Asian Journal of Psychiatry 51 (2020) 102046

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Baduanjin mind-body exercise improves logical memory in long-term T

hospitalized patients with schizophrenia: A randomized controlled trial
Mingli Lia,b,*, Jing Fangb, Yang Gaob, Yali Wub, Lili Shenb, Yiming Yusubujiangb, Jin Luob,**
a
Mental Health Center and Psychiatric Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
b
The Mental Rehabilitation Centers, Karamay Municipal People’s Hospital, Karamay, Xinjiang 830054, China

A R T I C LE I N FO A B S T R A C T

Keywords: Neurocognitive impairment is one of the core symptoms in schizophrenia and poses a great challenge to effective
Baduanjin exercise treatment. Sixty-one long-term hospitalized patients with schizophrenia were recruited and randomly assigned
Mind-body intervention to two groups: Baduanjin exercise and brisk walking. Patients in the Baduanjin group received 24 weeks of
Neurocognitive function Baduanjin training (5 days/week, 40 min/day), while patients in the brisk walking group received 24 weeks of
Schizophrenia
brisk walking (5 days/week, 40 min/day). Scores on the Wechsler Memory Scale, Digit Symbol Substitution Test
Memory
(DSST), and the positive and negative syndrome scale were used to evaluate the logical memory (LM), processing
speed, and clinical symptoms of all participants, while the score of Trail Making Test-A (TMT-A) was applied to
assess the visual attention and graphomotor speed, at baseline and the 16th week and 24th week of intervention.
The one-way repeated measures analysis of variance (ANOVA) was used to test the differences in neurocognitive
changes between the two groups. Repeated measures ANOVA showed significant differences between the two
groups in the LM immediate (F = 6.21, p = 0.003) and LM delayed (F=5.60, p = 0.005) scores, but not in the
completion times of TMT-A (F=.22, p = 0.806) or DSST scores (F=0.97, p = 0.328). A significant effect of time
was also detected in the LM immediate (F=10.24, p = 0.000) and LM delayed (F=4.93, p = 0.009) scores and
in the completion time of the TMT-A (F=33.10, p = 0.000), but not in the DSST scores (F=2.12, p = 0.122).
Baduanjin exercise could improve logical memory in the long-term hospitalized patients with schizophrenia.

1. Introduction
Neurocognitive impairment is one of the core symptoms in schizo-
phrenia. Almost all the domains of neurocognitive function, such as
memory, attention, processing speed, verbal learning, reasoning and
executive functions, are affected by the disease (Ma et al., 2007; Melle,
2019). Neurocognitive impairment usually appears at the onset of
schizophrenia, but may appear even prior to the onset, and persists
throughout the course of the disease (Mollon and Reichenberg, 2018;
Shmukler et al., 2015). It is also highly related to the disability and
social function outcomes of patients with schizophrenia (Addington and
Addington, 2000; Sheffield et al., 2018). Unlike positive symptoms that
could be significantly improved by treatment with antipsychotics, the
treatment of cognitive deficits still poses significant challenges.
Pharmacology, cognitive remediation, and repetitive transcranial
magnetic stimulation are currently the three main trial therapies for
cognitive deficits in schizophrenia(Choi et al., 2017; Jiang et al., 2019;
Rass et al., 2012; Sartory et al., 2005; Wang et al., 2019). However,
besides the inconsistent results and the small effect sizes of these stu-
dies, these therapeutic methods would impose additional financial
burdens on patients with schizophrenia, and are unavailable in poor
rural areas and primary hospitals. Therefore, there is a need to develop
an efficient and cost-effective therapeutic method for cognitive deficits
in schizophrenia.
Some empirical data suggest that physical activities and mental
training practices have positive impacts on cognitive function in pa-
tients with mild cognitive impairment (MCI) or age-related cognitive
impairment (Vakhrusheva et al., 2016). In particular, traditional Chi-
nese mind-body exercises such as Tai Chi and Baduanjin exercise–which
combine physical exercise postures with breathing and deep relaxation
techniques–could enhance neurocognition in patients with MCI
(Sungkarat et al., 2017, 2018; Tao et al., 2019). For example, Baduanjin
exercise could improve executive functions of the young and healthy
people after 8-week exercise (90 min/day, 5 days/week) (Chen et al.,

