Tag Archives: exercise

Applying Physical Therapy to Tai Chi – Part 3: Range of Movement

Improving the range of movement (ROM) of a joint is arguably one of the primary functions of a physical therapist. Physical therapists employ many techniques to improve the ROM of a patient’s joint, including stretching, active and passive exercises, and direct mobilisation and manipulation of the joint. Tai Chi also have techniques involved in achieving optimal use of the joints of the body. One of these is peng jin; in simplest terms, the ability to ‘open’ the joints to assist free flow of qi (energy) through the body. Understanding and being able to apply peng jin could assist physical therapists improve ROM in their patients.

What is ‘Normal’ Range of Movement and Why is it Important?

Normal ROM is considered to be the standard acceptable range a joint can move through in a given plane of direction given normal anatomical considerations. For example, normal active ROM for a knee is generally considered to be 0 (extended) to 140 degrees (flexed). Maintaining normal ROM of joints is essential to preserving normal functional capacity; when the joints don’t move the way they’re supposed to, we are no longer able to do the things we want to do.

Injuries, diseases, deformities, foreign bodies, and limitations of soft tissues can all restrict the ROM of a given joint, resulting in reduced function, pain, and disability. A good example of this is the reduced ROM seen in osteoarthritis of the knee. As the disease progresses, many people demonstrate reduced knee extension (ability to straighten the knee). This is often observed as a tendency for the person to stand or walk with the knee bent. This starts as response to pain and the person’s attempt to reduce weight-bearing on the joint especially when walking.  In time and with progression of the disease it can produce physiological changes, such as tears or deterioration of the cartilage and abnormal surface changes to the bone resulting in decreased joint space, as well as shortening of (primarily) the hamstring tendons. It is a self-perpetuating process: the more time a person spends walking on a bent knee, the more damage and changes are done, the more the person tries not to straighten the knee because of pain.

How Can Tai Chi Help?

There have been a number of clinical studies have demonstrated that practicing Tai Chi can be beneficial in improving physical function of people with osteoarthritis (for example, see the meta-analysis published by Yan and colleagues). However, not all patients seen by physical therapists are able to integrate Tai Chi forms into their rehabilitation, especially in its earliest stages (for example, post-joint replacement therapy). There are however concepts within Tai Chi, such as peng jin, which could be utilised early within the rehabilitation process to facilitate a patient’s progress.

A simplified way of understanding peng jin is to think of it as opening the space between the joints of the body, thereby extending the limbs and trunk. In the early stages of learning, students often use mental imagery to conceptualise the opening of the joints as they practice their forms. A skilled practitioner is able to demonstrate a physical change when applying peng jin to a specific part of the body.

Consider what happens to the knee in the case of osteoarthritis, as demonstrated in an x-ray image below:

The loss of joint space in the affected knee results in a decrease in ROM, both from the narrowing of the joint space, and the subsequent pain resulting from bone-on-bone contact. If the principle of peng jin is to ‘open’ the joint – effectively open the joint space – then it stands to reason that the application of peng jin could result in increasing the joint space, thereby relieving both the physical restriction and pain-producing factors which limit ROM.

Applying Tai Chi to Physical Therapy: Recovery from Joint Replacement Surgery

A common acute limitation to ROM after total knee replacement surgery is the inability to fully extend the knee. Improving extension range in the acute phase of rehabilitation can be challenging, as the patient is often limited by pain and swelling, as well as being preconditioned to not fully extend the knee. Improving extension ROM at this stage often comprises passive and gentle active techniques as more aggressive techniques – for example, manual therapy techniques – are contraindicated while the patient recovers from surgery.

One such past patient of mine had considerable difficulty improving their range of knee extension post-surgery. Using traditional physical therapy techniques, over ten days the patient was able to demonstrate an improvement in knee extension from -10 degrees to -4 degrees extension (the negative indicating the shortfall from a neutral 0 degrees position). However, despite rigorous adherence to their home exercise program and employment of available techniques during appointments, the patient seemed unable to make further progress beyond -4 degrees.

