Pickleball has been on my to-do list for several years. It’s a fast moving, engaging sport with welcoming participants who are eager to include new enthusiasts. I enroll in an “Intro to Pickleball” class for a couple of sessions every six months or so. When these classes triggered an old tennis elbow, I invested in a low vibration paddle and never had another bout of tendinitis. But as much as I enjoy these intro classes, I have never felt confident enough in my skills to move into the habit of weekly play with the regulars.
Recently, what I thought was going to be yet another intro class turned out to be a fitness class focusing on specific target areas to improve pickleball play and prevent injury. We stretched, did soft lunges, walked heel to toe along a line, worked on eye/hand coordination with ball bounces on our paddles, made wide springs to each side and got our hearts rate up. Then we practiced playing pickleball together.
Through my Ai Chi practice I have developed good core strength, limberness and balance that were all boons for the Pickleball Fit class, however the ballistic movements and aerobic activities presented unexpected challenges. I realized that this was what was missing from my workouts. In addition to Ai Chi my usual routine includes individual aquatic exercises with buoyant dumb bells and stretch cords, laps with short fins and skateboarding on a kick board, as well as weekly group water aerobics classes, but the next step I needed to take to be an engaged pickleball player had to come on land. After a couple of Pickleball Fit classes, I could already see improvements in my game.
So much of what we do in the water transfers well to our usual activities, but we can’t forget to include activity specific progressions to be better at what we do and have more fun with it.
Who knows? Maybe I’ll even be in a pickleball league one day!
Ai Chi performance factors can be varied for different outcomes. When strength or balance is a focus, the base of support set for Ai Chi performance can be wider or narrower, to challenge balance at varying levels and to promote strengthening.
Here’s a personal case study: Almost nine years ago, someone accidentally backed an electric wheelchair over my foot. It was a little sore and swollen, but I ignored it for months before finally seeking help from an orthopedist. X-rays showed that I had a metatarsal fracture, which was declared “healed” following a couple of months of stabilization in a “moon boot.”
While my bone had knitted together, other tissues were affected that caused minor lingering issues. Over the years, my left foot has bothered me off and on with mild swelling, an occasional feeling of “giving out” when going down steps, and intermittent aching and discomfort. I’ve done some self-foot mobilization and had reflexology treatments, both of which were helpful. I found great relief through a friend’s instruction in MELT Method foot mobility exercises and by changing to more comfortable and supportive footwear. I’ve used stability discs for home exercise (see the April 11, 2020 post, Sequestered Ai Chi). The improvements I’ve made for this nagging minor malady have opened the door to a focused awareness of the persisting weakness of my left foot muscles. As I now do Ai Chi, I am mindful of how my feet feel in the “core position” as I go through the first six Ai Chi postures. Moving to Gathering and Freeing, I decrease the width between my foot positions to challenge to the muscles in my feet and ankles. In moving from a semi-tandem (one foot behind and slightly off to the side) to tandem positioning (one foot directly behind the other), my left foot and ankle muscles are getting a good workout. When I move into the one-leg stances of Accepting with Grace, Rounding and Balancing, I can adjust the stance time on the supporting leg to give a good challenge without overdoing it.
Here’s the “plus” I’ve added to my current water exercise for my foot issues: I warm up with several repetitions on both sides of slow heel lifts, holding the raised position for several seconds, then slowly lowering. I progress to doing heel lifts on one side at a time with the opposite knee raised, noticing the difference between my left and right sides. I can increase the challenges while standing on “tip toes” on one foot by moving my raised right leg forward, to the side and backwards, or by holding this position when water turbulence is present. I can also try to rely less on arm movements and more on my ankle muscles to maintain my balance. Finally, I’ve added swimming laps with a kick board and short fins to strengthen my ankles.
Every situation is unique, requiring a customized approach, but you can address particular needs by adjusting components of Ai Chi practice. Watch for more ideas about this in upcoming blogs…
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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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Darren’s story began in March 2020 when he arrived home from a long day of work as a hospital physical therapist, so exhausted that he fell into bed. He awoke the next morning with fever, shortness of breath, and pain. Recognizing these as COVID-19 symptoms, he isolated himself for 10 days before returning to work. For the next six months, Darren worked at the hospital with lingering fatigue and shortness of breath before finally embarking on a graded exercise program to increase his activity levels. But instead of getting stronger, Darren struggled to walk on his work commute and arrived sweating, short of breath, dizzy, and pale. Then simple activities like showering, walking from the bed to a sofa and even watching tv or reading left him exhausted.
