Active Relaxation in Water Training of coordination, balance and fascial health

Anne Bommer & Johan Lambeck Senior Lecturers Association IATF

www.clinicalaichi.org

History

§ Originated by Jun Konno since 1995 § Designed as an individual preparation for , progressing to Ne § Based on Zen-Shiatsu by Masunaga (stretch meridians) § Combines posture, breathe and relaxation

o Shizuto Masunaga (1977). Zen-Shiatsu: how to harmonize yin and yang for better health.

1 Conceptual map of High intensity aquatic activities

strengthening Cardio fitness

slow fast

Ai Chi

Open loop coordination Relaxation Ballistic movements stretching

Low intensity

2 Urine Bladder

Sacrum movement, centre of balance

Also liver

Gal bladder

3 Also Heart Small intestine/ duodenum

Stretch 1: Lung and large intestines / cabeon Adapted for water >> balancing

4 : Qi sinks in Dantian with large circles, regulation of the central and the peripheral Qi Push a balloon under water

Weizhong Sun, german centre for chinese medicine

5 Concepts

§ Continuity and slowness § Movements must flow, without force § Movement and breath belong together § Repetition: affects energy flow and connective tissue § Pelvic mechanics and alignment are important

How to breathe

§ Breath mechanics • Exhale slowly • Inhale deeply • Hold for a moment • Slow exhalation with pursed lips • Long exhalation pause § Think of the abdomen, should be heavy § Feel your body long and large § Not for ATrelax, more for Ai Chi

§ > at some moment a disconnection between breathing and movement § > but deep breathing is important to activate activity of the n.vagus (Pranayama)

6 General information

§ Water depth at shoulder level § Temperature at 30 – 35 degrees § Work to the point of tension, no pain § Benefits for: • Equilibrium, coordination ,ROM, muscle tension, respiration, and trophotropic effects, mental effects

Contemplating, Floating, Uplifting, Enclosing and Folding (1-5)

§ A symmetrical trunk position with a wide symmetrical stance and a visual fixation point. There is no movement of the center of gravity (COG.) The arms move symmetrically.

7 Soothing and Gathering

§ Soothing (6) • A symmetrical trunk position with a wide symmetrical stance and a visual fixation point. There is no movement of the COG. The arms move asymmetrically. § Gathering (7) • A trunk position as symmetrical as possible in a tandem stance, with a visual fixation point. There is no movement of the COG during the repetitive asymmetrical arm movements.

Freeing and Shifting

§ Freeing (8) • Trunk rotations in tandem stance, with the eyes following the moving hand. The COG changes because of the continuous change of side. The arms move asymmetrically. § Shifting (9) • Rotations between thorax and pelvis with a wide symmetrical stance, while continuously shifting the COG in the coronal plane. The arms move asymmetrically and the eyes follow the moving hand.

8 Accepting, Accepting with grace, Rounding and Balancing (10-13)

§ Accepting • A symmetrical trunk activity in a tandem stance, with continuous shifts of the COG in the sagittal plane. There is a visual fixation point § Accepting with grace and Rounding: • Symmetrical arm movements in unipedal stance where either the front leg or the hind leg is lifted during one breath cycle. There is a visual fixation point. § Balancing: • Symmetrical arm movements in unipedal stance during 3 breath cycles. There is no real visual fixation point.

Halfcircling, Encircling, Surrounding, Nurturing (14-17)

§ Symmetrical arm movements, in accordance with T’ai Chi, in a symmetrical stance with continuous movements of the COG. The eyes follow the hands

9 Flowing, Reflecting, Suspending (18-20)

§ Flowing and Reflecting • Symmetrical arm movements occur while walking laterally, making cross-steps and pivots. A visual fixation point is possible.

§ Suspending • Symmetrical arm movements with a body turn and a floating phase. There are no visual fixation points.

Regulatory conditions:

§ Increase of difficulty from:

§ a symmetrical trunk position to (rotatory) trunk movements. § a static to a dynamic COG. § small hand movements to large reaching movements. § wide support to narrow bases of support. § visual control to non-visual / vestibular control. § symmetrical to asymmetrical arm movements.