Based on the principle of peng jin, I taught the patient a visualisation technique of ‘opening the joint’ and ‘extending the limb’ while performing a seated knee extension exercise. Within four repetitions the patient demonstrated improved extension range, and by the completion of ten repetitions was able to demonstrate 0 degrees (neutral) knee extension. At the next appointment the patient demonstrated that they had maintained some improvement, measured at -2 degrees knee extension, and by the following appointment demonstrated consistent ability to achieve 0 degrees extension in all positions.

Again, this is at best observational evidence of a specific application of Tai Chi principles to physical therapy. However, it does support the increasing body of evidence-based research advocating  Tai Chi as a means of improving function and mobility, and in my opinion, is worth further investigation as an adjunct to physical therapy.

5 Reasons Tai Chi is the Most Accessible Form of Exercise

Photo courtesy of Gold Coast Tai Chi Academy

Tai Chi – or taiji ch’uan – is a popular form of exercise well recognised for its health benefits. One of the great things about Tai Chi is that it is readily accessible to everyone. It doesn’t matter how old you are, how fit you are, how much time you have, or whether you have any previous experience in sports, martial arts, or fitness: if you can breathe, you can do Tai Chi.

Here are five great reasons why Tai Chi is the most accessible form of exercise for everyone.

Tai Chi is appropriate for all ages.

You are never too young or too old to practice Tai Chi. Due to its low-impact nature, This is an important consideration when choosing exercise for both the pre-adult and the older adult. Excess forces on the body can be counter-productive for both these age groups. In the pre-adult, the developing musculoskeletal system generally responds well to the forces that various exercises place on it. However, excessive forces can alter or damage critical components – such as growth plates – which can lead to developmental problems. In the older adult, many tissues simply will not take the strain of excessive force, which ultimately leads to injury. Tai Chi movements improve strength and balance without putting a lot of strain or force through the body.

Tai Chi is suitable for all fitness levels.

Tai Chi has no prerequisite level of strength, balance, or cardiovascular fitness level in order to start practicing it. In fact, you don’t even need to be able to stand or walk in order to practice Tai Chi. However, if you have already achieved a moderate or even high level of athleticism, Tai Chi will still offer challenges to you that will benefit your existing health and fitness. The two key reasons for this are Tai Chi’s progressive nature – that is, starting with very basic movements and concepts, and advancing over time to whatever end your mind and body can achieve; and it’s adaptability – a knowledgable Tai Chi instructor will be able to recognise a person’s strengths and limitations, and adapt their training accordingly so they can participate and advance at their own pace.

Tai Chi is gender neutral.

While all forms of exercise are (or should be) equally accessible to women and men, many are developed for, targeted towards, or tend to attract, one gender in greater numbers than the other. Tai Chi is one form of exercise that is truly gender neutral. While some may stereotype the ‘soft’ nature of Tai Chi to be  more suited to females, or its martial aspects to be more appropriate for males, the very nature of Tai Chi is to strike a balance between feminine and masculine aspects. A good Tai Chi class will make women and men feel equally at ease practicing their Tai Chi with each other.

Photo courtesy of Gold Coast Tai Chi Academy

Tai Chi requires no special clothing or equipment.

Whatever you are wearing right now, you are dressed for Tai Chi. Wherever you are, you can do Tai Chi. In addition, many of Tai Chi’s forms are practiced ’empty-handed’, meaning there is no need for special equipment. Ideally you will be wearing loose, comfortable clothing, and have enough space to be able to move through the form you are doing, but neither of those are essential to being able to practice Tai Chi. You can do literally do Tai Chi anywhere. They even do Tai Chi in space!

Tai Chi is easy to learn.

Tai Chi is something that anyone, of any background or ability, can jump straight into. Quality instructors introduce new people to Tai Chi in such a way that they have something they can go home and practice right after their first lesson. It is often said of Tai Chi that it is easy to learn, difficult to master, and with good reason. Yet I’ve seen so many people who are introduced to Tai Chi so pleasantly surprised that they can walk in to a class and just join in right from the start. It’s one of the few forms of exercising that, for the beginner, holds no intimidation.

