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Available online at www.sciencedirect.com

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journal homepage: www.ajgponline.org

Clinical Review Article

Qigong for the Prevention,

Treatment, and Rehabilitation of
COVID-19 Infection in Older Adults
Fan Feng, M.D., Ph.D., Sylvie Tuchman, B.A., John W. Denninger, M.D., Ph.D.,
Gregory L. Fricchione, M.D., Albert Yeung, M.D., Sc.D.

ARTICLE INFO ABSTRACT

Article history: The elderly are at high risk of contracting respiratory infectious diseases,
Received April, 24 2020 including COVID-19 infection. The recent pandemic has the potential to cause
Revised May, 6 2020 significant physical and mental damage in older adults. Similarly to other
Accepted May, 10 2020 mind-body exercises in Traditional Chinese medicine, Qigong features regula-
tion of breath rhythm and pattern, body movement and posture, and medita-
Keywords: tion. Given these traits, Qigong has the potential to play a role in the
Qigong prevention, treatment, and rehabilitation of respiratory infections, such as
COVID-19 COVID-19. Potential mechanisms of action include stress reduction, emotion
respiratory infections regulation, strengthening of respiratory muscles, reduction of inflammation,
older adults and enhanced immune function. Three forms of Qigong; abdominal breathing,
Ba Duan Jin and Liu Zi Jue, all of which are gentle, smooth, and simple for the
elderly to practice, are recommended in this context. (Am J Geriatr Psychiatry
2020; &&:&&−&&)

Clinical practitioners and researchers are working

to find effective treatments for COVID-19, and com-
plementary and alternative medicine may be a feasi-
INTRODUCTION ble and valuable option. In China, Traditional
Chinese medicine (TCM) and Qigong have played
T he outbreak of coronavirus disease 2019
(COVID-19), that was first reported by local
health facilities in Wuhan, China, in December 2019,
important roles in the battle aga#inst this disease. The
Chinese herbs Qingfei Paidu decoction have been rec-
has rapidly spread throughout the world. Older peo- ommended by the National Health Commission of
ple and patients with existing medical conditions are China as a treatment for COVID-19 infected patients
prone to have severe complications associated with with mild to moderate symptoms.2 For COVID-19
Covid-19 infection.1 infected patients with severe respiratory symptoms,

From the Benson Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA; and the Depression Clinical and
Research Program, Massachusetts General Hospital, Boston, MA. Send correspondence and reprint requests to Albert Yeung, M.D., Sc.D.
MGH Depression Clinical and Research Program, One Bowdoin Square, 6/F, Boston, MA 02114. e-mail: ayeung@mgh.harvard.edu
© 2020 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jagp.2020.05.012

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Qigong for the Prevention, Treatment, and Rehabilitation of COVID-19 Infection

