Effects of 2 Rehabilitation Protocols on Pulmonary Function in Lung Cancer Patients After Thoracoscopic Surgery: A Randomized Controlled Trial of Baduanjin Versus Bedside Cycle Ergometer Training.

Introduction
Lung cancer has the highest incidence and mortality rate among malignant tumours globally.1 With the development of medical technology, video-assisted thoracoscopic surgery (VATS) has become the first choice of surgical treatment for early-stage lung cancer due to its advantages of less trauma and faster recovery.2 However, postoperative lung function impairment remains the primary problem affecting patient recovery, typically manifesting as cough, dyspnoea, and reduced vital capacity. Therefore, timely postoperative pulmonary rehabilitation is crucial. Bedside cycle ergometer training, as a commonly used standardized pulmonary rehabilitation method in clinical practice, has been adopted as a routine rehabilitation protocol.3 Through regular lower limb exercise, this training can effectively enhance respiratory muscle function and improve patients’ lung capacity and ventilatory efficiency.4 However, the substantial cost of the requisite equipment, the need for a dedicated training site, and the high physical requirements of patients limit its wide application in the clinic to a certain extent.5 In comparison, Baduanjin, as a traditional Chinese exercise emphasizing the coordinated regulation of “form, breath, and mind,” has become a research focus in the field of pulmonary rehabilitation and demonstrates unique advantages in clinical application.6 The training integrates meridian theory and breathing control technology and promotes the operation of lung qi and blood in the form of soothing exercises through specific body movements coordinated with breathing rhythms. Clinical studies have shown that Baduanjin also plays a positive role in relieving post-operative pain and enhancing immune function.7 Moreover, Baduanjin requires no specialized equipment and adapts well to diverse settings, resulting in higher patient acceptance and compliance than conventional rehabilitation. This makes it a highly disseminable pulmonary rehabilitation intervention. Therefore, this study compares the effects of Baduanjin and bedside cycle ergometer training on pulmonary function recovery post-VATS, aiming to provide a more comprehensive clinical basis for rehabilitation programme selection.

Methods

Type of study design
This study is a randomized controlled trial (RCT). Participants were assigned to either the experimental or control group using a random number table. The experimental group received the Baduanjin training and the control group received the bedside cycle ergometer training. The aim was to assess the clinical effectiveness of these 2 rehabilitation training modalities.

Allocation concealment and blinding
Allocation concealment was implemented using sequentially numbered, opaque, sealed envelopes. The inner envelope contained group assignment information, while the outer envelope displayed only the sequential number. An independent supervisor signed all sealed flaps to prevent tampering. Due to the nature of the interventions, neither therapists nor participants could be blinded; However, outcome assessors remained blinded throughout the study. Researchers opened envelopes sequentially following enrolment to reveal group assignments.

Ethics approval and consent to participate
This study was conducted in strict accordance with the ethical principles of the Declaration of Helsinki. The study protocol was approved by the Medical Ethics Committee of Henan University (Approval No: HUSOM2025-799). All participants were fully informed regarding the study objectives, procedures, potential risks, privacy protection measures, and the principles of voluntary participation and freedom to withdraw at any time. Written informed consent was obtained from all participants.

Study subjects
Patients who underwent VATS at the Department of Thoracic Surgery of Huaihe Hospital of Henan University from January 2022 to January 2025 were selected for this study. Inclusion criteria: (1) The diagnosis of primary lung cancer was confirmed by pathological examination and the clinical stage was I-IIIA. (2) First time undergoing VATS. (3) Age > 18 years. (4) Normal cognitive level, good understanding and communication skills, able to understand and co-operate with rehabilitation training. (5) No regular participation in exercise training (≥3 sessions/week) in the past 6 months and no prior practice of Baduanjin/Qigong. (6) Voluntarily enrolled with signed informed consent. Exclusion criteria: (1) Combined with other malignant tumours. (2) Combined severe cardiac, pulmonary, hepatic, renal and other vital organ dysfunction. (3) Non-first surgery for lung cancer (such as previous secondary VATS procedures or open thoracic surgery history). (4) Those who are unable to complete the research project due to defective limbs or extreme physical weakness, etc. (5) Those with an expected survival time of <6 months. (6) Those with poor compliance and who withdrew from the study midway.

