Effects of Chinese traditional ethnic sports on sleep quality among the elderly: a systematic review and meta-analysis

Introduction

As the global population continues to age, the prevalence of sleep disorders among the elderly is increasing, posing a significant public health challenge (Pappas & Miner, 2022; Wolkove et al., 2007). By 2050, it is estimated that individuals aged 60 and older will account for more than one-third of the world’s population (Grigsby & Olshansky, 1989). For older adults, maintaining good sleep quality is essential for preserving overall health and ensuring a high quality of life (Nelson, Davis & Corbett, 2022). Chronic sleep deprivation has been associated with a higher risk of numerous health issues, such as cardiovascular disease, diabetes, cognitive decline, and emotional disorders (Gulia & Kumar, 2018; Ma et al., 2020; Tian & Li, 2017). Addressing sleep disorders and enhancing sleep quality in the elderly has become a key focus in geriatric research. Historically, the treatment of sleep disorders has been primarily reliant on pharmacological interventions. However, conventional pharmacotherapy often presents challenges for older adults due to increased medication tolerance and heightened susceptibility to adverse side effects (Fatemeh et al., 2022; Schroeck et al., 2016). Consequently, there has been a growing interest in non-pharmacological approaches, which are now considered preferable for managing sleep disorders in this population.

With the increasing cultural exchange between China and other countries, Chinese traditional ethnic sports have garnered significant attention, especially for their potential health benefits. These sports, including Taijiquan, Wushu, and Qigong, are gaining popularity globally, with more international competitions and demonstrations emerging (Vergeer et al., 2017). Taijiquan is a traditional Chinese martial art characterized by slow, deliberate, and fluid movements that emphasize balance, relaxation, and controlled breathing. It involves a series of postures performed in a flowing sequence designed to improve flexibility, strength, and mental focus. Practitioners are encouraged to maintain a calm and mindful state, aligning their movements with deep abdominal breathing to enhance the body’s energy flow (Qi). Qigong is another traditional Chinese practice that combines movement, breathing techniques, and meditation to cultivate and balance the body’s vital energy, or “Qi”. It consists of various exercises, ranging from gentle movements to more static postures, all emphasizing slow, controlled breathing patterns. Qigong practices aim to harmonize the body and mind, alleviate stress, and promote relaxation.

Given that sleep disturbances are common among older adults and can profoundly impact health, well-being, and quality of life, understanding effective interventions is crucial. Recent studies have begun to investigate the effects of these traditional sports on sleep patterns among older individuals. Chinese traditional ethnic sports, deeply rooted in Chinese culture and characterized by their unique movement styles and philosophies, encompass a wide array of practices, such as Taijiquan and Qigong. These practices emphasize the integration of mind and body through coordinated breathing, posture, and movement, offering a holistic approach that is believed to benefit both physical and mental health.

However, the evidence regarding the impact of Chinese traditional ethnic sports on sleep in older adults remains inconsistent (Chan et al., 2014; Jahnke, Larkey & Rogers, 2010). While some studies suggest that these practices significantly improve sleep quality, reduce the prevalence of sleep disorders, and enhance both the satisfaction and sustainability of sleep, other studies failed to observe significant improvements. Given these discrepancies, this review seeks to comprehensively assess the impact of Chinese traditional ethnic sports on sleep quality in older adults (aged 55 years and above) and identify potential influencing factors. The findings aim to provide a scientific basis and theoretical support for promoting sleep health among older adults through these traditional practices.

Material and methods

The review was conducted in accordance with the PRISMA 2020 guidelines, an internationally recognized framework for systematic reviews, data inclusion, and statistical analysis (Page et al., 2021). This review was also registered with the PROSPERO International Registry of Systematic Evaluations (http://www.crd.york.ac.uk/PROSPERO/) (CRD42024548910).