the herbs were used in combination with Western The concept of Qi in TCM is very broad, and it is
medicine. In the Wuhan Fangcang Hospitals, field involved in nearly all physiological and pathological
hospitals for the isolation of mild cases instead of processes.6 According to its different functions, Qi
home quarantine, patients practiced Ba Duan Jin can be divided into different types, for example
Qigong under the guidance of TCM doctors for treat- defensive Wei Qi, and the organ Qi that regulates the
ment and exercise.3 This review discusses the applica- function of each organ. The channels through which
tion of Qigong in older people for the prevention, Qi moves in the body are called meridians, which are
treatment, and rehabilitation of respiratory infectious distributed on the surface of the limbs and trunk and
diseases, including COVID-19. extend to the inside organs.
Qigong is a mind-body training skill that can regu-
late body, breath and mind under the guidance of the-
METHODS ory of TCM to guide Qi operation in the meridian, to
regulate physical function, and to prevent and treat
Studies for inclusion were identified by querying
diseases.7 Qigong regulates the body through an
Pubmed, the China national knowledge infrastruc-
adjustment of body movement and posture. Qigong's
ture, the China Science and Technology Journal Data-
body regulation is aimed at relaxation, so the move-
base, and Wanfang data. The main mechanisms for
ments are typically gentle and smooth. Regulation of
the occurrence and development of COVID-19 are
breath involves changes in respiratory movement,
immunosuppression and cytokine storm.4 COVID-19
rhythm, and pattern. Breath in Qigong needs to be
patients with severe symptoms may develop respira-
slow, long, and deep. Sometimes changes in breath
tory impairment and need rehabilitation, including
pattern are also required, such as abdominal breath-
respiratory muscle training, whole-body movement
ing, and breathing with phonation, both of which are
and psychological rehabilitation.5 We searched in the
typical patterns of Qigong respiration. Abdominal
above databases using terms to address the potential
breathing refers to a breathing pattern with obvious
mechanism of Qigong in the prevention, treatment
abdomen movement, and breathing with phonation
and rehabilitation of COVID-19, including “immune
is a combination of breath and the production of
function,” “inflammation,” “cytokine,” “respiratory
speech sounds. Regulation of mind includes focusing
muscle,” “stress,” “mood” and “emotion,” combined
attention and visualization. Most operations of mind
with terms which address different types of Qigong:
regulation are similar to meditation, therefore Qigong
“Qigong,” “Qi Gong,” “Tai-Chi,” “Tai Chi,” “Taichi,”
is also considered a meditative movement.8
“Taiji,” “Yi Jin Jing,” “Yijinjing,” “Wu Qin Xi,”
Qigong originated in the primeval time of China as
“Wuqinxi,” “Liu Zi Jue,” “Liuzijue,” “Ba Duan Jin,”
a means of self-care. According to the first historical
“Baduanjin,” as well as “abdominal breathing” and
record in China “Shang Shu,” 4,000 years ago, ancient
“abdominal respiration.” Given that clinical studies
Chinese people found that stretching and dancing
on the intervention of Qigong for COVID-19 are lim-
could release pain. This is the rudiment of Qigong.
ited, we used the terms “respiratory infection” and
Almost all religions and philosophical schools, such
“respiratory rehabilitation,” combined with terms
as Taoism, Buddhism, TCM, and martial arts, have
mentioned above to search for clinical evidence about
elements of Qigong practice methods, with different
the application of Qigong in the treatment and reha-
appellations. In the 1950s, experts and scholars
bilitation of respiratory infection. The abstract and the
reached a consensus and coined this methodology
full text of each article were reviewed and included if
"Qigong", and the first Qigong institute was estab-
it identified as clinical research or as a clinical system-
lished in China in 1954.
atic review published in English or Chinese.
Many studies on Qigong have been carried out
through modern research methods, including the
Understanding Qi and Qigong
observation of physiological and psychological
"Qigong" is composed of two Chinese characters changes during or after Qigong practice, along with
“Qi” and “Gong.” "Qi" refers to the energy that moti- clinical trials of treating various diseases with
vates human life activities, and "Gong" refers to the Qigong. Qigong is particularly appropriate for older
regulation of Qi through practice. people due to its gentle and smooth movements, and

