Yost K.J.
        • Yount S.E.
        • Peterman A.H.
        • Neuberg D.S.
        • Sledge G.W.
        • Wood W.C.
        A combination of distribution- and anchor-based approaches determined minimally important differences (MIDs) for four endpoints in a breast cancer scale.
        J. Clin. Epidemiol. 2004; 57: 898-910
        • He X.
        • Ng M.
        • Wang X.
        • Guo P.
        • Li L.
        • Zhao W.
        • Zhang M.
        • So W.
        A dance program to manage A fatigue-sleep disturbance-depression symptom cluster among breast cancer patients receiving adjuvant chemotherapy: a feasibility study.
        Asia Pac. J. Oncol. Nurs. 2021; 8: 337-339
        • Heppner P.P.
        • Wampold B.E.
        • Owen J.
        • Wang K.T.
        Research Design in Counselling.
        fourth ed. Cengage Learning., Boston2015: 9
        • Hertzog M.A.
        Considerations in determining sample size for pilot studies.
        Res. Nurs. Health. 2008; 31: 180-191
        • Ho R.T.
        • Fong T.C.
        Factor structure of the Chinese version of the Pittsburgh sleep quality index in breast cancer patients.
        Sleep Med. 2014; 15: 565-569
        • Huong H.
        Self-administered Acupressure for the Cancer-Related Symptom Cluster of Insomnia, Depression, and Anxiety: a Feasibility Randomized Controlled Trial.
        The Hong Kong Polytechnic University, Hong Kong2020 (PhD thesis)
        • Jain S.
        • Boyd C.
        • Fiorentino L.
        • Khorsan R.
        • Crawford C.
        Are there efficacious treatments for treating the fatigue-sleep disturbance-depression symptom cluster in breast cancer patients? A Rapid Evidence Assessment of the Literature (REAL(©)).
        Breast Cancer. 2015; 7: 267-291
        • Ji Y.B.
        • Bo C.L.
        • Xue X.J.
        • Weng E.M.
        • Gao G.C.
        • Dai B.B.
        • Ding K.W.
        • Xu C.P.
        Association of inflammatory cytokines with the symptom cluster of pain, fatigue, depression, and sleep disturbance in Chinese patients with cancer.
        J. Pain Symptom Manag. 2017; 54: 843-852
        • Lee C.
        How can mindfulness-led breathing of qigong/Tai Chi work on qi and the meridian network?.
        Adv. Integr. Med. 2018; 5: 122-127
        • Li M.
        • Fitzgerald P.
        • Rodin G.
        Evidence-based treatment of depression in patients with cancer.
        J. Clin. Oncol. 2012; 30: 1187-1196
        • Li Q.
        • Lin Y.
        • Hu C.
        • Xu Y.
        • Zhou H.
        • Yang L.
        • Xu Y.
        The Chinese version of hospital anxiety and depression scale: psychometric properties in Chinese cancer patients and their family caregivers.
        Eur. J. Oncol. Nurs. 2016; 25: 16-23
        • Li X.
        • Wang X.
        • Song L.
        • Tian J.
        • Ma X.
        • Mao Q.
        • Lin H.
        • Zhang Y.
        Effects of Qigong, Tai Chi, acupuncture, and Tuina on cancer-related fatigue for breast cancer patients: a protocol of systematic review and meta-analysis.
        Medicine. 2020; 99e23016
        • Liu L.
        • Tan H.
        • Yu S.
        • Yin H.
        • Baxter G.D.
        The effectiveness of tai chi in breast cancer patients: a systematic review and meta-analysis.
        Compl. Ther. Clin. Pract. 2020; 38101078
        • Liu C.Y.
        • Zhao Y.N.
        • Wang X.Q.
        • Qin S.
        • Wan Q.Y.
        • Zheng S.Y.
        • Wu W.Z.