10 ICF subcategories

Function level: domain b7 Actvity level: domain d4 Neuromusculoskeletal and movement Mobility related functions

710 mobility of joint functions 4106 shifting the body’s the center of 715 stability of joint functions gravity 720 mobility of bone functions (scapula) 4154 maintaining a standing position 730 muscle power 4452 use of arms: reaching 755 involuntary movement reaction functions 7602 coordination of voluntary movement 7603 supportive functions of the legs 7800 sensation of muscular stiffness 7801 sensation of muscle spasm

In order to use muscle activity for joint function, one needs (to train) functional and structural integrity of connective tissue

Ai Chi: balance strategies non-intentional movements

§ Predictive/preparation § Reactive/correction expected prevention, static unexpected loss mechanisms. Ø Ankle/hip strategies - static mechanisms: Ø Insecurity strategy - stiffening joints Ø Stumble strategies - increase base of sup. Ø Sideways § Counter-weight, dynamic = Supporting and balance reactions reactions that accompany intentional movements

Guccione cs 2001, Bronstein cs 2004, Pijnappels 2005, Rose 2010

11 Ankle strategy Hip strategy Stumble strategy

Bronstein A, et al (2004) Clinical disorders of balance, posture and gait

12 Intentional movements and specific balance

- initiation (go/stop) - maintain weight-bearing during a task - limits of reaching with concentric and eccentric activity - unipedal weight (= stance on 1 leg)

Ai Chi and

§ Resemblances • Breath control • Balance control • Relaxation • Progression / disengagement o Small > large ROM o Symmetry > asymmetry o Decrease base of support • ICF: function, activity and participation

13 Sagittal Rotation Control

Transversal Rotation Control

14 Longitudinal Rotation Control

Therapy

§ Anecdotal cases (+ indirect evidence since 2004) • Lymph drainage after mamma-amputation o `10 years of various therapies, also 4 years of weekly : no effects – Thixotropic effects of connective tissue – Sympathetic effects through (rotational) movements (T2-L3) • Neurodynamic stretch effects § Cohorts • Increase of ventilation parameters in COPD patients (Mooneyham 2000, unpublished) • Increase of balance (BBS) in FMS patients: hungarian physiotherapy thesis 2005)

15 Breast cancer related lymph edema

§ On the basis of clinical experience and early clinical data, practitioners indicate that moderate aerobic exercise that involves trunk and extremity muscle contraction actually assists in breast-cancer related lymph edema (BCRL) volume control. o P.Richley Geigle at the APTA congress 2010 § Aquatic exercise utilizes hydrostatic pressure to reduce residual arm volumes. In addition to the constant hydrostatic pressure, buoyancy allows women to move more freely than on land, creating more muscle pump activity to mobilize lymph fluid

Programme by Richley-Geigle

§ See next slide § In an unpublished cross-over design with a rate of 2/ wk: • Some effects on decreasing volume were found • No adverse effects were registered • Arms felt ‘soft” o Ambroza 2010 o Confirmed by Jamison, 2005

16 Exerciseprotocol for lymphedema Activity Intensity Time Materials Remarks - Warming-up: 1 set, all 7 – 10 min Gradually Core stability, walking directions more expanded materials to chest - Legs increase - Cardio resistance - Arms - Cardio - Functional - Cooling- down Waterdepth: clavicula. Watertemp = 32C. Always diaphrafmatic respiration. Continuous activity of 30 to 40 minutes

Uit: Ambroza & Richley Geigle 2010

Aqua lymphatic therapy 1

§ N=3, 14 months, 1 to 2 times / wk § Postmastectomy with dissection of the glands § Breath ex., slow and rhythmic movements. First the proximal and then the distal joints were involved. Standing till the shoulders in water of 32C0. § Included was a self lymphatic in water § Volume of the arm decreased with 249, 326, 116 ml § Wellbeing and strength increased o Tidar, 2004

17 Aqua lymphatic therapy 2

§ RCT, n = 48: self-management (n=32) vs self- management + ALT: 3 months, 1/wk (n=16) + follow up. § Conclusion : ALT is a safe intervention with high compliance in women with a mild to moderate lymph edema. A sign. direct and an insign. long-term effect on arm volume could be recorded. • > the authors relate this to a low frequency or low adherence to self- management o Tidar, 2010