⁎
Corresponding author at: The Mental Health Center and psychiatric Laboratory, West China Hospital, Sichuan University, No 28 Dian Xin Nan Road, Chengdu,
Sichuan 610041, China.
⁎⁎
Corresponding author at: The Mental Rehabilitation Centers, Karamay Municipal People’s Hospital, No 5 Fenghua Road, Karamay, Xinjiang 830054, China.
E-mail addresses: limingli0517@qq.com (M. Li), 577827619@qq.com (J. Luo).

https://doi.org/10.1016/j.ajp.2020.102046
Received 7 September 2019; Received in revised form 20 March 2020; Accepted 25 March 2020
1876-2018/ © 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
M. Li, et al. Asian Journal of Psychiatry 51 (2020) 102046

2016), and attention ability (Schulte Grid test) of college students after
12-week exercise (Li et al., 2015). These findings endorse the potential
ability of Baduanjin exercise in improving neurocognition and well-
being.
To date, no randomized controlled clinical study has been con-
ducted to test if Baduanjin exercise can improve cognitive deficits in
schizophrenia. In the present study, comparing with the effects of brisk
walking, we explored the intervention effects of 24 weeks of Baduanjin
exercise on memory, visual attention, graphomotor speed, and proces-
sing speed in patients with long-term hospitalized schizophrenia.
2. Methods
2.2. Design
The sample size for the study was calculated by the G*Power soft-
ware (Faul et al., 2007). With 95 % power (β = 0.050), a type I error
rate of 5 % (α = 0.05), and effect size of 20 %, the estimated total
sample size was 56 participants. With an estimated dropout rate of 10
%, a final sample size of 61 was required. Patients were randomly as-
signed to the Baduanjin exercise (treatment) or the brisk walking
(control) groups using a random permuted block design. The types of
intervention were written on a piece of paper and put in a sealed black
box, and we picked one for each patient who agreed to be in the study.
30 patients were randomly allocated to the Baduanjin group, and the
other 31 patients were assigned to the brisk walking control group.