        Acupuncture combined with traditional Chinese medicine e-aid cognitive behavioral therapy for insomnia (TCM-eCBT-I) for chronic insomnia: study protocol for a randomized controlled trial.
        Trials. 2022; 23: 1-12
        • Lu T.Y.
        Validation and Minimum Important Difference of the Pittsburgh Sleep Quality Index, Master Thesis.
        Guangzhou University of Chinese Medicine, China2012
        • Lu Y.
        • Qu H.Q.
        • Chen F.Y.
        • Li X.T.
        • Cai L.
        • Chen S.
        • Sun Y.Y.
        Effect of Baduanjin qigong exercise on cancer-related fatigue in patients with colorectal cancer undergoing chemotherapy: a randomized controlled trial.
        Oncol. Res. Treat. 2019; 42: 431-439
        • Ma C.
        • Zhou W.
        • Tang Q.
        • Huang S.
        The impact of group-based Tai chi on health-status outcomes among community-dwelling older adults with hypertension.
        Heart Lung. 2018; 47: 337-344
        • Mendoza T.R.
        • Wang X.S.
        • Cleeland C.S.
        • Morrissey M.
        • Johnson B.A.
        • Wendt J.K.
        • Huber S.L.
        The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory.
        Cancer. 1999; 85: 1186-1196<1186::aid-cncr24>;2-n
        • Meng T.
        • Hu S.F.
        • Cheng Y.Q.
        • Ye M.N.
        • Wang B.
        • Wu J.J.
        • Chen H.F.
        Qigong for women with breast cancer: an updated systematic review and meta-analysis.
        Compl. Ther. Med. 2021; 60102743
        • Molassiotis A.
        • Vu D.V.
        • Ching S.
        The effectiveness of qigong in managing a cluster of symptoms (Breathlessness-Fatigue-Anxiety) in patients with lung cancer: a randomized controlled trial.
        Integr. Cancer Ther. 2021; 2015347354211008253
        • NCCN Cancer-Related Fatigue Panel
        National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology.
        Cancer-Related Fatigue, 2018 (version 2)
        • Nho J.H.
        • Kim S.R.
        • Park M.H.
        • Kweon S.S.
        Symptom clusters and quality of life in breast cancer survivors after cancer treatment in a tertiary hospital in Korea.
        Eur. J. Cancer Care. 2018; 27e12919
        • Oh B.
        • Butow P.N.
        • Boyle F.
        • Beale P.J.
        • Costa D.
        • Pavlakis N.
        • Clarke S.J.
        Effects of qigong on quality of life, fatigue, stress, neuropathy, and sexual function in women with metastatic breast cancer: a feasibility study.
        J. Clin. Oncol. 2014; 32e20712
        • Puhan M.A.
        • Frey M.
        • Büchi S.
        • Schünemann H.J.
        The minimal important difference of the hospital anxiety and depression scale in patients with chronic obstructive pulmonary disease.
        Health Qual. Life Outcome. 2008; 6: 46
        • Sarmento C.
        • Moon S.
        • Pfeifer T.
        • Smirnova I.V.
        • Colgrove Y.
        • Lai S.M.
        • Liu W.
        The therapeutic efficacy of Qigong exercise on the main symptoms of fibromyalgia: a pilot randomized clinical trial.
        Integr. Med. Res. 2020; 9100416
        • Schober P.
        • Boer C.
        • Schwarte L.A.
        Correlation coefficients: appropriate use and interpretation.
        Anesth. Analg. 2018; 126: 1763-1768
        • Singh B.
        • Spence R.R.
        • Steele M.L.
        • Sandler C.X.
        • Peake J.M.
        • Hayes S.C.
        A systematic review and meta-analysis of the safety, feasibility, and effect of exercise in women with stage II+ breast cancer.
        Arch. Phys. Med. Rehabil. 2018; 99: 2621-2636
        • Star A.
        • Boland J.W.