18 Relation with Clinical Ai Chi

§ Based on the limited evidence, elements of a programme seem to be: • A moderate aerobic programme • Slow and rhythmic movements of trunk and upper extremities • Breathing exercises

• This coincides with some of the basic elements of Clinical Ai Chi

Sympathetic system

19 Neurotension/dynamics

§ Stretching the neuromeningeal tissues: • Nerve roots, dura/pia mater, meningea, neuraxis, nerve sheaths, arachnoidea § Procedures: • ULNT1 – Median nerve • ULNT2 – Median and Radial nerve • ULNT3 – Ulnar nerve • SLR, slump, PKF (passive knee flexion) § “Sliders” would fit in Ai Chi

20 21 Tai Chi

§ Tai Chi emphasizes total body movement, particularly in rotational planes, with gradual narrowing of basis of support o Partly in Ai Chi

§ Tai Chi emphasizes the management of energy, feeling it’s centre (Dantian) with different breathing techniques o Not specifically in Ai Chi

22 Tai Chi

§ Tai Chi promotes confidence (in a fear of falling questionnaire) without reducing postural sway. Wolf SL et al, 1997 § Tai Chi does not improve measures of postural stability in older objects § A 1 year TC programme for patients with low risk coronary artery bypass surgery is effective for enhancing cardio-respiratory function. Lan C, et al. Med Sci Sports Exerc, 1998

Tai Chi

§ In older persons: § Lowers blood pressure before and after 12-minute walk § Fear of falling reduces § Fall risk is reduced by 47.5% § Wolf SL et al. J Am Geriatric Soc, 1996

23 Tai Chi

§ TC is performed in a semi squat position with varying degrees of concentric and eccentric contractions. Moderate work on the musculature of the lower extremities is demanded. TC is also effective to enhance flexibility and endurance when done in a 12 month programme. § Lan C, et al. Med Sci Sports Exerc, 1997.

Tai Chi

§ Decreases the movement force variability of curvi- linear arm movements like pointing, reaching, aiming o Yan JH 1990, J Gerontol § ES of Tai Chi over computerized changes of the COP (centre of pressure) = 0.9

24 Tai Chi

§ TC improves strength, balance and decreases functional limitations, based on self-rating. Compared to e.g. TC is a desirable alternative that provides similar health and social benefits. § Li F, et al. Ann Behav Med, 2001

Tai Chi

§ Cross-sectional: n = 48 / age = 70 ± 5 § 24 Tai Chi for a minimum of 3 years § Vestibular tests and body sway § ss differences § Controls received 4 weeks intensive Tai Chi, also with ss increases in the tests • Tai Chi: proprio better / central representation better? o Tsang et al, Arch Phys Med Rehabil (87) 2006

25 Effects of ‘In Balans’ (T’ai Chi) § Project Free University A’dam 2003-2005 - frail elderly (high fall risk, average 85 year) - 2x/week; - test: POMA (Tinetti) - effects: * 38 % scores higher * controls decrease 5% * reduction of fear not proven, although pp perceive less fear - 1 y after the programme, still a fall reduction of 51%

------= Obstacle course; - - - = Tai Chi; …… = Controls Age 85 y, N = 278, 20 wk, 2/wk Fall incidence decreased with 29% in the Obstacle course group and 45% in the Tai Chi group, but only after 3 months less risk that in the control group. Persons with walking aids have a risk increase initially. Faber M et al, Fysiotherapie & Ouderenzorg 2005

26 Hydro and T’ai Chi in knee OA RCT by M. Fransen, Arthritis & Rheumatism 2007

§ T’ai Chi: = 56, Hydro: n = 55, waiting list controls: n = 41 § Mean age = 70, minimum = 63 y § 12 wk, 2/wk and 12 wk follow up § > adherence hydro better than T’ai Chi § > hydro larger improvements in objective measures of physical performance than TC § > improvements sustained in follow-up

Effect sizes at 12 wk

Hydro vs control TC vs control

WOMAC pain 0.43** ns*

WOMAC function 0.62*** 0.63

SF12 physical 0.34 0.25

TUG 0.76 0.32

16m walking time 0.49 0.36

*: knee pain on land because of T’ai Chi position: semi squat **: recent meta-analysis about graded exercise in knee OA: ES = same range for pain ***: same study: ES physical function (0.23 – 0.39) much lower than here