Results

Literature search results

A comprehensive search of seven major electronic databases, including WOS, PubMed, Embase, Cochrane, CNKI, Wanfang, and VIP, yielded a total of 839 documents. After importing these into Endnote and removing 144 duplicates, 695 unique papers remained for initial screening based on their titles and abstracts. During the initial screening, 639 documents were manually excluded, leaving 56 papers for further evaluation. Of these, three articles could not be retrieved, resulting in 53 articles for re-screening using the predefined inclusion and exclusion criteria. In this phase, 44 articles were excluded for the following reasons: eight articles lacked sufficient data for extraction, 18 articles showed inconsistency in outcome indicators, 12 articles were non-RCTs, five articles were master’s theses, and one article had inconsistencies in the intervention content. Ultimately, nine articles met the inclusion criteria. An additional article was manually identified, bringing the total to ten articles included in the final review (Chen et al., 2012; Fan et al., 2020; Hosseini et al., 2011; Irwin et al., 2014; Irwin, Olmstead & Motivala, 2008; Li et al., 2004; Nguyen & Kruse, 2012; Siu et al., 2021; Wang et al., 2024; Wang, Li & Bi, 2019). The literature screening process is visually summarized in Fig. 1.

Quality evaluation of the included literature

The studies included in this review were all RCTs, each providing clear descriptions of their study designs and the characteristics of the participants involved. All articles reported robust data without evidence of selective reporting. However, only four studies achieved allocation concealment and researcher blinding, while assessor blinding was reported in three articles. Additionally, one article exhibited other potential biases. These findings are summarized in Fig. 2.

Meta-analysis

Meta-analysis of the total PSQI score

All ten articles included in this analysis reported the total PSQI scores, revealing significant heterogeneity among studies (I² = 78.71%, P < 0.1). The meta-analysis demonstrated a significant improvement in sleep quality associated with traditional Chinese ethnic sports among older adults (Hedges’s g = −0.60, 95% CI (−0.89, −0.31), P < 0.05). The Egger test indicated no significant publication bias (Z = 0.51, P > |z| = 0.6086). Detailed results are shown in Figs. 3 and 4.

To investigate the factors influencing the effects of traditional Chinese ethnic sports on the total PSQI scores, subgroup analyses were conducted based on intervention modes, intervention time, intervention period, and participant type.

The intervention modality did not show a moderating effect on the total PSQI score (P = 0.136). However, both modalities, ‘Fitness Qigong’ and ‘Taijiquan’, demonstrated statistically significant effects, with the effect size Hedges’s g = −0.925 (P < 0.001) for the ‘Fitness Qigong’ group, and Hedges’s g = −0.476 (P = 0.006) for the ‘Taijiquan’ group.

There was no moderating effect of intervention time on the total PSQI score (P = 0.581). Duration was categorized into ‘0–45 minutes’ and ‘46–120 minutes’ groups. Both groups showed significant effects, with Hedges’ g = −0.526 (P = 0.030) for the ‘0–45 minutes’ group and Hedges’s g = −0.693 (P < 0.001) for the ‘46–120 minutes’ group. Similarly, there was no moderating effect of intervention period on the total PSQI score (P = 0.296). Periods were categorized into ‘13–36 weeks’ and ‘8–12 weeks’. A significant effect was observed only for the ‘8–12 weeks’ group, with Hedges’ g = −0.749 (P < 0.001).

The type of participant (e.g., normal older adults vs. insomniac older adults) did not moderate the total PSQI score (P = 0.388). Significant effects were found in both groups, with Hedges’s g = −0.455 (P = 0.018) for the ‘insomniac elderly’ group and Hedges’s g = −0.702 (P = 0.001) for the ‘normal elderly’ group. Table 2 shows a detailed breakdown of the results.

Table 2:

Subgroup analysis table PSQI total score.

Moderator variable	N	I2	Hedges ’g, 95% CI	P	P value between groups
Intervention mode					0.136
Fitness Qigong	3	71.63%	−0.925 (−1.405, −0.445)	0.000
Taijiquan	7	78.86%	−0.476 (−0.818, −0.133)	0.006
Intervention time					0.581
0–45 min	5	83.32%	−0.526 (−1.000, −0.051)	0.030
46–120 min	5	73.41%	−0.693 (−1.050, −0.336)	0.000
Intervention cycle					0.296
13–36 Weeks	4	87.11%	−0.427 (−0.957, 0.103)	0.114
8–12 Weeks	6	58.24%	−0.749 (−1.041, −0.457)	0.000
Types of elderly					0.388
Insomnia elderly	4	71.55%	−0.455 (−0.830, −0.079)	0.018
Normal elderly	7	81.51%	−0.702 (−1.118, −0.285)	0.001

DOI: 10.7717/peerj.19019/table-2

Meta-analysis of sleep quality

Four studies reported data on sleep quality. However, there was significant heterogeneity among the included studies (I² = 94.30%, P < 0.1), necessitating the use of a random-effects model for the combined analysis. The meta-analysis revealed that traditional Chinese ethnic sports had a significant and pronounced effect on improving the subjective sleep quality of older individuals compared to the control group (Hedges’s g = −1.06,95% CI [−2.00 to −0.13], P < 0.05) (Fig. 5A).