Tai Chi is easily one of, if not the, most accessible forms of exercise available to everyone. Why not give it a try for yourself?

Applying Tai Chi to Physical Therapy – Part 2: Gait Training

Walking is a skill that many of us take for granted – let’s face it, when was the last time you actually thought about the way you walk? Yet it is still a skill, and when your ability to walk is suddenly impeded, or lost altogether, you realise just how important it is to your life. Even with disease or injury, many of us find a way to maintain our ability to walk, however any deviation from ‘normal’ gait (the medical term for walking) can often result in the development or compounding of other problems: pain, muscle imbalance, and arthritis being some of the more common, not to mention the difficulty in attending to day-to-day activities.

What is ‘Normal’ Gait and Why is it Important?

I often explain gait as a “controlled fall”. In order to walk, we shift our center of mass (CoM – see Part 1 for an understanding of the importance of CoM) forwards so that our body starts to move forwards. If we allowed this shift in CoM to continue unchecked, we would fall flat on our face. To avoid this, we use a complex pattern of movements to support ourselves on one leg while we place the other one in front of us to arrest our fall. If we keep our CoM moving forward, we have to repeat the pattern again: the leg in front now becomes the supporting leg, and the leg that was supporting us must now swing forward to save us. Repeat over and over again and you are walking.

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The way our limbs and body produce this – not just the movements themselves, but the way they are coordinated – is referred to biomechanically as a ‘gait pattern’. A ‘normal’ gait pattern is a complex, ideal version of these coordinated movements that result in a stable and efficient means of locomotion which has minimal impact on our musculoskeletal system. It is defined by a number of different factors, including joint angles, distribution of mass (ie: the location of CoM), forces applied to the body, and synergy of movements. For a more in-depth explanation of normal gait, check out this article on Physiopedia.

Anything that doesn’t comply to a ‘normal’ gait pattern is considered to be an ‘abnormal’ gait pattern. This is not to say that it is wrong as such, merely that it does not conform to the ideal that is normal gait. Physical Therapists strive to teach people to walk with a normal gait pattern, or as close to a normal pattern as is achievable. For some people this might not be possible, for example, due to anatomical differences, muscle weakness, imbalances, or tightness, neurological changes or deficits, pain and/or injury, disease, aging, or some combination of these factors. However, while the ‘perfect’ gait pattern might not always be achievable, many people who experience problems with walking can be assisted through Physical Therapy to improve their gait pattern, and in doing so their overall functional capacity.

How Can Tai Chi Help?

Tai Chi

Photo courtesy of Gold Coast Tai Chi Academy

Students of Tai Chi spend a lot of time learning to walk correctly. One main example of this is the technique known as mao xing, or ‘cat walking’. In mao xing, the Tai Chi practitioner shifts weight into one leg while stepping forward with the other. The stepping leg has no weight in it right up to the point the heel makes contact with the ground. The practitioner completes the step by gradually transferring weight from the supporting leg to the stepping leg, involving a shift from side-to-side and back-to-front. As the stepping leg is loaded it becomes the supporting leg, eventually freeing up the other leg to take another step forward.

This sounds very similar to normal gait, however a key difference is the location of the person’s CoM. As already described, normal gait requires the CoM to be displaced forwards outside the person’s base of support BoS), providing momentum. In mao xing, however, the CoM is maintained within the BoS while weight is shifted from one limb into the other, effectively eliminating the “falling” part of walking. To do this successfully, the Tai Chi student must develop a deeper understanding and awareness of how their body moves, in terms of coordination, weight shift, loading and unloading of the limbs, and placement of the feet. As a Physical Therapist, if I could have all my patients mao xing I wouldn’t have to worry about any of them having falls!

