The paradox of the ritual of Ai Chi

Not long after I was certified as an Ai Chi Trainer, I was excited to share Ai Chi with my friend. As we ended our first session together, my friend asked me, “Am I supposed to feel something?”

Ai Chi is not magic. It is not a cure-all. And while it draws from ancient Asian roots, it is not even a time-honored tradition. It is a ritual, purposely designed to stretch our muscles, our thoughts and our mindfulness, to strengthen our core muscles, our stamina and our perseverance, to broaden breath, awareness and calm and to bring balance and stability to our bodies, our autonomic nervous system and our outlook on life.

Rituals require preparation. Poet Laureate Joy Harjo opens her book POET WARRIOR with a preface appropriately entitled “Prepare” that mirrors aspects of Ai Chi:

Copyright © 2022 by Joy Harjo, from POET WARRIOR by Joy Harjo. W.W. Norton & Company, Inc.

That first earth gift of breathing
Opened your body, these lungs, this heart
Gave birth to the ability to interact
With dreaming
You are a story fed by generations
You carry stories of grief, triumph
Thankfulness and joy
Feel their power as they ascend
Within you
As you walk, run swiftly, even fly
Into infinite possibility

Harjo ponders how different our perspective would be if we learned to listen to the world and the creatures around us with our whole being; listening not just with our ears, but also with our eyes, throat, abdomen, toes… Sometimes I think of seeing with eyes wide open- but it is in stretching all of our senses beyond their normal bounds that we become mindful of our world.

 

My preparation for Ai Chi has evolved to include giving attention to setting the scene for finding calm, as well as including a bit of personal mindfulness practice before participants arrive to put myself in the right mindset. When I share Ai Chi with others, I have grown to realize how important it is to set expectations by providing an explanation of what Ai Chi is and giving an overview of what is to come, while at the same time opening the door for serendipities that Ai Chi practice may bring. I review diaphragmatic breathing and core positioning, then begin time in the water with a mindful walking warm up.

Rituals require regular practice and dedicated attention. The paradox that exists with Ai Chi is that while practicing it in a precise manner over time enhances its benefits, however your Ai Chi practice turns out in the moment for you, is exactly how it was meant to be. We each come to Ai Chi practice with our own constantly updated life stories. You may go through the same motions you have done before, but each time you do Ai Chi is unique, unlike any time you have ever done it before or will ever do it again. And no two people share the same Ai Chi experience, even when doing Ai Chi together. Breathe, dream, listen with your whole being and be open to the infinite possibilities Ai Chi may bring.

 

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Hot off the press…

 

Pierce, MN. Ai Chi for Long COVID: Transitioning to a Post-Rehabilitation Community Program. J Aquat Phys Ther. 2022:30(3):60-64. DOI: 10.1097/PXT.0000000000000019

Abstract

Background: 

As the COVID-19 pandemic continues to impact lives around the world, long COVID symptoms plague a significant number of survivors in their daily lives. Guidelines are available for individualized rehabilitation during acute and subacute phases; however, safe community options are needed for those with lingering symptoms who are transitioning away from formal rehabilitation. A lack of access or resistance to COVID-19 vaccination worldwide, and the emergence of more aggressive coronavirus variants, is predicted to result in many more positive COVID-19 cases and consequentially in more long haulers, increasing the need for community resources.

Discussion: 

Ai Chi is a gentle aquatic body-mind practice employed worldwide by aquatic therapists and trainers to reduce stress, enhance breathing, strengthen core muscles, extend joint range of motion, improve balance, stabilize heart rate, and promote focus and centering. It can address some of the common persisting symptoms in medically stable individuals with long COVID including pain, difficulty breathing, muscle weakness, and stress. While Ai Chi is a promising community aquatic intervention, exercise providers need to be aware of special considerations that may impact this population in community programming, such as postexertional malaise, cardiac impairment, oxygen desaturation, and autonomic nervous system dysfunction when providing exercise programs. Research is needed to validate the effectiveness of Ai Chi with post-rehabilitation COVID long haulers in a community setting.

This would be an ideal research area for physical therapy and occupational therapy students as an educational experience, and would help make the world a better place.

Some important factors to consider:

  1. Participants must be medically stable COVID long haulers. Recruiting could come from Long COVID clinics, Long COVID support groups, or from social media outreach.
  2. A warm water pool (86-93 degrees F) is needed, where participants can work at shoulder depth with slightly flexed knees. Pools that offer an Arthritis Foundation Exercise Program (AFEP) often meet these parameters.
  3. Teaching is typically done on the pool deck for groups by a provider who has been trained in Ai Chi.
  4. Background and practical understanding of specific issues pertinent to this population is key when providing exercise programming, including post-exertional malaise, orthostatic hypotension, cardiac impairment, oxygen desaturation and autonomic nervous system dysfunction.
  5. Depending on the research focus areas, evidence based examination tools such as the DePaul Symptoms Questionnaire screen for post-exertional malaise (DSQ PEM), the Timed Up and Go test (TUG), the 6-minute walk test (6MWT), the Berg Balance Scale (BBS), functional surveys or cognitive tests could be utilized.