Heather-Elizabeth is a 36-year old corporate trainer who started having a fever and feeling fatigued in April, 2020. Her fever rose to 103F and she developed gastrointestinal issues over the next several weeks. Then she began to have trouble breathing and her blood oxygen levels dropped dangerously low. When advanced COVID-induced pneumonia showed up on X-ray, Heather-Elizabeth was admitted to the hospital and was placed in a medically induced coma on a ventilator for a month. In the process, blood clots formed in her leg and she developed left-sided body weakness with walking difficulties. Now over a year later, she still has a chronic lung condition and experiences chronic pain and mobility issues. She has been diagnosed with type 2 diabetes with visual changes requiring insulin injections several times per day. While she once had an excellent memory, she now posts sticky note reminders everywhere to accommodate for brain fog.
April from Boise, Idaho was young and healthy and had been vaccinated for COVID-19 in January, 2021, but in July she was diagnosed with coronavirus. She was relieved that the course of illness was short, but as time went on she became increasingly fatigued and was unable to do even simple housekeeping tasks without sweating, and her pulse raced to 160 beats per minute. Then muscle and joint pain and dehydration began. The more active she was, the worse she felt the following day.
Darren, Heather-Elizabeth and April’s real-life stories are a sampling of the experiences of the growing number of COVID survivors. These “long haulers” are no longer contagious and test negative for COVID, but experience persisting function-limiting symptoms, uncertainty, and stress.
Studies show that more than one-half of unvaccinated COVID survivors and almost one-fifth of those few who have had vaccine break through experience one or more of a broad array of persisting physical and psychological symptoms, regardless of the severity of their initial illness. Many can only return to work part-time and some cannot work at all. (No data is available yet for the Omicron or future variants-stay tuned, I am following this!) The good news is that physical therapists have the expertise and tools to help guide long haulers along the road to recovery. Furthermore, exercise practitioners who are well-versed in the challenges long haulers face can offer help and hope for medically stable “graduates” of these programs who have lingering symptoms. Collaboration between therapists and community exercise providers can enhance a smooth transition for COVID long haulers from a rehab setting to community-based exercise venues. Community exercise providers need to be aware of the special considerations impacting this population as they work with them in personal training and group situations, to avoid triggering acute symptoms, set backs and relapse.
Please join me and Mary Wykle at the ATRI National Aquatic Therapy Conference in Chicago on April 9, 2022 as we share important information about the transition to safe and effective post-rehab long COVID interventions. Our presentation will highlight the gentle aquatic body mind practice of Ai Chi as a tool for addressing many of the most common persisting sequelae facing individuals with Long COVID.
Ai Chi Day 2021 is nearly upon us, and it promises many valuable presentations to expand knowledge of this practice and to spark ideas for new applications. Since Jun Konno introduced Ai Chi to the world over 2 decades ago aquatic specialists and therapists have successfully shared it with clients with many different issues and in a wide variety of settings. When the 2011 tsunami in Japan left many fearful of water, Jun developed new Ai Chi steps to reestablish comfort in the water. When an aquatic expert in the Netherlands could not find warm water pools where she could share Ai Chi, she developed a faster version that brought many of the same result through a different approach. A pediatric therapist found ways to use Ai Chi to help children with neurological deficits. Other practitioners have brought Ai Chi to wounded warriors suffering from PTSD.
Jun Konno’s gift of Ai Chi has proven to be a very useful tool that can be adapted to many situations, if we look mindfully at the possibilities and do not get caught up in performing it in one particular way. Jun often shared the Japanese proverbial saying: “Willow will not break under weight of snow.” The strong branches of trees can support the weight of snow in winter, but if too much snow accumulates, the branches will break. However, the willow tree does not need to bear as much weight. Its flexible branches are able to bend so that snow falls off, yet they are strong enough to spring back in shape.
Those who have been vaccinated against COVID-19 also seem to be protected against the new variants of coronavirus, (at least for now). However the variants are more aggressive and spread more easily than the original virus, making those who are unvaccinated at a higher risk of contracting it. Even a mild case can lead to long lasting, often debilitating symptoms~ now recorded at a rate of one out of every three who have tested positive for COVID. Ai Chi holds the possibility of addressing many of the most common COVID symptoms, however mindful adaptations are needed to avoid relapses. Both the CDC and the APTA have developed guidelines for assessment and outcome measures for post-COVID syndrome for healthcare professionals, including evidence based tools for fatigue, breathlessness, exercise capacity, balance, pain, functional mobility, cognition and anxiety. The results of these measures will shape the Ai Chi practice for each individual. And a prudent model will be needed for safe and effective general community group applications for extended help once therapy services are exhausted. Once again, however it turns out is how it was meant to be.
