When Jun Konno developed the practice of Ai Chi, one of his primary mantras was, “However it turns out is how it was meant to be.” No two Ai Chi experiences are the same, whether done by two people at the same time or the same person at different times. Sometimes I will be drawn to do extra repetitions of certain postures, and sometimes I will skip a posture that does not feel right at the time. Ai Chi can be done to a variety of genres of music, to poetry, or to meditative mantras and visualization prompts. It is all good.
Taking this concept another step, Ai Chi practitioners have offered variations to allow for practice to a wider audience. A focus on breath, range of motion and mindfulness are presented in Ai Chi introductory classes. Katrien Lemahieu has gifted the world with Ai Chi in Three, a faster paced version of Ai Chi that works well in cooler water and establishes calm and stress reduction by finding flow. Nachiko Onuki teaches Power Ai Chi with intensity progressions, rhythmic breathing and strength training based on Ai Chi protocols. Ashley Bishop teaches a land version of Ai Chi that incorporates dance techniques for situations where water practice is not preferable or possible. Donna Lewen has customized an Ai Chi practice for those with post-traumatic stress disorder (PTSD). Clinical Ai Chi allows therapists to customize Ai Chi for the rehabilitation needs of their patients. And I have suggested guidelines for doing Ai Chi with those who are dealing with symptoms experienced with long COVID, chronic fatigue syndrome and myalgic encephalomyelitis.
Many of these Ai Chi variations will be highlighted at the AEA International Aquatic Fitness and Therapy Conference (IAFTC) at the Sanibel Harbour Marriott in Fort Myers, FL (USA) May 7-11, 2024. Aquatic fitness practitioners and aquatic rehab professionals will be gathering to collaborate and learn through a wide variety of classes and events. There is still time to register for this enriching biennial event. I hope to see some of you there!
Ai Chi Day is nearly here! Join us online on Sunday, July 23. The schedule is chocked full of a great variety of 10 minute Ai Chi presentations, with presenters from around the world.
I will be speaking about adapting your Ai Chi practice for those with persisting COVID issues- much of which pertains to those with other post-viral symptoms, myalgic encephalopathy and chronic fatigue syndrome as well.
Don’t miss this potpourri Ai Chi information! There is something for everyone!
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:
Participants must be medically stable COVID long haulers. Recruiting could come from Long COVID clinics, Long COVID support groups, or from social media outreach.
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.
Teaching is typically done on the pool deck for groups by a provider who has been trained in Ai Chi.
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.
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.
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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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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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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Polio was once a looming threat in America, with outbreaks in the early 1950’s causing over 15,000 cases of paralysis each year prior to the introduction of the polio vaccine. The wide-scale vaccination process brought cases down to less than 100 cases in the 1960’s. In the 1970’s there were less than 10 cases, with the last reported case in the United States being in 1979. The most devastating symptom of polio is profound muscle weakness, with up to 10% succumbing to it, due to respiratory muscle involvement. Up to 40% of those who had recovered from polio had an unpleasant surprise 15-40 years after their original onset when they experienced the sudden return of muscle weakness, muscle and mental fatigue and joint pain, now called “Post-polio syndrome.” Thankfully this state is not contagious, nor is it considered life threatening, but it certainly can lead to profound disability. I remember my first post-polio syndrome patients as a young physical therapist in the 1980’s. While there is no true cure for the progression of symptoms, studies showed that non-fatiguing exercise could improve muscle strength and reduce tiredness; the key for us as therapists was to find a delicate balance of not too much exercise, but not too little.
Now here we are in the midst of a coronavirus pandemic, with far more cases than we saw with polio. Over 30 million people have been infected in the USA as of March 2021. Early studies report that 20-27% of those who have technically recovered from even mild cases of COVID-19 continue to show symptoms over 2 months later.
This group has been dubbed “COVID-19 long haulers,” with their presentation being called “long COVID syndrome,” “post-acute sequelae of SARS-CoV-2 infection,” or “Post-COVID-19 syndrome.” Their symptoms include various combinations of fatigue, weakness, low endurance, brain fog, headache, numbness and tingling, distorted sense of smell, altered taste, dizziness, blurred vision, chest pain, cough, shortness of breath, anxiety, variation of heart rate and blood pressure, abdominal pain, nausea, low back and other joint pain. It has become obvious that COVID-19 is a multi-organ disease with nervous system involvement that has a very broad reach. For some these symptoms are a bother; for others they are debilitating.
As the number of “long haulers” begins to increase, health care professionals are at a crucial point to find valid ways to help. Ai Chi is a credible intervention for many of the symptoms that COVID-19 long-haulers experience, as it provides core muscle strengthening, increases joint mobility, improves focus, brings relaxation and reduces stress, enhances breathing, decreases heart rate and blood pressure and relieves back and joint pain. Importantly however, we need evidence-based research showing its effectiveness in Post-COVID-19 syndrome. A good place for practitioners to start is with case studies employing good research practices, including informed consent, controlled parameters and valid test measures. And those who have the resources can undertake larger scale studies with control groups based on the initial findings suggested by case studies. As a reviewer for the APTA’s Journal of Aquatic Physical Therapy, I see this as an important research area today that can have a big impact on the lives of many. I am looking forward to seeing your research!
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