2.1. Participants 2.3. Intervention

A longitudinal randomized controlled trial design was employed. 2.3.1. The Baduanjin exercise group
Participants were recruited from the mental rehabilitation center in Patients in the Baduanjin group received 24 weeks of Baduanjin
Karamay Municipal People’s Hospital. All the patients were diagnosed training (based on the Health Qigong Baduanjin Standard published by
with schizophrenia based on the structured clinical interview for DSM- the General Administration of Sport of China, 2003) with a frequency of
IV (First et al., 1997). All the patients had been inpatient for at least 1 2 Baduanjin sessions 5 days/week, totally 40 min/day. The sessions
year, and had been on a stable dose for at least 3 months. The patients included a 5 min warm up, 30 min of Baduanjin training, and a 5 min
received antipsychotic medications, mood stabilizers, and anti- cool down. During the warm-up stage, the participants relieved their
depressants according to the preferences of the treating clinician and tension and warmed up their joints, while during the cool-down stage,
the patient. The dosage of antipsychotic medication taken by each pa- they regulated their breathing patterns. Nurse Fang and Nurse Wu
tient was recorded and converted to equivalent dosages of chlorpro- guided the patients to conscientiously take part in the Baduanjin ex-
mazine using the conversion tables provided by Atkins (Maria Atkins, ercise.
1997) and Woods (Woods, 2003) (Table 1). The exclusion criteria were
as follows: (1) having serious physical diseases, such as severe cardio- 2.3.2. Brisk walking group
vascular, pulmonary and musculoskeletal system diseases; (2) having Patients in the brisk walking group received 24 weeks of brisk
uncorrected vision and/or hearing problems and inability to complete walking (5 days/week, 40 min/day). Nurse Shen guided the patients to
the neurocognitive test; (3) having acute or chronic conditions that complete the walking sessions.
would preclude exercise; (4) exercising regularly within 6 months of the
study (or > 6 months with a frequency of 3–4 times per week and at 2.4. Clinical and neurocognitive assessment
least 30 min per session).
All participants were give a complete description of the study before The memory, visual attention, graphomotor speed, and processing
they provided written informed consent. The trial was approved by the speed were assessed for all participants at 3 time points: before the
Ethics Committee of Karamay Municipal People’s Hospital. intervention, at the 16th week of intervention, and at the 24th week of
intervention.
The positive and negative syndrome scale (PANSS) was used to
evaluate the clinical symptoms of the patients; Dr. Yusubujiang con-
Table 1 ducted these assessments.
Demographics and clinical symptom scales characteristics of participants. Memory was assessed by Logical Memory (LM) subtest in the
Wechsler Memory Scale. Participants were instructed to listen to, and
group Baduanjin Walking group T/χ2 df P value
remember, the contents of a short story that was verbally presented to
group (n = 30) (n = 31)
them, then repeated it immediately. After a delay of 30 min, they were
Age (year) 51.00(6.86) 50.97(8.54) 0.016 59 0.987 asked to repeat each story as accurately as possible again. Three dif-
Education (year) 10.77(2.61) 10.77(3.31) −0.010 59 0.992 ferent stories were presented at the 3 time points, so as to avoid
Duration of illness 21.63(10.13) 19.84(10.47) 0.680 59 0.499
learning effects. visual attention and graphomotor speed were assessed
(year)
Gender(male/ 24/6 23/8 0.055 1 0.814 using the Trail Making Test (TMT)-A, in which patients were instructed
female) to draw a line and connect consecutive numbers in numerical order as
Ethnicity (Han/ 26/4 23/8 0.815 1 0.367 quickly and correctly as possible (Kortte et al., 2002). Processing speed
other) was evaluated by the Digit Symbol Substitution Test (DSST). The coding
Medication
AP typical /atypical 0/30 1/30
task involved translating 9 different symbols into the digits 1–9 ac-
Mood stabilizer 5 7 cording to a key of digital-symbol pairs, which was presented on top of
Antidepressants 4 1 the task sheet. The participants were asked to decode the list of symbols
Total CPZ (5 rows, each with 25 symbols) one by one as fast as possible, within a
equivalent
preset limit of 90 min (Cornelis et al., 2014).
dosages (g)
16weeks 40.41(22.81) 36.97(15.79) 0.687 59 0.495 The neurocognitive tests of all patients were administered by Dr.
24weeks 61.74(34.42) 55.40(23.90) 0.838 59 0.405 Luo, who was blinded to the participants’ group assignment. All pa-
The score of PANSS tients were inpatients, and completed all assessments during the trial.
Baseline 61.67(11.38) 62.58(14.42) −0.274 59 0.785
16weeks 60.47(12.55) 61.77(14.14) −0.381 59 0.704
24weeks 59.47(13.84) 59.16(16.87) 0.304 59 0.939
2.5. Statistical analysis

Note: CPZ, chlorpromazine; AP, Antipsychotic; PANSS, Positive and Negative All statistical analyses were performed using SPSS software (IBM
Syndrome Scale. Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0.