Meta-analysis of sleep onset

Six studies reported data on sleep onset. Due to the high heterogeneity in the included studies (I² = 89.83%, P < 0.1), a random-effects model was used for the combined analyses. The results showed that Chinese traditional ethnic sports did not have a statistically significant effect on reducing sleep onset in older adults compared with the control group (Hedges’s g = −0.40, 95% CI [−0.93–0.13], P > 0.05) (Fig. 5B).

Meta-analysis of sleep duration

Six studies reported data on sleep duration. With considerable heterogeneity in the included studies (I² = 77.19%, P < 0.1), a random-effects model was applied. The results of the meta-analysis showed that Chinese traditional ethnic sports had a significant positive effect on prolonging the sleep duration of older adults compared to the control group (Hedges’s g = −0.52, 95% CI [−0.87 to −0.17], P < 0.05). As fewer than ten studies were included, Egger’s test for publication bias was not conducted (Fig. 5C).

Meta-analysis of sleep efficiency

Six studies reported data on sleep efficiency. Due to the statistical heterogeneity in the included studies (I² = 71.28%, P < 0.1), a random-effects model was used for the combined analyses. The results of the meta-analysis revealed that Chinese traditional ethnic sports significantly improved sleep efficiency in older adults compared to the control group (Hedges’s g = −0.50, 95% CI [−0.81 to −0.18], P < 0.05) (Fig. 5D).

Meta-analysis of sleep disturbance

Four studies reported data on sleep disturbance. Due to moderate heterogeneity among the included studies (I² = 56.92%, P < 0.01), a random-effects model was used for the combined analysis. The meta-analysis showed that Chinese traditional ethnic sports did not have a significant effect on reducing sleep disturbance among older adults compared to the control group (Hedges’s g = −0.22, 95% CI [−0.54–0.10], P > 0.05) (Fig. 5E).

Meta-analysis of the usage of sleep medicine

Four studies reported data on the use of sleep medications. As no heterogeneity was observed among these studies (I² = 0.00%, P > 0.1), a fixed-effects model was used for combined analyses. The results of the meta-analysis revealed a significant reduction in the use of sleep medication among older adults in the intervention group compared to the control group (Hedges’s g = −0.24, 95% CI [−0.44 to −0.03], P < 0.05) (Fig. 5F).

Meta-analysis of daytime dysfunction

Four studies reported data on daytime dysfunction. Due to high heterogeneity among the included studies (I² = 90.34%, P < 0.1), a random-effects model was used for the combined analyses. The results of the meta-analysis showed that Chinese traditional ethnic sports did not have a significant effect on reducing daytime dysfunction in older adults compared to the control group (Hedges’s g = −0.35, 95% CI [−1.04–0.34], P > 0.05) (Fig. 5G).