Experimental methodology

Control group interventions
During the intervention period from 48 hours to 12 weeks postoperatively, patients in the control group received standardized bedside cycle ergometer training under the guidance of uniformly trained rehabilitation therapists(Figure 1).8 The specific protocol was as follows: During the in-hospital phase (postoperative days 2-7), therapists conducted bedside cycle ergometer training at a fixed frequency of 3 times per week on alternate days. The initial intensity was set at 10 W for 15 minutes per session. Vital signs were continuously monitored during training, and the exercise intensity was dynamically adjusted based on individual tolerance, with control criteria including a Borg scale score 4-6, a target heart rate maintained within (220 − age) × 50%-70%, oxygen saturation ≥ 92%, and stable blood pressure. The load was increased by 5 W after every 2 completed sessions to achieve progressive overload. From discharge until week 12, patients transitioned to continued training in the rehabilitation outpatient clinic, maintaining the same fixed frequency of 3 sessions per week to ensure continuity of the rehabilitation effect. During this period, the training intensity was gradually increased from the discharge level, reaching a maintenance intensity of 30 W for 30 minutes per session by week 12. All training sessions were continuously monitored wirelessly using the Philips IntelliVue MX40 system throughout.

Experimental group interventions
During the intervention period from 48 hours postoperatively to 12 weeks, patients in the experimental group received standardized Baduanjin training under the guidance of uniformly trained rehabilitation therapists. This traditional mind-body exercise consists of 8 standardized movements (Figures 2 and 3).9 The specific training protocol was as follows: During the in-hospital phase (postoperative days 2-7), therapists conducted personalized bedside sessions at a fixed frequency of 3 times per week on alternate days. The training focused on breath-movement coordination (respiratory rate maintained at 6-8 breaths per minute) and was maintained at a low intensity (15 minutes per session, Borg scale 3-4). From discharge until week 12, patients transitioned to video-guided home-based training, continuing the same frequency of 3 sessions per week. The intensity was adjusted to a moderate level (30 minutes per session, Borg scale 5-6). Rehabilitation therapists remotely assessed movement quality through uploaded videos and provided timely corrective feedback. All training sessions were conducted through a combination of direct supervision and video assessment to ensure standardization and safety of the intervention.

Control of intervention intensity
This study employed the Borg CR-10 scale (0–10 points, where 0 indicates “no exertion” and 10 indicates “maximal exertion”) to monitor and standardize the intensity of all interventions. For the Baduanjin group, a phased intensity protocol was implemented based on the adaptive loading principle of mind-body exercise therapy, with targets set at Borg CR-10 3–6 points (“moderate” to “hard”). This approach allowed for individualized adjustment within a comfortable range while ensuring proper movement form and coordinated breath‑mind focus. The intensity target for the bedside cycle ergometer training group was maintained at Borg CR-10 4–6 points (“somewhat hard” to “hard”), based on the intensity-threshold principle of exercise prescription, aiming to achieve an effective workload sufficient to stimulate cardiopulmonary function and induce metabolic adaptation. The intensity settings for both groups conformed to the best practice guidelines of their respective interventions. This standardized intensity control protocol helps to mitigate potential confounding effects on outcome comparisons that may arise from differences in exercise load.