2
M. Li, et al.
Armonk, NY: IBM Corp).
Demographic variables were analyzed using independent Student’s
t-tests (for continuous variables) and χ2 tests (for nominal variables).
The one-way repeated measures analysis of variance (ANOVA) was
applied to test the differences in neurocognitive changes between the 2
groups. The within-subject factor between time points was denoted by
“Time”, and the between-subject factor, i.e. Baduanjin exercise vs. brisk
walking was denoted by “Group”. A significant “Time × Group inter-
action” thus indicated a difference in response between the two inter-
vention groups. Partial Eta Squared (ɳ2) was used to assess effect size in
ANOVA model. The significance level was set at p < 0.05 (2-sided).
3. Result
3.1. Clinical and demographic characteristics
The flow chart of patient participation is shown in Supplementary
Fig. No patients dropped out during this study.
There were no significant differences between the participants in
the Baduanjin exercise and brisk walking groups at baseline in terms of
demographic characteristics such as age (51.00 ± 6.86 and
50.97 ± 8.54 years, respectively), gender (male/female: 24/6 and 23/
8, respectively), years of education (10.77 ± 2.61 and 10.77 ± 3.31
years, respectively), ethnicity (Han/others: 24/6 and 23/8, respec-
tively), and duration of illness (21.63 ± 10.13 and 19.84 ± 10.47
years, respectively), or in the type of antipsychotic medicine and the
equivalent dosages of chlorpromazine. We also found no significant
differences in PANSS scores between the two groups at the 3 time points
(Table 1).
3.2. Neurocognitive assessment
There were no significant differences in the LM immediate (t59 =
0.28, p = 0.778), LM delayed (t=−0.64, p = 0.949) scores, comple-
tion time of TMT-A (t=0.23, p = 0.816), or DSST scores (t=0.43, p =
0.672) between the 2 groups at baseline.
For repeated measures ANOVA, a significant effect of “Time” was
detected in the LM immediate (F = 10.24, p < 0.001, ɳ2 = 0.148), LM
delayed (F = 4.93, p = 0.009, ɳ2 = 0.077) scores, and in the com-
pletion time of the TMT-A (F = 33.10, p < 0.001, ɳ2 = 0.359), but not
in the DSST (F = 2.14, p = 0.122, ɳ2 = 0.035) scores.
A significant effect of “Group” was detected in the LM scores (LM
immediate: F = 4.91, p = 0.031, ɳ2 = 0.077; LM delayed: F = 4.07, p
= 0.048, ɳ2 = 0.064), but not in the completion time of the TMT-A (F
= .004, p = 0.949, ɳ2 < 0.001), or the DSST (F = 0.97, p = 0.328, ɳ2
= 0.016) scores.
A significant “Time × Group interaction” effect was found in the
LM immediate (F = 6.21, p = 0.003, ɳ2 = 0.095) and LM delayed (F =
5.60, p = 0.005, ɳ2 = 0.087) scores, but not on the TMT-A timing (F =
0.22, p = 0.806, ɳ2 = 0.004), or DSST (F = 2.12, p = 0.125, ɳ2 =
0.035) scores (Table 2, Fig. 1).
4. Discussion
In the present study, we have 3 primary findings. Firstly, compared
with brisk walking, Baduanjin exercise improved the logical memory
functions of long-term hospitalized patients with schizophrenia.
Patients experienced 48 % and 52 % improvements in immediate and
30-min delayed logical memory, respectively. Secondly, both Baduanjin
exercise and brisk walking reduced the completion time of TMT-A,
indicating that regular exercise could improve the visual attention and
graphomotor speed of patients with schizophrenia. Thirdly, the scores
of DSST were unchanged in both groups, indicating that the two ex-
ercises have little effect on processing speed in these patients. These
findings suggested that Baduanjin exercise might be an effective alter-
native method to improve logical memory of the chronic, long-term
3
Asian Journal of Psychiatry 51 (2020) 102046
hospitalized patients with schizophrenia.
Contrary to our expectations, we found that only Baduanjin exercise
caused significant improvements in the memory function of patients
with schizophrenia. A moderate effect size (partial eta squared = 0.09)
was observed for this intervention (Cohen, 2013). Possible explanations
for this might include the following factors: firstly, although a number
of studies have found that exercise has some effect on memory (Loprinzi