        Updates in palliative care - recent advancements in the pharmacological management of symptoms.
        Clin. Med. 2018; 18: 11-16
        • Teare M.D.
        • Dimairo M.
        • Shephard N.
        • Hayman A.
        • Whitehead A.
        • Walters S.J.
        Sample size requirements to estimate key design parameters from external pilot randomised controlled trials: a simulation study.
        Trials. 2014; 15: 264
        • Thongteratham N.
        • Pongthavornkamol K.
        • Olson K.
        • Ratanawichitrasin A.
        • Nityasuddhi D.
        • Wattanakitkrilert D.
        Effectiveness of Tai Chi Qi Qong program for Thai women with breast cancer: a randomized control trial.
        Pac. Rim Int. J. Nurs. Res. 2015; 19: 280-294
        • Turkistani A.
        • Shah A.
        • Jose A.M.
        • Melo J.P.
        • Luenam K.
        • Ananias P.
        • Yaqub S.
        • Mohammed L.
        Effectiveness of manual therapy and acupuncture in tension-type headache: a systematic review.
        Cureus. 2021; 13e17601
        • Wan C.
        • Zhang D.
        • Yang Z.
        • Tu X.
        • Tang W.
        • Feng C.
        • Wang H.
        • Tang X.
        Validation of the simplified Chinese version of the FACT-B for measuring quality of life for patients with breast cancer.
        Breast Cancer Res. Treat. 2007; 106: 413-418
        • Wang X.S.
        • Hao X.S.
        • Wang Y.
        • Guo H.
        • Jiang Y.Q.
        • Mendoza T.R.
        • Cleeland C.S.
        Validation study of the Chinese version of the Brief fatigue inventory (BFI-C).
        J. Pain Symptom Manag. 2004; 27: 322-332
        • Wayne P.M.
        • Lee M.S.
        • Novakowski J.
        • Osypiuk K.
        • Ligibel J.
        • Carlson L.E.
        • Song R.
        Tai Chi and Qigong for cancer-related symptoms and quality of life: a systematic review and meta-analysis.
        J. Cancer Surviv. 2018; 12: 256-267
        • Wei X.L.
        • Yuan R.Z.
        • Jin Y.M.
        • Li S.
        • Wang M.Y.
        • Jiang J.T.
        • Wu C.Q.
        • Li K.P.
        Effect of Baduanjin exercise intervention on cognitive function and quality of life in women with breast cancer receiving chemotherapy: study protocol of a randomized controlled trial.
        Trials. 2021; 22: 405
        • Wong W.M.
        • Chan D.
        • He X.
        • So W.
        Effectiveness of pharmacological and nonpharmacological interventions for managing the fatigue-sleep disturbance-depression symptom cluster in breast cancer patients undergoing chemotherapy: a systematic review.
        Cancer Nurs. 2022; 10: 1097
        • Yao L.Q.
        • Tan J.Y.
        • Turner C.
        • Wang T.
        • Liu X.L.
        Traditional Chinese exercise for cancer-related sleep disturbance: a systematic review and descriptive analysis of randomized controlled trials.
        Compl. Ther. Clin. Pract. 2020; 40101197
        • Yao L.Q.
        • Tan J.Y.
        • Turner C.
        • Wang T.
        Development and validation of a Tai chi intervention protocol for managing the fatigue-sleep disturbance-depression symptom cluster in female breast cancer patients.
        Compl. Ther. Med. 2021; 56102634
        • Yao L.Q.
        • Tan J.B.
        • Turner C.
        • Wang T.
        Feasibility and potential effects of tai chi for the fatigue-sleep disturbance-depression symptom cluster in patients with breast cancer: protocol of a preliminary randomised controlled trial.
        BMJ Open. 2021; 11e048115
        • Zigmond A.S.
        • Snaith R.P.
        The hospital anxiety and depression scale.
        Acta Psychiatr. Scand. 1983; 67: 361-370