Please register at the following link to join ATRI for a very special online Ai Chi Day on Sunday, July 25, in celebration of Jun Konno and Ai Chi: https://ruth-sova-103927.square.site/product/ai-chi-day-2021/452?cs=true&cst=custom
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As a physical therapist, I have found that many clients assume that faster recovery is dependent on longer therapy sessions or more vigorous exercise. This is in fact a myth. The truth is that while there are times when the best results come by pushing limits, there are also times when pacing is the key to success. In Scandinavia this middle ground is referred to as “lagom,” not too much, not too little. With attention to known information about disease processes, health professionals are tasked to listen to and observe their patients to determine that “sweet spot” of lagom for best outcomes.
Our world is now consumed by a novel virus that we are still learning about. We do not have a complete picture of the disease processes involved, but our understanding of it is emerging. Thankfully, an array of relatively quickly developed vaccines have been successful in curtailing the spread and severity of COVID-19, but not before many had contracted it. While more than we ever thought possible have succumbed to it, it is estimated that millions of people worldwide live with the aftermath, experiencing a wide range of persistent mild to debilitating symptoms, even after just a light case of the virus. Long haulers have turned to exercise to combat physical deconditioning and fatigue, with inconsistent responses. An editorial in the May 2021 Journal of Orthopaedic & Sports Physical Therapy was co-authored by researchers and by both those who have experienced long COVID and those with prolonged post-viral symptoms from another multi-system virus, myalgic encephalomyelitis/chronic fatigue syndrome. The article brings home the message of “lagom” to avoid relapses, which may take hours or even days to emerge. Their message is simple:
STOP trying to push your limits. Overexertion may be detrimental to your recovery. REST is your most important management strategy. Do not wait until you feel symptoms to rest. PACE your daily physical and cognitive activities. This is a safe approach to navigate triggers of symptoms.
How do you find that balance of “not too much, not too little?” The Borg Scale of Perceived Exertion is a good tool to find your personal pace (see March 15, 2017 Ai Chi Plus blog post, “Stretch your limits”). Start off by working or doing daily activities at a “fairly light” level (green range), even if it seems too easy. As your endurance improves you will find that what was “fairly light” initially is now very light and you will be able to do a bit more without ill effect. The Borg scale can be applied to everything from length of time out of bed, to walking distance, to exercise regimes~ even to doing Ai Chi steps that challenge core strength, balance, breath, mobility and reduce stress. Pace yourself to find that moving target of lagom.
If you are patient and pace yourself, you will get there!
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We are in the midst of a pandemic, and life has changed for everyone on our planet. The coronavirus is a formidable opponent in a forced game of hide-and-seek, drawing people everywhere into isolation in their own dwellings or behind masks and gloves when they venture out into the quiet outside world. While properly maintained pools are not a coronavirus hazard, the clubs and public pools where people often practice Ai Chi are now all closed because of social distancing concerns. Classes of all kinds are now limited to solo practice, perhaps with an online or pre-recorded instructor’s guidance. There are no group gatherings or conferences. These are strange times. None-the-less at a time when moving about is limited, the goals of Ai Chi practice are more important than ever. We need to maintain core strength, mobility, full breaths, balance and especially to reduce stress. While you may miss out on the benefits of socialization and a water environment during this interval, you can still reap Ai Chi benefits by practicing on land.
The first 5 steps of Ai Chi, contemplating, floating, uplifting, enclosing and enfolding, are done while standing in a “core posture.” Weight is on the forefoot, knees gently bent, low back slightly flattened by pulling in your abdominals, shoulder blades down and in, ears over shoulders. Maintaining this posture throughout these steps causes isometric contraction of the tiny muscles surrounding the spine and the trunk muscles. It’s a real workout! In the water, turbulence adds to the challenge, but if you feel like you need something more, there are ways you can up the game on land by making your base less stable. When you stand on a less firm surface while doing these first 5 steps, your core muscles must work harder, and your balance is challenged. Be sure to wear sturdy shoes and try standing on a rubber mat, a pillow, an inflatable disc, a wobble board, or my favorite challenge, a pair of hard plastic balance and stability discs. These first 5 steps are a great place to start with Ai Chi on land. Two to three repetitions of a few steps may be your Ai Chi practice for a while. When you are ready for more, experiment with the other steps one at a time, first on a firm surface with a counter or stable object to hold onto. Always keep in mind that you won’t be able to move as safely and easily doing Ai Chi on land as you can in the very protective environment of water.