27 AT and postural balance

§ Chronic stroke > 6 m. § Intervention: Halliwick + Ai Chi (n= 9) § Control: dry bicycle conditioning (n=8) § Design: RCT, 8 wk / 3*wk / 1 hour § Outcomes: • BBS, force plate weight bearing, gait (Modified Motor Assessment Scale), isokinetic strength

o Noh D-K et al, Clinical Rehabilitation 2008

Noh programme

§ Halliwick/Ai Chi (115 cm deep, 34°) • 5 min warming up • 25 min SRC weight transfer, TRC and CRC • 25 min Ai Chi rounding and balancing • 5 min cooling down o * supported by a pt when needed (only first week) § Dry gym • Combination of bicycle ergometer, arm ergometer

28 Rounding

Balancing

P<0.05, sign difference between pre-post and between both groups posttest ES calculated by the authors: BBS = 1.03, forward shifting = 1.14, backward shifting = 0.72 (both on the affected side)

Conclusion: Halliwick and Ai Chi are effective in promoting balance and weight-bearing in people with stroke

29 Noh results 1

BBS Anterior Posteriorw Knee ext MMAS weight eight force bearing bearing

Exp 11%↑ 7% ↑ 12% ↑ 22 %↑ 30 %↑ group

SS SS SS

Controls No Δ No Δ No Δ 5 %↑ 12 %↑

Noh results 2

§ At the end of the programme • backward weight bearing became almost symmetrical (= similar in both legs) • Back extensors increased their strength more than abdominals • Gait pattern also increased (MMAS)

30 CVA – Ai Chi case

o Hartley 2014 JAPT (abstract) § CVA patient: 10 AT + 8 land treatments § AT: Ai Chi, gait, step training, strengthening § Land: balancing and gait § BBS: 44 > 54 = > MCII § 6MWT with cane: 271 m >> 303, = >MCII § self selected speed = 0.77 m/s > no clinical relevant change

Covill 2016

§ Ai Chi vs Impairment based AT (IBAT) § Elderly without primary balance problems, but initial TUG > 14 s and BBS around 43 § IBAT: many walking exercises with much variation

§ Both groups increased but within MCII / MDC § BBS Ai Chi + 2.5 and of IBAT + 4 § TUG Ai Chi – 2 and of IBAT – 1

§ > comparable intervention, low dosis, healthy elderly, intervention not specific enough

31 Elderly

§ Comparison of Ai Chi and Impairment-Based (IBAT) for Older Adults with Balance Problems. Covill et al 2016 § No differences on BBS and TUG: same progression § IBAT: mostly walking exercises § Ai Chi: Sova protocol

32 Santana 2010 CCT of 8 FMS women

§ FMS Impact Questionnaire and pain § 10 times of 40 min Ai Chi § Watertemperature 34 – 36 C

§ No difference between groups § No change of pain in the Ai Chi group § No change of the FIQ in both groups § Controls: no intervention § 100% adherence in the Ai Chi group

The influence of Ai Chi on balance and fear of falling among older adults

Rita Teixeira1, Laura Pérez2, Johan Lambeck3, Francisco Neto4

1Hospital Privado da Trofa, Trofa, Portugal 2Hospital du Jura Bernois, Saint Imier, Switzerland 3Katholieke Universiteit Leuven, Belgium 4FisioNeto, Fisioterapia e Bem-Estar, Póvoa de Varzim, Portugal

33 Materials and Methods Methods § Design • Randomized controlled study, assessor blinded, concealed allocation § Setting • Therapeutic pool in a day care centre in Portugal § Subjects • Home dwelling older people of the Lar la Tranquillidade population, Santo Tirso o Inclusion criteria – Age between 77 and 88 years; – High or medium risk of falling (POMA score between 0 and 24). o Exclusion criteria – Physiotherapy treatment or physical activity practice during the study;

– Absence from the Ai Chi sessions more than 4 sessions. § Statistical analysis • Wilcoxon signed rank test for intra-group comparisons • Mann-Whitney U test for inter-group comparisons

The study was approved by the ethics committee of the Escola Superior de Saúde do Vale do Sousa

Measurements

Outcome measures

1. Tinetti Performance-Oriented Mobility Assessment (POMA) to measure static and dynamic balance capabilities (0 - 28 point scale)

2. Falls Efficacy Scale (FES) to measure fall related self-efficacy (fear of falling), scale: 10 – 100. Higher values correlate with less fear of falling

Time points 0 (pre-intervention) and 6 weeks (post-intervention).