et al., 2018), most of the results are from treatments with acute exercise
(Roig et al., 2013; Yanes and Loprinzi, 2018), and secondly, the ex-
ercise-memory interaction is intensity- and time-dependent (Loprinzi,
2018; Loprinzi et al., 2019). Only acute exercise with moderate-to-
vigorous intensity (Erickson et al., 2019; Loprinzi et al., 2019), and
acute exercise prior to memory encoding, is reported to be optimal in
enhancing memory function (Haynes Iv et al., 2019; Loprinzi, 2018;
Loprinzi et al., 2019). In our study, patients in the brisk walking group
only received mild-to-moderate intensity exercise, and no acute ex-
ercise overall. Moreover, Baduanjin exercise involves not only physical
exercise, but also mindfulness training. Previous studies have shown
that meditation can improve memory of adults with subjective cogni-
tive decline (Farhang et al., 2019; Innes et al., 2017; Wong et al., 2017),
and that mind-body interventions such as Yoga, Tai Chi, and Qigong
could also improve memory of older adults with MCI (Brenes et al.,
2019; Farhang et al., 2019).
Several studies have suggested that both the hippocampus and the
prefrontal cortex play important roles in memory (Barker et al., 2017;
Eichenbaum, 2017; Geib et al., 2017), and neuroimaging studies have
found that memory deficits in patients with schizophrenia might be
related with structural impairment and dysfunction of the hippocampus
and prefrontal cortex (Avery et al., 2018; Hutcheson et al., 2015;
Ragland et al., 2017). Exercise may affect memory by modulating the
function of the hippocampus (Loprinzi et al., 2017). In alignment with
these studies, Tao et al. (2017b) reported that participants had higher
volumes of gray matter in the left hippocampus, left amygdala, bilateral
putamen, and left insula after 12 weeks of Baduanjin exercise. Fur-
thermore, the volumes of the left hippocampus and putamen were as-
sociated with changes in the memory quotient (Tao et al., 2017b). The
Baduanjin exercise group also had a higher fractional amplitude of low-
frequency fluctuations (fALFF) in the medial prefrontal cortex in the
slow-5 and low-frequency bands, and this increase was positively as-
sociated with memory function improvement (Tao et al., 2017a). These
findings might reveal the likely neurobiological mechanisms of Ba-
duanjin exercise in improving memory of patients.
Patients with schizophrenia show deficits in visual attention and
graphomotor speed even in their first-episode untreated stage, and take
longer to complete the TMT-A (He et al., 2012; Ma et al., 2007). Con-
sistent with previous studies, physical exercise is reported to be bene-
ficial to executive functions in healthy peoples (Smith et al., 2010), as
well as patients with schizophrenia (Firth et al., 2017). In this study, we
found that after 24 weeks of exercise, long-term hospitalized patients in
both groups showed improved ability in completing TMT-A. Our find-
ings suggest that psychiatrists should encourage their patients to ex-
ercise regularly, although the mechanism through which aerobic ex-
ercises could improve visual attention and graphomotor speed have not
been fully understood yet. Our previous study found that decreased
fALFF in the left superior gyrus was negatively correlated with the
mean executive time of TMT-A (He et al., 2012), suggesting that that
prefrontal cortex might be the neural substrate of deficits in processing
speed of patients with schizophrenia.
In this study, we found that the DSST score did not change sig-
nificantly after 24 weeks of exercise intervention. DSST primarily re-
flects the processing speed of subjects. Our finding is in line with the
results of a recent systematic review and meta-analysis study, which
showed that processing speed does not respond to aerobic exercise in
patients with schizophrenia (Firth et al., 2017). While another meta-
analysis including 2021 participants suggested that aerobic exercise
could significantly improve processing speed (Smith et al., 2010), the
M. Li, et al. Asian Journal of Psychiatry 51 (2020) 102046

