When studying exercise for treating diabetic peripheral neuropathy (DPN), achieving mind-body exercise is essential. This study proposes a protocol for mindfulness training combined with Tai Chi to achieve mind-body exercise.
Diabetic peripheral neuropathy (DPN) is one of the most prevalent chronic complications of diabetes. One of its crucial therapy approaches is mind-body exercise. Recently, various exercise modalities, including stepping, resistance, aerobics, balance, and whole-body vibration, were investigated to construct the most suitable form of exercise for patients with DPN. The purpose of this study is to describe a standard protocol for mindfulness training combined with Tai Chi. The convenience sampling method was used to select 90 patients with DPN who met the inclusion and exclusion criteria from three communities. The three communities were randomly divided into the control group (CG), the Tai Chi group (TCG), and the mindfulness training combined with the Tai Chi group (MTCG). The CG was given routine health education guidance once a month, a total of three times. Based on the CG, the TCG practiced Tai Chi three times; the MTCG received mindfulness training combined with Tai Chi exercise a week for a total of 12 weeks. Before the intervention and 12 weeks after the intervention, the clinical symptoms, neurological function, attention awareness level, pain, and quality of life of the subjects were evaluated by Toronto Clinical Scoring System (TCSS), Mindful Attention Awareness Scale (MAAS), Visual analog scale (VAS), Diabetes Specificity Quality of life Scale (DSQL) and tumor necrosis factor-α. Overall, the addition of mindfulness training to Tai Chi effectively enhances the exercise effects of Tai Chi. Therefore, mindfulness training combined with Tai Chi is worthy of promotion and application.
Diabetes Mellitus (DM) is a serious health concern globally, affecting millions of people worldwide1. The International Diabetes Federation (IDF) reveals that the prevalence of DM could increase up to 12.2% by 20452. Type 2 diabetes (T2DM) accounts for about 90% of DM2. Patients with T2DM, particularly those who struggle to control their blood glucose levels, are likely to suffer from adverse complications, including macrovascular disease, microangiopathy, and diabetic peripheral neuropathy (DPN)3. DPN is a prevalent microvascular complication, with at least 50% of DM patients showing DPN signs and symptoms over time4. Unfortunately, DPN is often ignored, and the actual figures of patients suffering are much higher than reported in most cases2.
Patients with poor glycemic control are prone to developing DPN with an insidious onset. The initial symptoms of DPN are often unremarkable, which makes it easy for patients to overlook the condition. When obvious symptoms and functional impairment appear, irreversible neurological damage has been caused5. DPN has a complex clinical presentation. Patients suffer from long-term metabolic disturbances and oxidative stress damage. This can result in symmetrical limb numbness, pain, or paresthesia6,7. As the disease progresses, neurological and vascular injuries are further aggravated, eventually leading to irreversible tissue damage8. The incidence of diabetic foot ulcers and amputations is associated with mortality from DPN9. In addition, as symptoms of DPN often persist, many patients experience depression, sleep disturbances, and activity limitations, leading to a decrease in overall quality of life and even disability10.
Currently, lifestyle interventions (including exercise, diet, psychotherapy, etc.) are well recognized as effective treatments for DPN patients in addition to glycemic control and pharmacotherapy11. According to the American Diabetes Association (ADA), "valuable exercise is beneficial to all patients with DM". For example, it can improve glycolipid metabolism and insulin resistance1. Studies have shown that exercise can improve metabolic, vascular damage, and neurological function in patients with DPN12,13. However, patients with DPN are reluctant to exercise due to a lack of motility, pain, and fear of foot injury.
The diabetic peripheral neuropathy (DPN) patients' physical discomfort and limitations on daily activities, according to the Fear-Avoidance Model (FAM), can reduce their capacity for social interaction, which in turn can contribute to negative emotional reactions like anxiety and depression14. Conversely, negative emotions can affect glycemic control and increase the rate of complications15,16,17,18. Therefore, mind-body therapy is recommended for DPN, which focuses on the interaction between thoughts, emotions, bodies, and behaviors. The aim is to achieve homeostasis of the body and mind.
Tai Chi is a traditional Chinese mind-body exercise. Tai Chi has received much attention from scholars worldwide because of its unique exercise modes and therapeutic effects on diseases. Multiple high-quality clinical trials published in international journals have confirmed the effectiveness of Tai Chi for the treatment and rehabilitation of chronic diseases such as Parkinson's disease19, stroke20, metabolic syndrome21, knee arthritis22, and breast cancer23. Tai Chi belongs to a class of moderate-intensity aerobic exercises that uses continuous body spiral exercise and regulated breathing to improve aerobic capacity, muscle strength, balance, and exercise capacity. Traditional Chinese medicine holds that Tai Chi can balance yin and Yang, run Qi and blood, and relax meridians24. It is a suitable form of exercise for patients with DPN. Many studies have found that Tai Chi improves insulin resistance and blood lipids, and reduces the incidence of anxiety and depression25,26. In addition, Tai Chi could improve quality of life and decrease body mass index for patients with T2DM 27.