Discussion

The review consolidates evidence that can guide healthcare practitioners in selecting and recommending interventions that can improve sleep outcomes among the elderly. This review indicates that Chinese traditional ethnic sports can improve the overall sleep conditions of older adults, enhancing sleep quality, increasing sleep duration, and improving sleep efficiency. These findings are consistent with previous studies (Liu et al., 2023; Saeed, Cunningham & Bloch, 2019; Yilmaz Gokmen et al., 2019). Numerous studies have highlighted a positive correlation between moderate physical activity and sleep quality. Regular exercise has been shown to regulate the biological clock, reduce sleep onset latency, and increase both the duration and depth of sleep (Bisson, Robinson & Lachman, 2019). Although aerobic exercise and strength training are also effective in improving sleep, low-intensity balance and flexibility training, such as tai chi, may be particularly beneficial for some older adults whose physical functions are gradually declining (Takemura et al., 2024). In addition to physical benefits, positive thinking meditation has been found to alleviate psychological problems such as anxiety and depression, thereby improving sleep quality by promoting mindfulness and reducing inner turmoil (Black et al., 2015). Traditional Chinese ethnic sports, as an effective intervention, can enhance sleep quality in older adults through various interrelated mechanisms, often overlapping with the effects of other physical and mental health interventions. The improvement in sleep quality through traditional Chinese ethnic sports can be explained from several perspectives. Firstly, Tai Chi increases physical activity levels, leading to higher energy expenditure and consequently, better sleep quality. Secondly, it helps alleviate negative emotions, such as anxiety, depression, and other mental health issues, which are often significant disruptors of sleep. Thirdly, Tai Chi and Qigong enhance physical stability and coordination, reducing nocturnal restlessness and promoting deeper, more restful sleep (Rogers, Larkey & Keller, 2009). Fourthly, these practices facilitate a balance between the sympathetic and parasympathetic nervous systems, promoting relaxation and an overall state of calmness (Chang et al., 2019; Yang et al., 2007). Lastly, regular participation in these exercises helps regulate the biological clock of older adults, making it easier to fall asleep and maintain a consistent sleep schedule (Jahnke et al., 2010).

The present review has identified a significant finding that traditional Chinese ethnic sports are effective in reducing dependence on hypnotic medication. This finding contrasts with the results of a previous study by Chan et al. (2016), which found no significant changes in the frequency of sleep medication use among older adults practicing Tai Chi and Qigong. However, it is important to note that Chan et al. (2016) included older adults with cognitive impairment and excluded those on medications, whereas the present review focused exclusively on older adults without underlying health conditions, including those both using and not using sleeping medications. This difference in participant selection may account for the discrepancies observed between the two studies.

Furthermore, this review found that traditional Chinese ethnic sports did not have a significant impact on sleep onset or daytime dysfunction in older adults. This finding contradicts findings from a study by Wu et al. (2021), which reviewed 22 RCTs on the effects of Chinese traditional ethnic sports and aerobic exercise on sleep quality in older adults. Wu et al.’s results suggested that Tai Chi and Qigong significantly improved sleep latency. Additionally, our findings differ from those of Li et al. (2004), who randomized participants to either Tai Chi or low-impact exercise, with one 60-minute session three times per week for 24 weeks. Li et al. reported that exercise, specifically Tai Chi, was associated with a reduction in daytime sleepiness. It is worth noting, however, that both of these previous studies specifically targeted older adults with sleep disorders, while our study included both older adults with sleep disorders and those without. Therefore, the differences in participant characteristics such as age, health status, or baseline sleep conditions, could affect the outcomes of the intervention. Additionally, variations in the duration of the intervention or intensity of participation might influence the effectiveness of traditional sports in improving sleep. These discrepancies highlight the importance of considering such factors when interpreting the results and suggest that further research, with standardized protocols, is needed to clarify the true impact of traditional ethnic sports on sleep.

Subgroup analyses of the total PSQI scores in this review highlight that both Taijiquan and Qigong are effective interventions for improving sleep quality in older adults. The gentle, slow, smooth, and continuous movements of Taijiquan contribute to enhancing muscle strength, coordination, flexibility, and balance in older adults. Additionally, the focus on breathing and mindfulness during practice (Huang et al., 2022) has been shown to significantly reduce stress and anxiety levels (Liu et al., 2020). This reduction in psychological stress plays a crucial role in alleviating sleep disturbances, such as difficulty falling asleep.

Similarly, Qigong emphasizes mental calmness and, through regulated breathing and deep relaxation, helps to balance the activities of the sympathetic and parasympathetic nervous systems. This balance induces a deeper state of physical relaxation, thereby preparing the body for sleep (Koh, 1982). The current study found that both shorter intervention times (0–45 min) and longer sessions (46–120 min) were effective in enhancing sleep quality in older adults. Taijiquan and Qigong, as forms of gentle physical and mental exercises, are not strictly dependent on session duration to yield improvements in sleep quality. Both short and longer practice sessions offer physical and mental benefits that positively influence sleep. Even brief sessions can help relax the body and alleviate physical pain and discomfort, a common factor affecting sleep quality in older adults (You et al., 2018). This flexibility and adaptability underscore the suitability of traditional Chinese exercises like Taijiquan and Qigong for older adults, making them ideal interventions for enhancing overall well-being.