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there are wide applications of Qigong in geriatric stress and negative affect. Thus, those who engage in
medicine,9 including in the treatment of musculoskel- extensive practice of passive Qigong may be likely to
etal disorders, pain relief, and muscle strengthening. experience better psychological outcomes.
As a mind-body skill, Qigong has been found to
impact internal and psychosomatic diseases, such as
How Qigong Can Treat Respiratory Infective
asthma, hypertension, peptic ulcers and diabetes.
Disease Utilizing TCM Theories
Qigong is also used as a meditative movement for
treating geriatric mental conditions including mood Respiratory infectious diseases belong to the cate-
disorders and cognitive impairment.10,11 gory of external pathogens diseases in TCM. Its path-
ogenesis is that external pathogens invade the human
body and produce tension in the balance between
Classification of Qigong
“good and evil.” The “evil” refers to exogenous
According to different operations, Qigong techni- pathogens, which can be considered similar to the
ques can be divided into two groups: dynamic or pathogen of infection. “Good” refers to the defensive
active Qigong, and passive or meditative Qigong. function of the human body. When exogenous patho-
Dynamic Qigong refers to those techniques that pri- gens invade the human body, defensive Wei Qi fights
marily focus on body movements and involve more against them. It can be considered that Wei Qi repre-
movements of the whole body or limbs. Tai-chi, Yi Jin sents immune function from the perspective of mod-
Jing (Muscle Change Classic), Wu Qin Xi (Five-animal ern medicine. The relationship between Wei Qi and
Exercise), Liu Zi Jue (Six-Healing Sounds), and Ba exogenous pathogens determines whether the disease
Duan Jin (The Eight Brocades) are examples of will develop and the prognosis of the disease. If Wei
dynamic Qigong that have gained worldwide popu- Qi is strong enough to defend against the exogenous
larity. Contrastingly, passive Qigong techniques have pathogen, the disease would not occur, or would be
almost no body movement, but require maintaining a easier to heal, and the prognosis would be good.
certain posture and carrying out exercises mainly Because of a decline in organ function and an
involving the breath and mind. increase in chronic medical conditions, older people
Dynamic Qigong is more successful than passive are considered to be in a state of weakness or insuffi-
Qigong with regards to physical regulation, therefore cient energy, conceptualized as Qi and blood defi-
it can be more effective in treating musculoskeletal ciency in TCM. Wei Qi is thought of as being scarce in
and psychosomatic disease. Practitioners who have the elderly. Therefore, according to theories of TCM,
difficulty focusing their attention can concentrate on when encountering infectious diseases such as
movements and actions in dynamic Qigong, which is COVID-19, the elderly are more likely to be affected,
an easier skill to master. Passive Qigong pays more and infections are more likely develop into severe dis-
attention to mind regulation. Attention training is an eases with poor prognoses. Given that Qigong regu-
important and common technique of mind regulation lates the function of Qi in the human body, in which
that asks practitioners to focus attention on an object Wei Qi is included, it may prevent respiratory infec-
or on the present, which is similar to mindfulness tion or promote recovery from respiratory infection in
meditation. According to theory of TCM, through the elderly.
extensive practice of focusing attention, practitioners
can enter a state of tranquility. Passive Qigong has Potential Mechanisms of Qigong in Respiratory
few requirements for physical strength, as it can be Infectious Diseases
practiced in any posture without movement. In addi-
tion, for those with impaired body movement ability, 1. Management of Stress and Emotion
passive Qigong is a better choice than dynamic
Qigong. A study on mindfulness, conducted by Outbreaks and illness are a source of stress, and
Lacaille et al.,12 indicated that prolonged mindfulness stress reactions or emotional problems can occur in
practice was associated with an increase in mindful hospital inpatients, people in isolation, and those in
responding, which was in turn associated with the general population. Benson et al.13 observed physi-
increased positive affect and with less perceived ological changes during meditation, and found that