Applying Tai Chi to Physical Therapy: Recovery from Joint Replacement Surgery

Recently I’ve been applying the principles of mao xing in retraining normal gait patterns in patients who’ve undergone total hip or knee replacements. In the first weeks after surgery, many joint replacement patients demonstrate a very “stiff-legged” gait pattern: they tend to hold the operated leg very stiff when attempting to mobilise, and limit the amount of time they bear weight through the limb. In some cases the patient will circumduct or swing their leg around rather than bend their hip and knee in order to take a step forwards. Some patients may also have been walking like this for sometime prior to their surgery due to the nature of the condition that required joint replacement.

It can be quite challenging to retrain patients to walk with a normal gait pattern again, and often requires very precise practice. This has been particularly true in patients who have had bilateral joint replacements, who don’t have a ‘good’ leg to support themselves on and so are very guarded with attempting to walk.Though I haven’t been trying to teach my patients mao xing as such (though I often think I would like to), I’ve found that incorporating a number of the principles of mao xing – stepping onto the heel, rolling through the foot to come up onto the toes and push-off – as well as instructing the patient in a similar manner to how I would teach the technique to a Tai Chi student, provides a much more correct and consistent result than other methods I’ve tried. I’ve also found in practice that focusing on the principles related to the foot (heel strike, weight shift, stance, toe off) produce a subsequent improvement in the pattern of movement at the knee and hip – that is, an increase in the amount of flexion at the hip and knee during swing phase – and tolerance to weight-bearing during stance phase. When I apply these principles to gait training, I seldom have to draw attention to or correct movements at the hip, knee, or lumbo-pelvic area as these seem to correct themselves when the patient is applying the principles to their feet.

Lastly, and in some ways the most exciting part, is that I’ve found that patients are more likely to practice this “creeping” (as several patients have referred to it) way of walking as part of their home exercise program than they are other techniques or exercises designed to improve their gait. The exact reason why is unclear, however I would suggest it is because it is easier for the patient to conceptualise, understand, and apply, than other techniques that are more detailed and require a higher level of cognitive processing. In practice this apparent increase in compliance and attendance to exercises between therapy sessions does appear to translate – in general – into a more timely improvement in gait and physical function.

Again, this is at best observational evidence of a specific application of Tai Chi principles to physical therapy. However, it does support the increasing body of evidence-based research advocating  Tai Chi as a means of improving balance and mobility, and in my opinion, is worth further investigation as an adjunct to physical therapy.

Applying Tai Chi to Physical Therapy – Part 1: Weight Shift

I have been an advocate for Tai Chi (taiji quan) for at least as long as I’ve been a Physical Therapist, and have previously written about the benefits Tai Chi can bring to physical therapists and physical therapy. In this series, I aim to share some of the ways I’ve been able to apply the principles and practice of Tai Chi to my therapy skills, an in doing so enhance my patients’ care.

What is ‘Weight Shift’ and Why is it Important?

In basic terms, weight shift is our ability to move our center of mass (CoM) – our ‘weight’ – around our body in order to maintain – or disrupt – our balance. Think of your CoM like a pendulum or a plumb-bob; when you stand with perfect balance, your CoM sits right in the middle of your base of support (ie: the area around your feet). Once you start moving, your ‘pendulum’ moves as well, generally in the direction you are moving. We do this all the time  – in fact, if we couldn’t move our CoM, we couldn’t move at all.

An easy way to understand weight shift is to attempt to stand on one leg. To do this, you have to move your CoM – or ‘swing your pendulum’ – over your supporting leg so you can lift the other leg off the ground. If you don’t, you won’t be able to lift your leg, or if you do, you body will want to fall over to that side. You can try this for yourself to see how it feels (just make sure you do it by a table or counter top so you’ve got something to grab onto if you need it!).

20131110232510-fall-menBeing able to weight shift not only facilitates movement, it can help prevent unwanted or undesirable movement, for example, falling. Falling is a major contributor to injury and death amongst many populations: in the US, falling is considered to be leading cause of both fatal and non-fatal injuries. Physical therapists spend a great deal of time trying to both prevent falls in patients, and help patients recover from falls. Teaching patients to understand both how their CoM affects their balance, and how to shift their weight appropriately for safe movement, is critical to achieving functional movement and stability. However, in many patients the ability to weight shift is impaired either because of disease (eg: neuropathy, arthritis, vertigo) and injury (eg: stroke, spinal and nerve injuries), and regaining the ability to control weight shift can be very difficult.