34

1. Sova R., Konno J. Ai Chi – Flowing aquatic energy. Washington: DSL Ltd.; 1996. 1. Sova R., Konno J. Ai Chi – Flowing aquatic energy. Washington: DSL Ltd.; 1996. 2. Hayes1. Sova K.,R., Konno Johnson J. Ai M.. Chi Measures – Flowing ofaquatic adult energy. general Washington: performance DSL tests. Ltd.; 1996. Arthritis Rheum 2003; 2. Hayes K., Johnson M.. Measures of adult general performance tests. Arthritis Rheum 2003; 2.49(S5):S28-S42 Hayes K., Johnson M.. Measures of adult general performance tests. Arthritis Rheum 2003; 49(S5):S28-S42 3. Larsen49(S5):S28-S42 J., Pryce M., Harrison J., Burton D., Geytenbeek J., Howell D. et al. Guidelines for 3. Larsen J., Pryce M., Harrison J., Burton D., Geytenbeek J., Howell D. et al. Guidelines for 3.physiotherapists Larsen J., Pryce working M., Harrison in and/or J., Burton managing D., Geytenbeek hydrotherapy J., pools. Howell Melbourne: D. et al. Guidelines Australian for Physiotherapyphysiotherapists Association; working 2002. in and/or managing hydrotherapy pools. Melbourne: Australian Physiotherapyphysiotherapists Association; working 2002. in and/or managing hydrotherapy pools. Melbourne: Australian Physiotherapy Association; 2002. Interventions

Exercise program

Subjects allocated to the control group did not participate in any exercise program and were asked not to change their usual pattern of activities.

Subjects assigned to the experimental group received 16 Ai Chi sessions in the period of 6 weeks, according to the sequence suggested by Sova and Konno1:

Exercise progression

week frequency Minutes Exercise reps of Ai Chi number 1 2 10 1 - 3 20

2 2 15 1 - 10 15

3 3 20 1 - 10 15

4 3 25 1 - 13 12

5 3 30 1 - 16 10

6 3 30 1 - 16 10

35

1. Sova R., Konno J. Ai Chi – Flowing aquatic energy. Washington: DSL Ltd.; 1996. 1. Sova R., Konno J. Ai Chi – Flowing aquatic energy. Washington: DSL Ltd.; 1996. 2. Hayes1. Sova K.,R., Konno Johnson J. Ai M.. Chi Measures – Flowing ofaquatic adult energy. general Washington: performance DSL tests. Ltd.; 1996. Arthritis Rheum 2003; 2. Hayes K., Johnson M.. Measures of adult general performance tests. Arthritis Rheum 2003; 2.49(S5):S28-S42 Hayes K., Johnson M.. Measures of adult general performance tests. Arthritis Rheum 2003; 49(S5):S28-S42 49(S5):S28-S42 3. Larsen J., Pryce M., Harrison J., Burton D., Geytenbeek J., Howell D. et al. Guidelines for 3. physiotherapists Larsen J., Pryce working M., Harrison in and/or J., Burton managing D., Geytenbeek hydrotherapy J., Howellpools. D.Melbourne: et al. Guidelines Australian for 3. physiotherapists Larsen J., Pryce working M., Harrison in and/or J., Burton managing D., Geytenbeek hydrotherapy J., Howellpools. D.Melbourne: et al. Guidelines Australian for Physiotherapy Association; 2002. Physiotherapyphysiotherapists Association; working 2002. in and/or managing hydrotherapy pools. Melbourne: Australian Physiotherapy Association; 2002. Results

Intragroup p-values Intergroup Intergroup p-values ES (d)