As you practice the Ai Chi steps on land, stretch and turn as far as you can without causing discomfort to any particular problem areas as you focus on mobility. Moving to end ranges is more difficult on land, as you cannot rely on the supportive buoyancy of water to lighten the load on your joints. Pay close attention to how you feel as you move and adjust excursion and the number of repetitions to a reasonable level. You don’t have to do the same number of repetitions for every step. Remember, however it turns out is how it was meant to be~ Ai Chi is YOUR experience, in this moment, not bound by hard and fast rules or numbers. And if you have pain lasting more than a couple of hours after your practice, you’ve gotten a signal that you’ve overdone it! Use your usual means of reducing inflammation and the next time you do Ai Chi don’t move as far or do as many repetitions.
Maintaining the strength and flexibility of your diaphragm and the tiny muscles between your ribs is more important than ever in the face of a respiratory virus. Focus on diaphragmatic breathing during Ai Chi practice and periodically throughout the day, both to maintain good lung mobility and expansion and to stimulate the parasympathetic nervous system to bring stress-relieving calm. Check out your posture to allow for full breaths. Let your tongue rest gently on the roof of your mouth as you breath in through your nose to activate your diaphragm, and concentrate on the pathway that your breath takes to the bottom of your lungs. Let your stomach poof out as your diaphragm drops to make room for your breath. Then relax and give a long exhalation through pursed lips.
And remember the other tools that enhance stress reduction during this tense time~ experience nature as you are able outdoors or virtually if you cannot. Listen to relaxing music ~music that you like that is relatively slow, with consistent volume and a small range of tones… Pray, read poetry, meditate, sing, smile, help others, share kindness… This too shall pass. Nothing lasts forever.
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Ai Chi touches many beneficial areas for good health~ decreasing stress, improving balance, core strengthening, enhancing breathing, increasing joint mobility… but don’t limit your exercise to just Ai Chi! The secret to successful aging is staying active, and it is important to make exercise a part of your everyday life. Choose enjoyable activities that improve large muscle strength, heart health and targeted stretching of tight muscles. I like bike riding, walking, horseback riding, water aerobics and kayaking, so those are fun ways for me to meet some of those needs. I ride my bike instead of driving when I can, and I tend to go for a more distant parking place when I drive. It’s fun to track the number of steps with an activity tracker, and you can even inspire friends by sharing your numbers through technology. I also keep a 10-12# weight and water bar bells nearby for daily use.
Exercise theories have changed a lot over the years. It’s not necessary to spend lots of time dedicated to working out~ the secret to results lies in how you spend your time. Studies show only a 2% gain in muscle strength in doing more than 10-12 repetitions of a strengthening exercise, if you are exercising at a somewhat hard to hard exercise level~ so I typically do 12 curls with my hand weight, which is somewhat hard when I start and hard by the final repetition. If the weight is too light or resistance cords are too stretchy, I lose out on the strengthening benefit. If they are too heavy and I am struggling against the resistance, I risk muscle strain and injury.
What if you want to improve endurance? Decrease your weight to fairly light to somewhat hard and do 23-25 repetitions. By adjusting resistance based on your perceived level of exertion you can work to achieve your personal goals in an efficient and effective way. The Borg Scale of Perceived Exertion is a handy visual chart for determining effort.
What about mobility? In the old days Jane Fonda modeled bouncing at the end of joint ranges to get more mobility. Studies now show that a quick stretch to muscles actually causes a reflex contraction of the muscle~ the opposite of what we want to achieve! But if you hold a stretch for 30 to 60 seconds, you achieve a muscle relaxation effect. So if you want to stretch a muscle, gently move to the end of its range where you feel some tension, hold it there to a count of 30 to 60, then gently release it. I often do this with my hamstrings before doing Ai Chi to enhance the mobility benefits during Accepting with Grace, Rounding and Balancing.
Finally, if you have discomfort after any exercise, use your best method of calming things down~ ice, mild heat, anti-inflammatory medications~ and if pain persists more than 2 hours following exercise, you have done too much. The next time you exercise, pace yourself and decrease the resistance, excursion, range of motion or number of repetitions. Don’t give up exercising if you meet some challenges, but mindfully adapt your approach.