How Can Tai Chi Help?

Weight shift is one of a number of fundamental skills Tai Chi training can improve or enhance. Almost every movement in any form from start to finish involves a gradual, controlled transfer of weight in coronal, sagittal, and transverse planes of movement. In order to perform the forms correctly, Tai Chi practitioners control the displacement of their CoM in all planes through slow, precise movements. In most instances, the CoM remains ideally located within the practitioner’s base of support, making it easy to maintain balance. This is evident even when the practitioner is performing ‘unbalanced’ movements, such as standing on one leg.

A classic example of this is the technique known as mao xing, or ‘cat walking’. In mao xing, the Tai Chi practitioner shifts weight into one leg while stepping forward with the other. The stepping leg has no weight in it right up to the point the heel makes contact with the ground. The practitioner completes the step by gradually transferring weight from the supporting leg to the stepping leg, involving a shift from side-to-side and back-to-front. As the stepping leg is loaded it becomes the supporting leg, eventually freeing up the other leg to take another step forward. (Note: this is a very simplistic description of mao xing and there is a lot more involved in it, however this illustrates the basic concept. I recommend trying Tai Chi to better understand mao xing)

One main difference between mao xing and regular walking is the way weight shift is controlled. In regular walking, the CoM is displaced forward of the body, and the body’s reaction is to shift weight to one leg while stepping through with the other. Keeping the CoM displaced forwards and alternately repeating the sequence facilitates movement while preventing a fall forwards. In effect, walking is a repeatedly controlled fall. (Note: again, this is an overly simple description of walking, however is biomechanically accurate) Mao xing on the other hand, keeps the CoM positioned ideally within a person’s base of support at all times, even when one leg is not supported on the ground. Consider this in terms of a person who has an impaired ability to weight shift, such as someone who has a dense hemiplegia following a stroke. Which method of walking would you consider safest to have them perform?

Applying Tai Chi to Physical Therapy: Stroke and Femoral Nerve Injury Examples

Recently I was able to apply the principles of mao xing to improve the mobility of two patients who had difficultly with weight shift: a middle-aged male with a dense left hemiplegia following a stroke, and an elderly female with the inability to maintain knee extension following an injury to her femoral nerve. Neither patient was able to support weight on their affected side and both were consequently such a high risk of falling they could only mobilize in a wheelchair. Therapy included exercises to encourage weight shift and improve the ability to bear weight over the affected side, however in both instances progress was slow and their was little retention between therapy sessions.

Using the principles of mao xing, I had both patients practice stepping into a lunge stance with their affected side, then returning to a neutral standing position. Patients practiced the gradual loading and unloading of the affected side, first supported and then with standby assistance as their skill improved. In both cases, within the completion of 2 sets of 10 repetitions there was an observed improvement in the patient’s understanding and ability to shift weight to the affected side, and in maintaining standing balance. With successive therapy sessions and in conjunction with other exercises, both patients advanced their ability to weight shift to the point where they were able to stand and mobilize with an appropriate aid. The male with the hemiplegia was ultimately able to mobilize with a cane independently. The female with the femoral nerve injury has so far progressed to be able to mobilize with a standard frame under supervision.

This is, at best, observational evidence of a specific application of Tai Chi principles to physical therapy, and weight shift is only one aspect of maintaining balance. However, it does support the increasing body of evidence-based research advocating  Tai Chi as a means of improving balance and mobility, and in my opinion, is worth further investigation as an adjunct to physical therapy.

Why Australian Health Insurers Should Cover Tai Chi

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Photo courtesy Gold Coast Tai Chi Academy

Regular readers will be well aware of my advocacy of Tai Chi as a means of maintaining optimal health for the lifespan. (For those who are new, click on the Tai Chi tag to read past articles about the benefits of Tai Chi). There are few forms of exercise that can boast the wide range of physical and mental health benefits, whilst being accessible to people of all ages and abilities, as Tai Chi does.