Correspondence: Melinda Nygren Pierce, PT, MS, CEEAA, ATRIC mindy@phossil.org

Full article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9665893/

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Dizzy

You may encounter Ai Chi participants who experience dizziness or lightheadedness while doing Ai Chi. As there are many causes for dizziness, some of which are quite serious, it is important for participants to explore the roots of their symptoms with their medical providers. Participants who are cleared for aquatic exercise but still have some issues with dizziness may need to modify their exercise routines to avoid setting off their symptoms. For example, those with vestibular involvement may experience dizziness with the turning postures of “freeing,” “reflecting” and “suspending.” Slowing down or omitting those postures may be a way to avoid triggering symptoms.

Those with orthostatic hypotension, (also known as postural hypotension) have a condition where blood pressure drops with changing body positions, such as moving from sitting to standing. This condition elicits lightheadedness, dizziness or even fainting when blood is not able to travel efficiently throughout the body’s circulatory system. A broad array of issues may cause orthostatic hypotension, but participants need proper diagnosis, treatment and to be medically stable before proceeding with Ai Chi practice.

Even those with orthostatic hypotension that is well controlled on land may experience blood pressure related symptoms as they leave the water, due to changes in hydrostatic pressure. Hydrostatic pressure is the static force of water exerted on the body. The beneficial effects of hydrostatic pressure include decreasing pain and edema, which promotes joint mobility; it assists in release of air during exhalation to enhance breathing. And importantly, it helps decrease blood pooling in the extremities by providing a compression force to increase venous return. When this extra assistance for circulation is suddenly relieved upon leaving the water, blood may pool in the legs resulting in a blood pressure drop, and causing lightheadedness or other blood pressure related symptoms. A staged exit from the water can help assist in a smooth transition from water to land.

Providing a little extra time and thoughtful attention to transitions can bring a rewarding experience to Ai Chi practice for those with dizziness.

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Nothing is new under the sun

We’ve seen it before… A brief illness, a seemingly good recovery, then unexpected symptoms that appear later~ sometimes much later. This is the road for those with long COVID, which can be an extension of symptoms after acute illness or unexpectedly appear up to 6 months after apparent recuperation from COVID. In an earlier posting I mentioned the symptoms experienced by patients I worked with in the 1980’s with post-polio syndrome, which surfaces 15 to 40 years post-acute illness. It’s widely recognized that those who have had chicken pox harbor the virus after they recuperate and are susceptible to getting shingles as adults if they have not gotten a shingles vaccine. A recent Nature Medicine review reveals that latent post-acute infection syndromes (PAIS) follow a wide range of illnesses, including Ebola, Dengue, West Nile virus, Epstein-Barr Virus, Giardia, Borrelia and Q fever, among others. Infectious agents may be viruses, bacteria or parasites. While there is often a long and varied list of complex symptoms across many different body systems, many PAIS manifest with functional limitations, exertion intolerance, severe fatigue and unrestful sleep.

So what do you need to know when you encounter aquatic clients who say they have exertion intolerance or fatigue, regardless of the etiology? Before beginning community exercise, your participants need to be medically stable~ body temperature, blood pressure, heart rate, and blood oxygen (SpO2) levels must all be within normal limits. A resting SpO2 level of 90% or better is recommended by the Royal Dutch Society for Physical Therapy before embarking on an exercise program.

For those who identify fatigue or brain fog as an issue, the 10-item DePaul Symptoms Questionnaire for Post-exertional malaise (DSQ-PEM) is a helpful tool. Those with post-exertional malaise (PEM) can track their own SpO2 levels with a splash-proof pool side finger monitor or a smart watch and stop exercise at 85% SpO2 to avoid reaching the tipping point where they “crash” a couple of days later. The Workwell Foundation recommends daily heart rate tracking, and slowing down when an activity results in more than 15 beats per minute of the weekly average. Laminated copies of the linear Borg Scale of Perceived Exertion are a helpful tool to have on hand to estimate heart rate based on perceived exertion while exercising. With this tool, the heart rate is approximately 10x the exertion level. Those with PEM should work at a maximum of the level that correlates with their average weekly heart rate + 15 bpm, but no more than a moderate exertion level on this scale. For a more accurate reading, breaks can be taken for heart rate tracking with digital devices.