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meditation can counteract stress response. Benson older adults with insomnia, Tai-Chi reduced proin-
coined the physiological change elicited by meditation flammatory gene expression and marginally reduced
a “relaxation response.” As a meditative movement, C-reactive protein by the end of the 4-month practice,
Qigong has been studied as a tool for stress manage- and reduced monocyte production of proinflamma-
ment. Ryu et al.14 observed changes in stress hormones tory cytokines at the end of the program and at the
during Qigong practice, and found that beta-endor- follow-up after 7 and 16 months, when compared to
phins increased in the middle of training while levels the control group. Additionally, a 12-week program
of adreno-cortico-tropic-hormone declined mid and of Tai-Chi has been found to increase levels of the
postpractice suggesting decreased stress levels. It has anti-inflammatory cytokine IL-10 in middle-aged
been suggested that Qigong regulates emotion through adults.24 Chen et al.25 found that in COPD patients,
enhancing nonreactivity to aversive thoughts and 60-day Liu Zi Jue practice lowered the level of IL-4,
impulses by focusing attention, regulating the hypo- IL-13 and IL-17, and increased the level of IL-10 when
thalamus-pituitary-adrenal axis reactivity and the bal- compared to a regular treatment control group.
ance of the autonomic nervous system, and through
changing the function of the brain, limbic system, and 4. Enhancing the Immune Function
expression of genes linked to inflammatory responses
and stress-related pathways.15 In a meta-analysis on Qigong’s enhancement of immune function has
treating chronic obstructive pulmonary disease manifested in both nonspecific immune response and
(COPD) with Qigong, Wu et al.16 reported that Qigong specific immune response. Regarding nonspecific
alleviated depression and anxiety among patients with immune response, Qigong can increase the amount or
COPD. Meanwhile, during the Severe Acute Respira- activity of immune cells in the body. Yeh et al.24
tory Syndrome outbreak, practicing Qigong was found found that in middle-aged healthy people, after a 12-
to strengthen individuals’ sense of control, and taking week program of Tai-Chi practice, there was a signifi-
part in a practicing group improved their senses of cant increase in the ratio of T helper to suppressor
social support.17,18 cells (CD4/CD8), CD4CD25 regulatory T cells, and
the production of the regulatory T cell mediators
2. Strengthening the Respiratory Muscles transforming growth factor b. Qiu et al.26 studied a
sample of elderly people using Ba Duan Jin and found
Qigong can enhance physical strength through the CD4, CD4/CD8 and NK cell percentage increased
training of specific muscle groups. Liu et al.19 found after a 24-week program when compared to a control
through measuring grip strength, jumping height, and group who received health education without exer-
toe contact test in older people that Qigong can cise. Yu et al.27 observed the effect of Wu Qin Xi
increase muscle strength. With regards to respiratory on NK-cell activity in elderly adults tested by
muscles, studies in stroke patients found that the lactate dehydrogenase release assay, and found that
myoelectricity and activity of the diaphragm increased the activities of NK cells increased after practicing for
after a 3-month abdominal respiration training when half a year when compared with a blank control
compared with thoracic breathing.20 In COPD patients, group. Study results indicated that Wu Qin Xi is a
Wu et al.21 observed improvement of respiratory mus- moderate intensity exercise for older people. Accord-
cle strength after 3-month Liu Zi Jue practice. ing to Nieman,28 moderate exercise can lower the risk
of respiratory tract infection, and heavy exercise can
3. Reducing Inflammation increase the risk of infection.
The effect of Qigong on specific immune response
Qigong can reduce both inflammatory factors and can be observed in the increase of immune cells and
inflammatory response. Irwin et al.22 examined the immunoglobulin. Chiang et al.29 selected 20 seden-
cytokines in older adults who had participated in a 6- tary males as subjects, and found that Tai-Chi
month Tai-Chi program, and found reductions in lev- increased the number of circulating myeloid dendritic
els of IL-6 in subjects in the intervention group who cells when compared with a blank control group, but
previously showed high levels of this inflammatory that plasmacytoid dendritic cells remained the same
marker. In another study, Irwin et al.23 found that in in both groups. The degree of growth in myeloid