Table 2
Memory, Executive function and Processing speed outcomes after 16 weeks and 24 weeks intervention in schizophrenia.
group Baduanjin Walking Time Group Time * group
(n = 30) (n = 31) (F, p value, ɳ2)

LM immediately
Baseline 7.67 (4.19) 7.35(4.42)
16 weeks 9.93(5.23) 6.90(3.83)
24weeks 11.37(5.03) 7.97(4.22) 10.24, 0.000, 0.148 4.91, 0.031, 0.077 6.21, 0.003, 0.095
LM delayed
Baseline 6.57(4.25) 6.65(5.33)
16 weeks 8.77(5.66) 5.42(4.37)
24weeks 10.03(5.68) 6.74(4.45) 4.93, 0.009, 0.077 4.07, 0.048, 0.064 5.60, 0.005, 0.087
Time of TMT
Baseline 123.92(96.41) 118.77(74.88)
16 weeks 84.02(72.59) 86.58(43.05)
24weeks 76.11(70.82) 75.57(38.43) 33.10, 0.000, 0.359 .004, 0.949, 0.000 0.22, 0.806, 0.004
Score of DSST
Baseline 29.43(17.45) 27.61(15.97)
16 weeks 29.67(14.12) 26.81(14.29)
24weeks 33.03(12.11) 27.26(12.50) 2.14, 0.122, 0.016 0.97, 0.328, 0.016 2.12, 0.125, 0.035

Note: LM, logical memory; TMT, Trail Making Test; DSST, Digital-Symbol Substitution Test. ɳ2, Partial Eta Squared was used to assess the effect size.

participants in that study were highly heterogeneous, including elderly
adults with MCI, healthy young adults, healthy elderly adults, seden-
tary adults, and so on. Physical exercise might not affect the processing
speed of patients with schizophrenia. In our study, the DSST score of
patients with schizophrenia increased by 12 % after 24 weeks in the
Baduanjin exercise group, but not in the brisk walking group. This
suggests that Baduanjin exercise might have a negligible effect on
processing speed even after a prolonged duration of intervention.
However, physical activity as a part of healthy lifestyle behavior was
beneficial to prevent premature mortality and positive symptoms of
patients with schizophrenia (Abdul Rashid et al., 2019; Gandhi et al.,
2019a, b), we still recommend patients to engaged in it.
Several limitations of this study should be noted. Since we only
recruited 61 patients from a single hospital, further multi-center studies
with larger sample sizes are needed to validate our results. The patients
in this study were inpatients who had chronic schizophrenia, and were
long-term hospitalized; however, studies also need be conducted for
outpatients with schizophrenia to test if Baduanjin exercise could also
be effective for other types of schizophrenia. It should be noted that this
study employed very few neurocognitive tests, and further studies that
include and assess many more neurocognitive domains need to be
conducted. Moreover, there was no non-active comparator or placebo
group in this trial. The significant effect of variable “Time” detected in
this study could not entirely reliably exclude confounding by learning
effects. Finally, this study lacked a follow-up assessment after the post-
assessment.
5. Conclusion
In summary, this study found that 24-week Baduanjin exercise could
improve the memory function of the long-term hospitalized patients
with schizophrenia. We recommend the application of this free, simple,
and safe technique to patients with schizophrenia, as an intervention to
help deal with their memory deficits.

Fig. 1. Scores of four neurocognitive test at baseline and following 16 and 24 weeks.
LM, logical memory, DSST, digital-symbol substitution test.

4
M. Li, et al.
Funding
Funding for this study was provided by 1.3.5 project for disciplines
of excellence, West China Hospital, Sichuan University (Grant Nos.
ZY2016203 & ZY2016103).
Declaration of Competing Interest
All the authors declare no conflict of interest.
Acknowledgement
We thank all individuals who have participated in this study.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.ajp.2020.102046.
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