Ai Chi Controls

FES 0.306 0.011* 0.001* 1.5

POMA total 0.001* 0.254 0.002* 1.3

POMA balance 0.001* 0.230 0.001* 1.4

POMA gait 0.001* 0.202 0.004* 1.1

* = significant, α= 0.05

36

1. Sova R., Konno J. Ai Chi – Flowing aquatic energy. Washington: DSL Ltd.; 1996. 1. Sova R., Konno J. Ai Chi – Flowing aquatic energy. Washington: DSL Ltd.; 1996. 2. Hayes1. Sova K.,R., Konno Johnson J. Ai M.. Chi Measures – Flowing ofaquatic adult energy. general Washington: performance DSL tests. Ltd.; 1996. Arthritis Rheum 2003; 2. Hayes K., Johnson M.. Measures of adult general performance tests. Arthritis Rheum 2003; 2.49(S5):S28-S42 Hayes K., Johnson M.. Measures of adult general performance tests. Arthritis Rheum 2003; 49(S5):S28-S42 49(S5):S28-S42 3. Larsen J., Pryce M., Harrison J., Burton D., Geytenbeek J., Howell D. et al. Guidelines for 3. physiotherapists Larsen J., Pryce working M., Harrison in and/or J., Burton managing D., Geytenbeek hydrotherapy J., Howellpools. D.Melbourne: et al. Guidelines Australian for 3. physiotherapists Larsen J., Pryce working M., Harrison in and/or J., Burton managing D., Geytenbeek hydrotherapy J., Howellpools. D.Melbourne: et al. Guidelines Australian for Physiotherapy Association; 2002. Physiotherapyphysiotherapists Association; working 2002. in and/or managing hydrotherapy pools. Melbourne: Australian Physiotherapy Association; 2002. Conclusion

Despite some limitations, findings in this study suggest that an Ai Chi program leads to a clinical relevant increase of balance in older people, but this was not correlated with a decrease in fear of falling

Ai Chi and MS Castro 2011

§ RCT, n=73 with 36 in Ai Chi. Age range 25 – 75 y • Y since diagnosis: about 11. Incl: EDSS < 7.5 / VAS > 4 § 40 sessions / 20 wk, 36º watertemp, 60 min • Ai Chi (16movements) + 10 min relax (breathing +CR) • vs abdominal breathing + contract relax § T1 = 20 wk, § T2 = 24 wk, § T3 = 30 wk

37

1. Sova R., Konno J. Ai Chi – Flowing aquatic energy. Washington: DSL Ltd.; 1996.

2. Hayes K., Johnson M.. Measures of adult general performance tests. Arthritis Rheum 2003; 49(S5):S28-S42

3. Larsen J., Pryce M., Harrison J., Burton D., Geytenbeek J., Howell D. et al. Guidelines for physiotherapists working in and/or managing hydrotherapy pools. Melbourne: Australian Physiotherapy Association; 2002. Castro: results T1 trend to go to baseline at T4

Change Pain VAS MPQ PRI MPQ PPI Roland Morris Spasm VAS MSIS-29 Physical MSIS-29 psychological MFIS physical MFIS cognitive MFIS psychosocial Fatigue severity Beck depression Barthel T0 7 19 2 7 5 48 34 26 23 5 6 14 91

T1 3 12 1 2 2 41 21 14 13 2 3 5 86

T4 5 19 2 3 4 48 24 22 17 3 4 11 89

% 50 40 40 100 91 78 81 48 61 58 39 52 9 T0-T1 ES 1.32 .79 1.19 .94 .47 .27 .23 .76 .73 .77 .35 1.7 .22

Controls

% 23 17 5 12 10 5 37 9 13 26 12 11 2 T0-T1

Ai Chi and MS

§ CCT: n = 11 Ai Chi, n = 7 home exercises § Median EDSS: 1-2 § 8 wk, 60 min 2/wk. Temp = 28º § 30 min Ai Chi; 16 movements § Measurements: • TUG, 6MWT, 1 leg stance, dynamometry, Fatigue Severity Scale

§ Bayraktar D, Guclu-Gunduz A, Yazici G, Lambeck J, Batur-Caglayan HZ, Irkec C, Nazliel B. Effects of Ai-Chi on balance, functional mobility, strength and fatigue in patients with multiple sclerosis: A pilot study. NeuroRehabilitation. 2013;33(3): 431-437