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dendritic cell significantly increased with the years of 2. Use of Qigong in Treating Respiratory Infectious
practice. Vera et al.30 examined the acute effect of Diseases
Qigong on adults who participated in a 1-month-Tao-
ist Qigong program. The researchers took blood sam- There are few studies on the intervention of Qigong
ples the day before the experiment commenced and in the acute phase of respiratory infection, but accord-
1 hour after the last session of the training program ing to limited research results Qigong can be found to
ended, and found higher values in the number and shorten the course of infection. In Ties’ study,36 90
the percentage of B lymphocytes, as compared with a female healthy students were separated into three
control group that did not engage in the practice. groups; a control group, a three times a week move-
Niu31 investigated the effect of Tai-Chi on middle- ment group, and a five times a week movement
aged participants and observed that blood IgA, IgG group, after a six-month Tai-Chi training. In the two
and IgM levels increased significantly in the Tai-Chi Tai-Chi groups, the levels of IgA and IgG became
exercise group with increasing exercise time. higher, as compared with the control group. There
The promotion of Qigong in the specific immune was no difference in the frequency of respiratory tract
response has also been reflected in the level of anti- infection in the three groups, however the duration of
bodies after vaccination. In Irwin’s study,32 partici- each onset became shorter in the Tai-Chi group.
pants took part in Tai-Chi or health education for 25
weeks, and after 16 weeks of intervention, subjects 3. Application of Qigong to Rehabilitation in Respi-
were vaccinated with Varivax. They found the Tai- ratory Infectious Diseases
Chi group showed higher levels of cell-mediated
immunity to VZV than the health education group. In Severe respiratory infections can cause reduced
Yang’s study,33 older adults practiced Tai-Chi and respiratory function and require rehabilitation.
Qigong for 5 months and then received the influenza Although research on the application of Qigong in
vaccine during the first week of the intervention. the rehabilitation of respiratory infections is limited,
Improvement of the magnitude and duration of the researchers have shown that Qigong can promote the
antibody response to influenza vaccine were rehabilitation of other respiratory diseases which
observed when compared to the control group. cause impaired respiratory function. Tong’s meta-
analysis37 on 10 studies examined 993 participants
Clinical Evidence on Qigong in Respiratory who were in the stable stage of COPD infection.
Infectious Diseases Results indicated that Qigong can improve lung func-
tion in COPD patients, including forced expiratory
1. Application of Qigong to the Prevention of Respi- volume in 1s (FEV1), forced vital capacity rate of 1s
ratory Infectious Diseases (FEV1/FVC), and forced expiratory volume in 1s/
predicted (FEV1/pre). Additionally, results showed
Some studies have demonstrated the effectiveness of that it can improve exercise capacity, Functional Task
Qigong in preventing respiratory infectious diseases. Evaluation, COPD Assessment Test for exercise, and
Hu et al.34 selected elderly men as experimental sub- increase the score of Short Form-36 Health Quality
jects and randomly divided participants into either a Survey, which indicates improvement in quality of
Qigong intervention group or a control group who life. The researchers analyzed the function of Ba Duan
performed jogging. Compared with the control group, Jin, Yi Jin Jing and Liu Zi Jue respectively, and found
the experimental group experienced significantly fewer the first two resulted in significant improvement, and
respiratory tract infections after Qigong exercise for that Liu Zi Jue did not have significant effect. How-
two years, and the difference between the two groups ever, other studies have shown Liu Zi Jue to be effec-
increased with exercise time. Wright et al.35 found that tive in the rehabilitation of COPD patients. A study
in swimmers who practiced Qigong at least once per by Li et al.38 indicated that COPD patients’ lung func-
week, cold and flu symptoms showed a significant tion (FEV1/pred, FEV1/FVC) improved significantly
nonlinear association with frequency of Qigong prac- with Liu Zi Jue practice, as did the 6-minute walking
tice, with a strong, inverse relationship between prac- test, 30-second sit-to-stand test, and St George’s
tice frequency and symptom scores. Respiratory Questionnaire score. Chen39 observed

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that in chronic bronchitis patients who practiced Ba kinds of Qigong are often used in the prevention and
Duan Jin, hospital stays decreased, and lung function treatment of respiratory infections, for the movement
(FEV1/FVC) and arterial blood gas analysis (PaO2, is smooth with low intensity, and easy to learn. In
PaCO2) improved when compared with the control addition, the range of these three Qigong movements
group who received regular treatment. is small, and the space requirements are not signifi-
cant. Thus, they are suitable for home practice during
the current epidemic.
How to Learn and Practice Qigong