Our analysis also revealed that intervention periods of 8–12 weeks effectively improved sleep quality, efficiency, and the total PSQI scores, while a longer training period of 13–16 weeks only significantly affected sleep duration. A shorter intervention period, compared to the extended periods of 13–36 weeks, may help reduce feelings of slackness and anxiety, making it easier for participants to maintain motivation. The 8–12 week duration appears sufficient for older adults to become familiar with the movements, master the techniques, and establish a consistent exercise routine. During this period, older adults are likely to remain more dedicated to their training, leading to greater effectiveness. In contrast, longer training periods may induce fatigue and stress, diminishing motivation and potentially reducing the overall impact of the intervention. Moreover, compared to older adults with insomnia, those without sleep disorders tend to have better health and adaptive capacity, making them more likely to benefit from traditional Chinese ethnic sports. In contrast, older adults with insomnia may require a more individualized and comprehensive combination of interventions to achieve optimal results.

Only four of the included studies achieved both allocation concealment and researcher blinding, while assessor blinding was present in only three studies. Furthermore, one study exhibited other potential biases, which may further influence the interpretation of its results. When allocation concealment is not properly implemented, there is a risk that the treatment groups may be imbalanced, leading to skewed or unreliable results. Additionally, the absence of researcher blinding in most studies introduces the possibility that outcomes could be influenced by the researcher’s knowledge of the treatment group, affecting their judgment and behavior. Despite the use of the Cochrane risk of bias tool, these methodological issues suggest that the findings of the studies may not fully reflect the true treatment effects. Future research should prioritize the implementation of these critical methodological safeguards to enhance the validity and generalizability of the findings. The GRADE assesment suggested low quality evidence for some key outcomes. To improve the quality of evidence in future research, several strategies can be employed. First, increasing the sample size and ensuring diverse participant inclusion can enhance the generalizability of findings. Second, ensuring rigorous methodological standards, such as consistent allocation concealment, blinding, and minimization of potential biases, will strengthen internal validity. Third, using standardized outcome measures and conducting long-term follow-up assessments can provide more reliable and comprehensive data. Lastly, conducting well-designed multicenter trials and adhering to reporting guidelines like CONSORT will help improve the transparency and reproducibility of results.

Furthermore, significant heterogeneity (e.g., I² > 70% in some analyses) is observed. As indicated in Table 1, several factors may contribute to the significant heterogeneity observed in the analyses, including differences in the countries where the studies were conducted, participant age, and population characteristics. Additionally, variations in the intervention modes, intervention duration, frequency of intervention, intervention cycles, and the content of the control groups across the ten studies could all play a role in the observed heterogeneity. However, the results of this review underwent sensitivity analyses to assess their reliability. The findings showed that the literature used to assess the total PSQI score and sleep quality fell within the confidence intervals, indicating that the results can be considered trustworthy. However, heterogeneity was observed in sleep duration and sleep efficiency, as derived from Siu et al. (2021). Upon removing these articles from Siu et al. (2021) and re-analyzing the data, the heterogeneity in sleep duration decreased significantly (I² = 67.38%, P < 0.1). It is important to note that Siu et al. (2021) primarily focused on older adults with moderate sleep disturbances who had not yet reached the threshold for diagnosable insomnia. This inclusion criterion may have introduced bias, as it combined older adults without insomnia disorders with those who had insomnia in both the intervention and control groups. Furthermore, the primary outcome variable in this study was self-assessed sleep quality, which should be considered when interpreting the results.

Study strengths and limitations

Conclusion

Existing evidence suggests that traditional Chinese ethnic sports may have significant potential to improve sleep quality in older adults. However, the current understanding of these effects remains limited, and the available data is not yet comprehensive or entirely reliable. Future research should delve deeper into the relationship between different forms of ethnic sports and sleep quality through more rigorous RCTs. In addition, personalized and targeted intervention programs, tailored to individual differences and needs, should be developed. By integrating the promotion of traditional Chinese ethnic sports with strategies to improve sleep, the overall quality of life for older adults can be enhanced. These activities can be promoted through community centers, senior living facilities, or local health programs as part of a holistic approach to enhancing well-being. Health professionals can collaborate with local organizations to design culturally relevant and accessible exercise routines that cater to older adults’ unique physical abilities and health conditions.

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