Mindfulness training is another prominent mind-body intervention that focuses on cultivating an intentional, moment-to-moment, nonjudgmental awareness of experience28. It helps to enhance attention to the present experience, including thoughts, feelings, breathing, and body sensations. Zeidan's research found that mindfulness training could make patients more objectively evaluate discomfort and improve self-regulation29. Wielgosz's study showed that the biggest problem of exercise intervention was poor compliance, which could be solved by adding mindfulness training to exercise30. Mindfulness training combined with exercise could effectively improve patients' willingness to move, increase the time and frequency of movement, and promote patients' perceiving body sensations in activity.
Meanwhile, exercise combined with mindfulness training can expand patients' vision and enhance their understanding of themselves. This helps the body to become more flexible, relaxed, and balanced, effectively relieving the negative experience of patients. The concept of mindfulness training is consistent with the idea of "unity of form and spirit" of Tai Chi. Most patients with DPN often receive misinformation from the feet provided by the brain due to impaired sensory function31. Mindfulness training can enhance the effect of movement through psychological regulation and nervous regulation32. Therefore, this study aims to verify the feasibility of mindfulness training combined with Tai Chi and explore its effect on DPN patients.
This study strictly adheres to the principle of ethical respect, beneficence, and justice. There were 30 subjects in each group, a total of 90 cases. This subject was approved by the ethics committee of the Hospital of Chengdu University of Traditional Chinese Medicine (2021KL-040). Informed consent was obtained from patients included in this study.
1. Study subjects
2. Method 1: Practice methods of the CG
3. Method 2: Practice methods of the TCG
4. Method 3: Practice methods of the MTCG
5. Collect information
6. Statistical analysis
In this study, 7 individuals failed to complete the trial. All necessary data were gathered from 83 individuals who completed the trial. There were 38 women and 45 men. The age ranged from 44 to 75 years old, with an average age of (60.57 + 8.76). DM might last anywhere between 4 and 22 years, with an average of 14.10 + 4.85 years. DPN lasted anywhere from one and fifteen years, with a mean of 5.76 + 2.78 years. The general data of the three groups did not differ significantly (p>0.05).
After the intervention, there was a statistically significant difference in the TCSS scores of the three groups (P < 0.001) (see Table 2). Further multiple comparisons showed that the TCSS score of the MTCG was significantly lower than that of the TCG and lower than the CG, and the difference was statistically significant (P < 0.05) (see Figure 1). These results revealed that the neurological symptoms improved after the intervention.
After the intervention, the MAAS scores of the three groups were significantly different (P < 0.05) (see Table 2). Further multiple comparisons showed no significant difference in the MAAS scores between the CG and the TCG (P > 0.05). The MAAS score of MTCG was significantly higher than that of TCG and CG (P < 0.05) (see Figure 2). The MAAS score revealed that mindfulness training combined with Taijiquan could improve the subjects' mindfulness levels. At the same time, it shows that the improvement of the exercise effect may be related to the improvement of mindfulness level.
After the intervention, there was a statistically significant difference in the VAS score between the three groups (P < 0.05) (see Table 3). Further multiple comparisons showed that the pain relief effect of mindfulness combined with MTCG was significantly better than that of TCG and CG, and the difference was statistically significant (P<0.05). (see Figure 3)
After the intervention, there was a statistically significant difference in the levels of TNF-α among the three groups (P < 0.05) (see Table 3). Further multiple comparisons showed that the level of serum TNF-α in the MTCG was significantly lower than that in the TCG and lower than that in the CG, and the difference was statistically significant (P < 0.05). (see Figure 4)
After the intervention, there was a statistically significant difference in the DSQL scores (P<0.05) (see Table 4). Further multiple comparisons showed that the DSQL score of the CG was significantly lower than that of the TCG and lower than the MTCG, and the difference was statistically significant (P < 0.05) (see Figure 5). This suggests that mindfulness training combined with Tai Chi can significantly improve the quality of life of patients with DPN.
Figure 1: Comparison of TCSS scores among the three groups. **P < 0.01 intergroup comparisons, *P < 0.05 intergroup comparisons, ##P < 0.01 within-group comparisons, #P < 0.01 within-group comparisons. TCSS, Toronto Clinical Scoring System; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.
Figure 2. Comparison of MASS scores among the three groups.**P < 0.01 intergroup comparisons, ##P < 0.01 within-group comparisons, and #P < 0.01 within-group comparisons. MAAS, Mindful Attention Awareness Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.
Figure 3. Comparison of VAS scores among the three groups. **P < 0.01 intergroup comparisons, and ##P < 0.01 within-group comparisons. VAS, Visual analog scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.