Some simple Qigong can be learned independently 1. Abdominal Breathing

through watching Qigong videos. Before learning
Qigong, consulting with doctors is necessary for Abdominal breathing can be found in a variety of
safety reasons. Learners can begin with physical mind-body exercises, including yoga, meditation, and
movements of the forms. After practitioners acquire Qigong. The technique is very straight forward: con-
the sequences of both isometric and isotonic segmen- sciously move your stomach when inhaling, tighten-
tal movements in upper and lower extremities, they ing your stomach muscles, and let them fall inward
can try to combine breathing techniques and focus as you exhale, while focusing attention on breathing.
their attention on movement, breath and Qi. Do not hold your breath.
Abdominal breathing can enhance respiratory
function, and create a relaxation response. Abdominal
Tips for Practice
breathing has been found to stimulate the vagus
Practice environment: Qigong can be practiced both nerve,40 which can regulate breathing and help with
indoors and outdoors, though indoor practice is more relaxation. Focusing attention on breath is one of the
appropriate during an epidemic of infectious disease. simplest ways to achieve emotional regulation and to
The practice environment should be clean and quiet decrease anxiety-related dysfunctional thoughts
for breathing exercises and concentration. Practice about the pandemic. Abdominal breathing requires
space needs to be chosen according to the type of the least amount of exercise of the three Qigong exer-
Qigong being practiced. For patients with fall risks, cises recommended, and can be practiced standing,
an instructor who is experienced in working with sitting, or lying on the back so that it can meet the
elderly people may be necessary. needs of practitioners with poor physical conditions
Practice time: Qigong practicing needs to be persis- or more serious illness. Since abdominal breathing
tent. Fixed time can help in forming a habit. Being can be practiced anytime, anywhere, and in most
either too hungry or too full is not suitable for practice. physical conditions, it is a highly recommended
Intensity: Attention needs to be paid to personal method for coping with COVID-19 related stress.
condition at each practice, on which intensity should
depend. As mentioned above, moderate exercise is 2. Ba Duan Jin
the best option for respiratory infection patients.
However, what can be considered moderate exercise Ba Duan Jin exercise consists of eight separate, deli-
differs between individuals, thus the increase in heart cate, and smooth exercise movements, to achieve self-
rate can be a indicator of intensity. Increasing heart psychosomatic regulation and enhance function.
rate by 60%-80% is recommended. Since Ba Duan Jin exercises emphasize body and Qi,
slow body movements along with musculoskeletal
stretching should be combined with physical relaxa-
Recommending Forms of Qigong
tion, deep breathing, and mental concentration.41
Considering the physiological characteristics of the Movements of the whole body can enhance physical
elderly, the pathological features of respiratory dis- well-being. According to TCM theory, stretching the
eases, and the psychosocial factors in the face of the upper limbs, where the lung meridians are, can facili-
COVID-19 epidemic, we recommend Ba Duan Jin, tate Qi moving in the respiratory organs and thereby
Liu Zi Jue, and abdominal breathing. According to promote recovery from respiratory symptoms. Deep,
the research results mentioned above, these three rhythmic breathing along with slow bodily

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movements accompanied by mental focusing fre- the prevention, treatment, and rehabilitation of respi-
quently leads to a state of meditation, which can pro- ratory infections, including COVID-19. The elderly, in
duce a relaxation response and stress reduction. We particular, could benefit from Qigong during the
recommend using Ba Duan Jin for the prevention of ongoing pandemic, for it is easy to practice. Future
COVID-19 and treatment of respiratory symptoms if studies are needed to confirm the effectiveness of
infected, as well as for the management of stress Qigong in this context and to provide more evidence
derived from the pandemic. on this topic.

3. Liu Zi Jue
Liu Zi Jue combines abdominal breathing and AUTHOR CONTRIBUTIONS
pursed lip breathing with uttering six different sounds,
along with corresponding mild-body movements and Albert Yeung: Design of the work; Agreement to be
a calm state of mind. This exercise is easy to learn and accountable for all aspects of the work in ensuring
can be performed in any position including standing that questions related to the accuracy or integrity of
(preferred), sitting, or lying down, since the exercise any part of the work are appropriately investigated
mainly involves mild upper-body movements.42 and resolved.
The type of respiratory pattern of pursed lip Fan Feng: Literature searching; Preparation of the
breathing performed by expiration to produce six dif- manuscript.
ferent sounds (xu, he, hu, si, chui, and xi) is similar to Sylvie Tuchman: Preparation of the manuscript.
the pursed-lips breathing in rehabilitation training for John W. Denninger: Preparation of the manuscript.
COPD patients.43 It can modify rapid shallow breath- Gregory L. Fricchione: Preparation of the manu-
ing patterns and retard the expiratory flow rate. script.
Additionally, the different sounds can produce vibra-
tions with different frequencies, which is commonly
used in neurorehabilitation44 and tension relaxation.45
Research indicates that Liu Zi Jue might help tissue DISCLOSURE
and organs in respiratory recovery through these
Declaration of Interest: Dr. Denninger reports non-
vibrations. Liu Zi Jue is a good choice for people seek-
financial support from Basis/Intel, grants from
ing to recuperate from respiratory dysfunction and
Onyx/Amgen. His declared interests are not related
sequela of COVID-19 infection.
to the submitted work. The other authors report no
conflicts with any product mentioned or concept dis-
cussed in this article. The authors alone are responsi-
CONCLUSIONS
ble for the content and writing of this article.
The available biological and psychological evi- No funding sources were used in preparation of this
dence suggest Qigong may be potentially useful for review.

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