Effects of Mindfulness Training Combined with Tai Chi in Patients with Diabetic Peripheral Neuropathy

Summary

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.

Abstract

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.

Introduction

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 paresthesia^6,7. 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 DPN^12,13. 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 complications^15,16,17,18. 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 depression^25,26. 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.

Protocol

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

1. Select 3 communities in Chengdu using the convenience sampling method.
2. Recruit patients with T2DM peripheral neuropathy from three communities.
3. Use the following inclusion criteria.
   1. Include patients of age 40-75.
   2. Include patients diagnosed with DPN.
   3. Include patients who can perform moderate-intensity aerobic exercises.
   4. Include patients who do not use any other complementary or integrative therapies during the study period.
4. Exclude patients with the following conditions: neurological conditions caused by other conditions, such as cervical and lumbar spondylosis, cerebrovascular illness, Guillain-Barré syndrome, and vasculopathy; pregnant or lactating women; the inability of mental anomalies to cooperate.
5. Draw lots to assign patients from the three communities at random to the control group (CG), the Tai Chi group (TCG), and the mindfulness and Tai Chi group (MTCG).

2. Method 1: Practice methods of the CG

1. Conduct 3 collective health education sessions, each lasting 40 min.
   ​NOTE: The health education content mainly consisted of diabetes diet, exercise, medication, blood glucose monitoring, foot care, and prevention and care of foot complications¹². Three groups conduct health education separately.

3. Method 2: Practice methods of the TCG

1. Select a public, quiet area to practice one of the 24 style simplified Tai Chi³³.
   NOTE: Implementation methods: It was divided into 3 parts: warm-up, training, and relaxation. The focused exercise was performed 3 times a week for 60 min each for 12 weeks.
2. Instruct the participants to complete two sets of adductor (i.e., internal rotation), abductor (i.e., external rotation), hamstring (i.e., single stiff leg forward bending stretch), gluteal (i.e., hip flexion and extension), and ankle-oriented (i.e., ankle rotation) dynamic stretching exercises for 10 min, as part of a warm-up preparation exercise³⁴.
3. Under the direction of Tai Chi instructors, let the participants perform Tai Chi movements to Tai Chi music for 40 min.
   NOTE: The movements of the Tai Chi include commencing from part the wild horse's mane on both sides, white crane spreads its wings, brush knee and twist step on both sides, play pipa, repulse monkey, grasp the bird's tail, single whip, wave hands like clouds, high pat on horse, kick with right heel, strike opponent's ears with both fists, turn and kick with left heel, snake creeps down, jade lady weaves shuttles, needle at sea bottom, flash the arm turn, deflect downward, parry and punch, cross hands and closing form³³.
4. Do upper and lower limb relaxation exercises and breathing adjustment exercises for 10 min as a relaxation exercise³⁵.
   ​NOTE: First, stand and repeatedly shake shoulders and arms. Then beat and massage legs. Finally, sit and adjust the breathing pattern.

4. Method 3: Practice methods of the MTCG

1. Choose an open and quiet place to spread Yoga mats to sit.
   NOTE: Mindfulness training combined with Tai Chi practice was performed 3 times a week for 60 min each for 12 week sessions. Subjects were encouraged to adhere to mindfulness exercises daily at home. The aim is to integrate mindfulness into daily life.
2. Start mindfulness training combined with Tai Chi.
   NOTE: The specific training arrangement is shown in Table 1.
   1. Mindfulness training combined with Tai Chi-specific practice methods
      1. Mindfulness meditation:
         1. Sit on Yoga mats.
         2. Slowly inhale and exhale 3-4 deep breaths.
         3. Feel the air entering the nose, filling the chest and abdomen, and leaving the body as exhaled.
         4. Adjust the breathing rhythm back to normal. Do not try to control breathing.
         5. Adjust the breathing rhythm back to normal. Do not try to control breathing.
         6. Pay attention to the things such as breathing, body, voice, thoughts, and emotions, slowly relaxing the body.
      2. Mindfulness body scan:
         1. Supine on yoga mats with legs naturally apart, eyes barely closed, and arms naturally seated without touching the body.
         2. Pay attention to how the complete body feels, from the toes to the brain. Choose to sit to prevent falling asleep when doing mindfulness body scanning exercises.
      3. Mindfulness movement (Tai Chi):
         1. Focus on each movement of Tai Chi.
            NOTE: In Tai Chi practice, use gentle language to guide the practitioner to feel the pressure and relaxation brought by the alternating contraction and relaxation of the leg muscles and feel the sensation of contact between the feet and the ground.
         2. Try to maintain a state of mindfulness at all times as much as possible.
         3. Feel stress and relaxation as the leg muscles alternately contract and relax. At the same time, feel the sensation of the feet touching the ground.
3. End activities
   1. Do upper and lower limb relaxation exercises and breathing adjustment exercises for 10 min as a relaxation exercise³⁵.
      ​NOTE: First, stand and repeatedly shake shoulders and arms. Then beat and massage legs. Finally, sit and adjust breathing.
   2. Sit in meditation without making any judgments about the various thoughts that enter the mind, and accept these concepts always.
   3. Convert each daily task, such as brushing the teeth, showering, or cooking, into a mindfulness exercise.

5. Collect information

1. Select data collection staff and carry out unified training.
   NOTE: Collect data before and after the intervention, respectively. Data collectors were solely responsible for data collection and were blinded to group allocation to reduce data collector subjectivity bias.
   1. Collect data for Toronto clinical scoring system (TCSS)³⁶, visual simulation scale (VAS)³⁷, mindfulness and attention awareness scale (MAAS)³⁸, diabetes-specific quality of life scale (DSQL)³⁹, and serum tumor necrosis factor-α(TNF-α) levels.
2. Before the study begins, debate and decide on the detailed collecting criteria for each indicator by the research team members.
3. Thoroughly explain to the subjects what the scale means, what each item means, and how to use it.
4. Help the participants get into position, do physical evaluations, and record in detail.
5. Collect the blood samples from the participants at neighborhood hospitals, then send them immediately to the lab.
6. Promptly check the accuracy and completeness of the information gathered.

6. Statistical analysis

1. Collect and analyze data using any statistical analysis software.
   NOTE: In this study, SPSS 24.0 was used.
2. Depict data by mean ± standard error of mean, frequency, or composition ratio.
3. Use chi-square test, ANOVA, Kruskal Wallis H test, paired t-test, and Wilcoxon signed rank test.
4. Take readings at least three times at all time points for each sample.

Results

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).

Af...

Discussion

Many previous studies have reported how to apply Tai Chi to treat and rehabilitate chronic diseases^40,41. 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....

Materials

Name	Company	Catalog Number	Comments
SPSS 24.0	IBM	version 24.0	Statistical analysis