Figure 4. Comparison of serum TNF- α level among the three groups. **P < 0.01 intergroup comparisons, *P < 0.01 intergroup comparisons, and ##P < 0.01 within-group comparisons. TNF-α, Serum tumor necrosis factor-α; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.
Figure 5. Comparison of DSQL scores among the three groups. **P < 0.01 intergroup comparisons, ##P < 0.01 within-group comparisons. DSQL, Diabetes Specificity Quality of life Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with Tai Chi group. Please click here to view a larger version of this figure.
Table 1: Mindfulness training combined with Tai Chi training program schedule. Please click here to download this Table.
Table 2: Comparison of TCSS and MAAS and scores among the three groups. TCSS, Toronto Clinical Scoring System; MAAS, Mindful Attention Awareness Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with the Tai Chi group. Please click here to download this Table.
Table 3: Comparison of VAS scores and TNF-α among the three groups. VAS, Visual analog scale; TNF-α, Serum tumor necrosis factor-α; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with the Tai Chi group. DSQL, Diabetes Specificity Quality of Life Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with the Tai Chi group. Please click here to download this Table.
Table 4: Comparison of DSQL scores among the three groups. DSQL, Diabetes Specificity Quality of Life Scale; CG, the control group; TCG, the Tai Chi group; MTCG, the mindfulness training combined with the Tai Chi group. Please click here to download this Table.
Many previous studies have reported how to apply Tai Chi to treat and rehabilitate chronic diseases40,41. Although Tai Chi has shown positive effects in the treatment and rehabilitation of chronic diseases, truly achieving physical and mental exercise is vital to the enhanced effects of Tai Chi. This study combined Tai Chi with mindfulness training, which successfully improved the practice effectiveness of Tai Chi and indeed achieved physical and mental movement.
This study successfully integrated mindfulness training into Tai Chi. Participants must understand the significance of mindfulness training and the combination of Tai Chi. Tai Chi is a traditional Chinese mind-body exercise different from other aerobic exercises. The entire set of actions of Tai Chi is done under the guidance of consciousness and emphasizes controlling the activities of the limbs with consciousness. Most Tai Chi practitioners, particularly beginners, pay more attention to whether the movements are correct but ignore attention and awareness. In this study, mindfulness breathing was the first step in mindfulness training with Tai Chi exercise. The subjects were then progressively encouraged to become cognizant of what is occurring and direct their attention to performing Tai Chi. Previous studies suggest that mindfulness training as a complementary therapy may not have a direct therapeutic effect on disease42. But mindfulness training can enhance treatment effects by increasing self-efficacy, illness cognition, mindfulness levels, and improving adverse emotions43. Therefore, the significance of mindfulness training combined with Tai Chi should be explained in detail before formally beginning the exercises.
It is also essential to guide the subjects to focus on the present and improve their attention to the body during exercise. First, a comfortable, quiet, and safe environment is favorable for entering the state of mindfulness. Secondly, we should not start Tai Chi in a hurry. The purpose is to make the participant completely relax physically and mentally before starting to practice Tai Chi. If necessary, we can extend the time of mindfulness meditation. Meanwhile, guiding the participant to focus on body sensations with mild language during Tai Chi exercises is also essential. For example, the practitioner is guided to focus on the arm while doing the reaching movements of the upper limbs, feeling the Qi in the body running from the shoulder to the fingertip. In addition, the participant is reminded to feel the sensation of pressure and relaxation brought about by the alternating contraction and relaxation of muscles in both legs. Therefore, it is important to remind the participants to be consciously aware of each action of Tai Chi.
As the understanding of mindfulness has advanced, some participants may perceive physical or psychological discomfort. At this time, the participants should be guided not to evaluate the discomfort subjectively but to accept the objective existence of the discomfort.
This protocol has several advantages. Mindfulness training combined with Tai Chi belongs to moderate-intensity exercise and is suitable for most people. Tai Chi and mindfulness training is simple and easy to learn, requires no equipment and is not limited by place43. Thus, Tai Chi is easy to promote in the population. Although mindfulness training combined with Tai Chi has unique advantages over Tai Chi, it also has limitations. First, mindfulness training combined with Tai Chi is inappropriate for those unable to be calm. Second, the concept of mindfulness needs to be correctly understood. Third, mindfulness training combined with Tai Chi requires long-term adherence to practice.
It was confirmed that the addition of mindfulness training to Tai Chi could effectively enhance the training effect of Tai Chi. Therefore, mindfulness combined with Tai Chi is worthy of promotion and application in patients with DPN.
The authors have nothing to disclose.
This study was supported by a grant from the Science and Technology Development Fund of the Hospital of Chengdu University of Traditional Chinese Medicine (20HL01) and the Sichuan Province cadre health research project (2023-505). This study was supported by a grant from the Sichuan Provincial Cadre Health Department (Chuan Gan Yan 2023-505).