38 Progression

week Always 16 movements 1 3 repetitions 2 3 rep‘s and 1 full tour of 16 movements with 3 rep‘s 3 5 rep‘s 4 5 rep‘s and 1 full tour of 16 movements with 3 rep‘s 5 10 rep‘s 6 10 rep‘s and and 2 full tours of 16 movements with 3 rep‘s 7 20 rep‘s 8 20 rep‘s and and 2 full tours of 16 movements with 3 rep‘s

Median changes in Ai Chi

pre post change % p TUG 6.31 6.21 0.1 sec 1.6 0.028 1 leg 30.6 57.8 26.8 sec 89 0.017 stance 6MWT 485 505 20 m 4 0.05 FSS 50 38 12 24 0.009 Strength 40 59 19 Nm 47 0.019 quadriceps TUG: small changes because of a ceiling effect 6 MWT: the distance might be about the norm value, also a ceiling effect? Strength: various mm of the LE increased strength significantly

Changes in the control group: TUG 5.6%, 1 leg stance 91%, 6MWT 0%, FSS 0.4%, Strength Qceps -3% In red the largest differences between the 2 groups

39 FMS convenience sample

§ This cohort study showed that patients preference plays an important role in outcomes like the FIQ and the VAS for pain. § Effects were better that in a randomized Spanish study by Soares et al (2010)

• Pérez-De la Cruz S, Lambeck J. Efectos de un programa de Ai Chi acuático en pacientes con fibromyalgia. Estudio piloto. Rev Neurol 2014; 59 (x): X (accepted for publication).

FMS 5 cases

o Gangaway 2014 (abstract) § 8 weeks 2/wk, 45 min Ai Chi § ABA design multiple baseline incl follow up § Pain-VAS § Functionin- FIQ § 6 MWT § postural sway

§ > all subjects improved physical function and severity of FM symptoms

40 FMS stress response

§ Kelly & Loy 2008: n= 3 time series § Ai Chi – land treadmill – usual care § Measure: salivary cortisol § Treadmill showed the largest cortisol reduction

Olabe Sanchez 2013

§ 14 consecutive days of Ai Chi in a spa § 54 elderly (60-85 y). controls: regular spa therapy § TUG, finger-floor distance, VAS pain

41 Pelloso 2014: Parkinson

§ CT n= 15 total H&Y 2 and 3, MMSE >24 § Mesuring: • UPDRS: 38 > 23 with esp the ADL domain changing • PDQ > P disease questionnaire, QoL, ns changes • Postural assessment with photo comparison, no change § Programme: contemplating – accepting. 5 rep’s, 35 min, 2/wk. 12 wk

March 2016

Session: 10 weeks , 2/wk, 45 minutes (Ai Chi 30 min) in 30 degrees N= 15, H&Y 1-3 Ai Chi: 19 movements always, also warmup/cool down: game/relax ES TUG T0-T2 = 0.88 > T2 is 1 month after treatment ES POMA balance T0-T2 = 0.55

42 Systematic review

Macías-Hernández 2015: Ai Chi in musculoskeletal diseases

Kurt 2017 PD

§ RCT n= 40, H&Y 2/3. 5wk, 5/wk, 60 min § Ai Chi: 16 kata’s: 30 min ai chi + 30 wu and cd § Land: many ex incl stand/gait with foam, reaching § All pp increased ss, but also a ss diff between both

§ BBS: ES 0.3, but MDC at 80% CI (4.4): clinical sign § QoL/PDQ-39: ES 0.6 § TUG: ES 1.04 (change land 1 s and ai chi 5 sec) § UPDRS: no clinical sinificantg changes

43 Case: patient with RA since 7 y + secondary OA

§ 3 mo after hospitalization (excacerbation) § Pain in LE joints: VAS = 4 to 6/10 § General stiffness: VAS = 4/10 § LE joints: decreased ROM to capsular signs § Strength LE: MRC = 4 in general § WOMAC: • Physical function = 43/68 • Pain = 10/20 • Stiffness = 4/5

Case 2

§ FR = 20 cm and TUG = 25 sec § Astrand: 16 ml/kg ffm (norm = 31) § Coping behavior is good

44 Justification

§ Sessions progress to 20 minutes as a low level

fitness “workout” at 40% VO2max or RPE 11/20 (some effort but not enough to speed up breathing) following the ACSM guidelines for arthritic patients. Muscular endurance fits training recommendations to achieve a high amount of repetitions with a low external load. The slow movements adequately address the connective tissue stiffness. The frequent change of the COG without using hands to additionally stabilize posture along with adaptations to decrease the base of support follow recommendations on balance training.