Compliance with interventions
This study strictly adhered to the intention-to-treat (ITT) principle, with all patients who completed randomization (262 in the experimental group and 263 in the control group) included in the efficacy analysis. To establish a clear criterion for compliance assessment, “poor compliance” was defined as completion of less than 80% of the total prescribed intervention sessions. During systematic monitoring, 2 patients in the experimental group and 3 in the control group were lost to follow-up or voluntarily withdrew. Patients who completed the full study (260 in each group) had their compliance recorded through standardized methods: the intervention group used rehabilitation diaries combined with weekly telephone follow-ups, while the control group relied on automated recording via training devices. The results showed that all patients who completed the full study strictly adhered to the protocol requirements, corresponding to a 100% adherence rate in this completer population. No patient who completed the study met the predefined criterion for “poor compliance.” There was no statistically significant difference in study completion rates between the 2 groups (P > .05).

Outcome indicators
(1) Pulmonary function: measured FEV1, FVC, and FEV1/FVC ratio using spirometry. (2) Postoperative pain: assessed using the Visual Analogue Scale (VAS), scored from 0 (no pain) to 10 (most severe pain). (3) Immune and inflammatory markers: Analysed CD4+/CD8+ ratio by flow cytometry and measured TNF-α and IL-6 concentrations via ELISA. (4) Cancer-related fatigue (CRF) comparison: evaluated using the Brief Fatigue Inventory (BFI), with scores of 0-10 indicating mild to severe fatigue.10 (5) Incidence of complications: including pulmonary infection, atelectasis, pneumothorax, and pleural effusion. (6) Quality of life comparison: assessed using the EORTC QLQ-C30 questionnaire, where higher scores indicate better quality of life.11

Statistical methods
Data were analysed using SPSS 22.0. Normally distributed measurement data are presented as mean ± standard deviation and compared with independent-samples t-tests. Categorical data are expressed as numbers (n) and compared using χ2 or Fisher’s exact tests. The Mann-Whitney U-test was used for ordinal data. P-values were 2 tailed, and when the value < .05, the result was considered statistically significant and Bonferroni correction was made as necessary for multiple testing.

Results

Comparison of general data between the 2 groups of patients
There was no statistical difference (P > .05) between the 2 groups in terms of general clinical data (including gender, age, average duration of disease, BMI, pathological type, etc.) and perioperative indexes (operation time, intraoperative haemorrhage, etc.), and they were comparable, as shown in Tables 1 and 2.

Comparison of lung function indexes between the 2 groups of patients
There were no significant differences in pulmonary function parameters (FEV1, FVC, FEV1/FVC) between the 2 groups at baseline and 1 week postoperatively (P > .05). At 2 weeks postintervention, the experimental group showed significantly better pulmonary function than the control group (P < .05), with continued improvement observed at 4, 8, and 12 weeks (all P < .05) (Table 3).

Comparison of postoperative pain levels between the 2 groups of patients
No significant differences were observed in pain scores between the 2 groups at 1 day and 1 week postoperatively (P > .05). From 2 weeks postoperatively, the experimental group showed significantly lower pain scores compared to the control group (P < .001), and this significant difference persisted at 4 weeks, 8 weeks, and 12 weeks follow-up (all P < .001) (Table 4).

Comparison of cellular immunity and inflammatory factor levels between the 2 groups of patients
No significant differences were observed in CD4+/CD8+ ratios, TNF-α, or IL-6 levels between the 2 groups at 1 day and 1 week postoperatively (P > .05). From 2 weeks after surgery, the experimental group demonstrated significantly higher CD4+/CD8+ ratios and lower TNF-α and IL-6 levels compared to the control group (all P < .001) (Table 5).

Comparison of CRF scores between the 2 groups of patients
No significant differences were observed in CRF scores between the 2 groups at 1 day and 1 week postoperatively (P > .05). From 2 weeks after surgery, the experimental group showed significantly lower CRF scores compared to the control group (P = .001), and these significant differences persisted at 4-week, 8-week, and 12-week follow-ups (all P < .001) (Table 6).

Comparison of incidence of postoperative complications between the 2 groups of patients
No significant differences were observed in the incidence of postoperative complications between the 2 groups (P > .05) (Table 7).