Health insurers around the world have increasingly recognised the benefits of enabling their members to engage in activities designed to promote healthy lifestyles, and thereby maximise health and well-being. The rationale is simple: engaging in preventative health practices minimises the risks of developing more serious, complicated, and/or debilitating conditions, and therefore reduces both the incidence and level (not to mention the expense) of future medical care required. For example, it is far better from an insurers point of view to support a member to engage in a weight management program, gym membership, and nicotine replacement therapy, than it is to support them through coronary artery bypass surgery and the follow-up care afterwards.

As a result, most, if not all, health insurers now offer some form of support for members to engage in activities designed to maintain or improve their health. The types of activities vary between insurers: in Australia, common activities covered include gym and personal training, yoga, Pilates, and weight management programs. Yet despite its known benefits to health, Tai Chi is not currently covered by any major Australian health insurer. Why?

It’s a good question. Considering that health insurers will, for the most part, only cover treatments or activities that are supported by clinical evidence to be effective in maintaining or improving health, Tai Chi is possibly one of the better examples of evidence-based interventions for good health. A good example of this can be found in a review published in the American Journal of Health Promotion (1.). In this article, Jahnke and colleagues examined the outcomes of randomised controlled trials investigating the outcomes of both Tai Chi and Qigong exercises, and found evidence of positive outcomes for numerous health factors, including bone health, cardiopulmonary health, physical function, falls prevention, immunity, psychological conditions such as anxiety, depression and self-efficacy, and general quality of life. This is by no means an exhaustive list: research since publication continues to identify more health conditions for which Tai Chi can be beneficial. In the face of such evidence, and considering that many insurers cover a range of complimentary or alternative health practices whose evidence based is equal to or less than that of Tai Chi, it seems odd that Tai Chi would not be covered alongside options such as yoga and Pilates.

It becomes even more confusing when you consider that Tai Chi has previously been covered by at least one insurer in Australia. In 2010 the Tai Chi Association of Australia (TCAA) reported that MBF (which has since merged and is now known as Bupa) had recognised Tai Chi for inclusion in its Lifestyle Bonus option, and as much as 70% of class fees could be covered under certain conditions. At the time of writing however, Tai Chi does not appear to be covered under Bupa’s Living Well programs, whereas other forms of exercise such as yoga and Pilates are, and the reasons for this remain unknown.

Another point of consideration is the fact that Tai Chi is gaining recognition and support from the broader health and medical industry for its health benefits. An increasing number of doctors, physiotherapists, exercise physiologists and other health professionals are recommending Tai Chi as a part of maintaining a healthy lifestyle. A number of hospitals and health services either conduct, or are connected to, Tai Chi classes, and promote this to their patients and the broader community. For example, the South West Hospital and Health Service in rural south-west Queensland offers free Tai Chi classes to the general public. This is similar to programs offered by local councils, such as the Gold Coast City Council’s Active and Health Program which includes Tai Chi amongst its variety of healthy activities. In addition, the benefits of Tai Chi have been formally recognised and endorsed by a number of peak representative bodies, including Arthritis Australia, Diabetes Australia and Osteoporosis Australia.

In the light of such evidence, recognition and support, it seems to only make sense that health insurers should be including Tai Chi alongside other already recognised activities such as yoga and Pilates. Indeed, health insurers in other countries, for example the United States, have already recognised the benefits of including Tai Chi in their own benefits packages. Surely the inclusion of Tai Chi within a healthy lifestyle package can only serve to benefit health insurer’s members, and in doing so, benefit the insurers themselves.

Do you practice Tai Chi? Do you have private health insurance? Do you think health insurance should cover Tai Chi, as it does other activities such as yoga and Pilates? Please share your comments below.

References

1. Jahnke, R., et al. (2010). A comprehensive review of health benefits of Qigong and Tai Chi. American Journal of Health Promotion, 24(6): e1-e25.