It’s not hard to give space for participants to work with post-exertional malaise during Ai Chi sessions. Simply extend the repetitions for soothing or shifting or add a “holding pattern” of the core stance with arms extended to the sides on the water surface, turning palms up and down for the group while participants who need to check their SpO2 or heart rate do so. Being flexible is all a part of Ai Chi. However it turns out is how it was meant to be…

Check out post-exertional malaise resources available through World Physiotherapy: https://world.physio/sites/default/files/2021-06/WPTD2021-InfoSheet3-Fatigue-and-PESE-Final-A4-v1.pdf

What has been will be again,
what has been done will be done again;
there is nothing new under the sun. Ecclesiastes 1:9

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Overcoming COVID stigmas

In 2020 I started looking for ways to make a difference in the midst of a frightening new pandemic. I read books about the Spanish flu of the last century that took the lives of some in my family tree, and learned that the annual flu shots we have available today stave off the evolving ancestors of that flu, saving the lives of many to this day. There have been historic global illnesses in the distant past, but it is good to remember that we have been through a pandemic just a couple of generations ago and we have learned to build tools to deal with it.

I then took an online contact tracer certification course, but soon sadly found that practicing my new skill would be difficult due to surprising responses on opposite ends of the spectrum. One place where I spend time chose not to provide any opportunities for this job which involves sharing news no one wants to hear, and another only offered full time positions, which was more than I felt I could handle.

Then came the realization that COVID did not end after a couple of weeks of illness for some of the survivors. Part of the population experiences a wild roller coaster ride of a broad array of continuous or intermittent symptoms, impacting their daily lives profoundly. This prompted me to explore the mounting research on the ill-defined phenomena that has been called long COVID, post-acute sequelae of SARS CoV-2 (PASC) or post-COVID syndrome, and I realized that Ai Chi could be helpful in addressing some of the more prominent symptoms. *Look for a manuscript I wrote about this in the December 2022 special COVID edition of the Journal of Aquatic Physical Therapy entitled “Ai Chi for Long COVID: Transitioning to a Post-Rehab Community Program.”

I then proposed a session on community Ai Chi for post-rehab COVID long haulers for an aquatic conference in early 2022, however it did not draw enough interest to hold the class. I then collaborated with an aquatic physical therapist knowledgeable in subacute rehab for long COVID and an aquatic expert in PTSD for a COVID Long Haulers Roundtable discussion at a larger aquatic conference later in the year. We were excited that it brought a high number of attendees from the United States and from around the world for the final class of the conference. They listened attentively and gave positive feedback on our presentations, but there was little discussion on behalf of the participants. Why is there such hesitancy around this topic?

I believe it comes down to a social stigma associated with COVID-19. We all want COVID to just go away, which has resulted in some minimizing its presence and others becoming hyper-vigilant, (a difficult task as best practices for dealing with this brand new virus emerged very slowly over time). The diversity of responses to COVID has made even talking about it a taboo for the majority of people who are tired of a world already filled with conflict. One person in our audience shared with me that she did not want to ask any questions or make comments because she did not want to risk upsetting anyone else.

This stigma is so strong that those who contract COVID worry about others judging them. Will people think they were socially irresponsible, without regard for other people’s health? Will they be villainized or ostracized by acquaintances, friends and family? This can lead to feelings of personal shame and a tendency to hide a positive test or illness from others, or to downplay their experience and not seek help when they need it. And because of this, we can only guess at the true prevalence of COVID or long COVID.

So what can we do in the face of these stigmas, as community aquatic exercise providers? Be aware that these stigmas exist. Set an example by being compassionate, non-judgmental and mindful in your communications with all. Use comforting, inclusive language and avoid terms which could be interpreted as marginalizing. One aquatic provider shared that she feared that her classes would shrink if they were marketed for COVID long haulers. While Long COVID is not a contagious disease that would preclude participation with others, her realization of the impact of this stigma is an important one.

COVID long haulers who want to improve breath, attention and focus, energy levels, strength and balance will find their way to Ai Chi classes, along with those with many other conditions who share these goals. Yes, we need to be aware of and support necessary adaptations for the special needs of each of our clients, but marketing and working from a goal oriented approach rather than a diagnostic one preserves personal privacy and offers protection against stigmatization. And if you find yourself in the midst of a discussion about long COVID, acknowledge the feelings your clients express, listen attentively and feel empowered to correct misconceptions with proven scientific data. Sharing Ai Chi is a gift you can give to everyone.

More information on this important topic is available from The World Health Organization (WHO) in their briefing, “Social Stigma associated with COVID-19.”

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