§ Objectives:

• increase ROM of the lower extremities • decrease the (sensation) of stiffness and pain • increase general muscle power of the lower extremities • increase muscle endurance of the LE • be able to change the COG while standing increasing her supportive leg • work on balancing and stabilising reactions during gait training • increase aerobic capacity • let her enjoy achievement of pain free movements

45 Week Exercise number Minutes Ai Chi Reps’s per kata

1 6 - 9 8 3

2 10 - 14 8 3

3 6 - 14 15 3

4 6 - 14 15 4, with challenging variations 5 6 - 14 20 4, with challenging variations

Breathing

§ Breathing is an important topic in the classical Ai Chi. Breathing techniques from various concepts can be included to focus on different kinds of inhalation and / or exhalation. § Finally, abdominal and diaphragmatic breathing will be most appropriate and are combined with proper positioning of the entire spine, also including the head. § Breathing means that the underwater-volume is changing constantly and that small movements of the centre of buoyancy and also the centre of gravity will facilitate small postural adaptations (non-intentional ankle strategies). § These movements may enhance proprioceptive awareness, in general a basis for concentration and relaxation.

46 Change centre of gravity (COG)

§ Being able to transfer weight – which is changing the COG – in all directions adds to reduce falling: during the regular kata’s no static moments are visualized. § Especially in the first six kata’s, the COG doesn’t move, but medio-lateral weight-transfer during the arm movements can easily be included. § These six kata’s are: contemplating, floating, uplifting, enclosing, folding and soothing. Also gathering in general doesn’t include a weight transfer, but changes of the COG can be included as well

47 Reaching

§ Reaching and maintaining a position at the end of a range of motion is an important ability in activities of daily living. § When postural control is impaired, both the functional reach in distance and the time in the end position are decreased. § It makes sense to stimulate clients to perform all kata’s with a reaching element as broad as possible and search the ‘comfortable limits of reaching”.

48 Stay in the end-position

§ kata’s can be performed in the end-positions instead of positions “in centre”. § Reaching and maintaining an end-position is not a static process. § In an end-position, one moves arms (and manipulates). § This is dynamic and can be shown better with videoclips

Thoracic spine

§ We assume that both direct articular and segmental effects will be elicited by these kata’s. § A part of the physiological background is explained in “Clinical Ai Chi connective tissue”. § In the classical kata’s, accents can be included on specific movement directions like thoracic extension or scapula retraction.

49 Narrow base

§ Normally Ai Chi is performed in a comfortable wide base, especially in the early part of the programme. § In order to challenge the medio-lateral stability, the base of support should be narrow. Exercising with a narrow base is one of the important characteristics of any fall prevention programme. § The pictures show the narrow base of both feet together or in a small tandem stance. § Also all kata’s with in a long stride position or in a unipedal stance belong to these narrow base kata’s

50 Metacentric effects

§ Buoyancy forces and gravity forces form a force couple with a vector. This results in a torque (rotational moment), which influences the balance position. § These metacentric effects are provoked on purpose by e.g. lifting body parts out of the water. The torques are used therapeutically in different ways: they have to be counteracted or on the contrary, they have to be allowed and followed by the patient. § By allowing the torques, joints and connective tissue will be mobilized. By preventing torques, patients will muscular stabilize (with isometric contractions) or strengthen (with isotonic concentric or isotonic eccentric contractions).The same principles van be used in Clinical Ai Chi: challenging balance by controlling the variable torques during the arm movements.

51 Other topics

§ Closing eyes can be a way to force the vestibular and somatosensory and systems to increase their activity. This depends on e.g. possibilities to train the vestibular system and/or inclusion of certain head movements. § Walking: Classical Ai Chi includes some lateral steps, these can be altered to make these fitting for e.g. Parkinson and also forward-backward walking ould be included

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