Comparison of quality of life scores between the 2 groups of patients
No significant differences were observed in quality of life scores between the 2 groups at 1 day and 1 week after surgery (P > .05). From 2 weeks postoperatively, the experimental group showed significantly higher quality of life scores compared to the control group (P < .001), and this significant difference persisted at 4 weeks, 8 weeks, and 12 weeks follow-up (all P < .001) (Table 8). The complete trend graphs of all primary outcome measures over time are detailed in Figures S1-S9.

Discussion
With its advantages of minimal trauma and rapid recovery, VATS has become a mainstream surgical approach for lung cancer treatment.12 However, postoperative pulmonary function decline and reduced exercise tolerance remain common clinical challenges.13 Bedside cycle ergometer training, as a conventional pulmonary rehabilitation method, can improve respiratory function through regulated lower-limb exercise. Nevertheless, its relatively monotonous training format and spatial requirements often lead to suboptimal long-term patient adherence.14 Meanwhile, Baduanjin, rooted in the Traditional Chinese Medicine theory of “harmonizing the body and spirit,” has gained increasing attention in rehabilitation.15 This practice combines gentle movements with breath regulation, aiming to enhance pulmonary function through the mechanism of harmonizing qi and blood,16 and is characterized by its equipment-free nature and ease of implementation.17 Currently, there is a lack of systematic comparison regarding the efficacy of these 2 rehabilitation modalities following lung cancer surgery. Therefore, this study aims to conduct a comparative evaluation to clarify the differences between the 2 approaches in terms of pulmonary function and overall rehabilitation outcomes in patients undergoing thoracoscopic lung cancer surgery, thereby providing evidence to inform the optimal selection of clinical rehabilitation strategies.
The results demonstrate that Baduanjin is significantly superior to bedside cycle ergometer training in improving pulmonary function, alleviating pain, modulating immune function, reducing CRF, and enhancing quality of life, while maintaining comparable effectiveness in controlling postoperative complication rates (P > .05). These findings confirm that both approaches serve as effective rehabilitation interventions following surgery, with Baduanjin offering more comprehensive clinical benefits. At the mechanistic level, the effects of Baduanjin may stem from its unique training model. In terms of improving pulmonary function, this practice combines limb extension with deep breathing, which may enhance respiratory muscle coordination and optimize breathing patterns, thereby promoting ventilation efficiency and pulmonary function recovery.18 For pain relief, it guides physical and mental relaxation, potentially regulating emotional and stress responses to improve pain perception and tolerance.19 Regarding immune function modulation, this mind-body integrative intervention may coordinate immune homeostasis through neuro‑immune interactions, supporting overall postoperative immune recovery.20 In alleviating CRF, it integrates mild exercise, breath regulation, and focused attention, potentially improving fatigue symptoms through dual physical and psychological pathways.21 As for quality of life improvement, this practice enhances patients’ physiological and psychological states.22 These combined improvements may contribute to the overall enhancement of postoperative quality of life.23 The above results demonstrate the short-term benefits of Baduanjin training on pulmonary function in postoperative lung cancer patients. This study will further evaluate its long-term effects through follow-up assessments at 1 year, 3 years, and 5 years.

Conclusion
Baduanjin training effectively enhances pulmonary function, alleviates pain, modulates immunity, reduces CRF, and improves quality of life in post-operative lung cancer patients. This method is practical, cost-effective, and well-accepted, demonstrating significant clinical value. Further large-scale studies are warranted to verify its long-term efficacy.

Limitations
The current intervention and evaluation period were confined to 12 weeks postoperatively, and although positive therapeutic effects were observed, the long-term efficacy of Baduanjin and patients’ adherence to self-directed exercise without supervision could not be assessed. Furthermore, as a single-centre study, despite the application of ITT analysis and false discovery rate (FDR) correction to control statistical bias, the generalizability of its conclusions across different medical institutions, rehabilitation settings, and patient populations still requires further validation. Future studies should extend follow-up duration and implement multicentre collaborative research to further clarify the long-term benefits and clinical applicability of Baduanjin in pulmonary rehabilitation.

Supplementary Material
ezag071_Supplementary_Data