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Ai Chi: Safety and Effectiveness

 Byline: Andrea Salzman, MS, PT

Ai Chi is a type of relaxing aquatic exercises, which utilizes modified Tai Chi movements. [1] There is a great deal of medical information to support the health benefits of Tai Chi, which include fall prevention and the alleviation of musculoskeletal pain. [2, 3, 4, 5, 6]

The aquatic environment of Ai Chi lowers physical stress while performing modified Tai Chi movements. Therefore, Ai Chi is especially suited for frail individuals, who are looking to reap the benefits of land-based Tai Chi. Through Ai chi, a participant makes slow gradual movements in a relaxed manner, modifying each component of movement with greater stabilization. The participant is encouraged to balance his/her body weight while performing the Ai Chi movements in water.

In the words of Ruth Sova, “The client should concentrate on working with balance and precision, not tightness and stress.” Circular Ai Chi movements involve more muscle and joint mobility functions than the linear movements.

Ai Chi utilizes diaphragmatic breathing. [7] This type of breathing stimulates the parasympathetic system, leading to reduced blood pressure and heart rate. Another health benefit of diaphragmatic breathing is improved lymphatic flow, which may in turn help prevent infections. Diaphragmatic breathing draws air to the deepest parts of the lungs, wherein oxygen exchange can occur most efficiently.

During Ai Chi exhalation is carried out through the mouth and inhalation through the nose.

Ai Chi uses trunk movements in the thoracic-lumbar area; and this might inhibit sympathetic activity, leading to a calming down effect. [8] Ai Chi is a relaxing experience that help mobilize connective tissues around joints, muscles and the nervous system. [8] The slow, repetitive movements along with muscle elongation activities of Ai Chi can benefit the viscoelastic properties of connective tissues.

Ai Chi movements are presented with increasing difficulties as a participant’s skills develop. With practice, a participant can perform these movements consistently without much physical / cognitive effort.

The postural Ai Chi movements are briefly outlined below:

  • Contemplating, Floating, Uplifting, Enclosing and Folding

  • Soothing

  • Gathering

  • Freeing

  • Shifting

  • Accepting

  • Accepting with Grace and Rounding

  • Balancing

  • Half Circling, Encircling, Surrounding, Nurturing

  • Flowing and Reflecting

  • Suspending [8]

The above sequence is based on increasing difficulty of regulatory control for the Ai Chi participant. The participant moves from a symmetrical trunk position to rotating trunk movements, from a static center of gravity (COG) to a dynamic COG, from small to large hand movements, from a wide base support to narrow support bases, from visual control to non-visual / vestibular control, and finally from symmetrical to asymmetrical arm movements. [8]

Variations: Ai Chi is performed in shoulder-deep thermoneutral water. The participant stands with knees slightly flexed. “Wall Ai Chi” is Ai chi performed while holding onto a bar for support. This may be useful for participants who are fearful of falling / losing balance. Participants may pair up and perform Ai Chi movements together; this group activity is called “Ai Chi Ne.”

Some individuals, who are unable to stand, may sit on a stool in shallow water while performing Ai Chi. This technique may benefit participants with conditions, such as leg paralysis and lower back pain.

“Clinical Ai Chi,” unlike Ai Chi performed in healthy individuals, is applied to people with disabilities or therapeutic conditions. Clinical Ai Chi involves multiple subcategories of both function and activity, [8] as defined by the International Classification of Functioning, Disability and Health (ICF). [9] Clinical Ai Chi supports numerous neuromusculoskeletal and movement functions, such as mobility of joints and bones, stability of joints, muscle power, involuntary movement reactions, coordination of voluntary movements, leg supportive functions and muscle stiffness and spasms. In addition, Clinical Ai Chi enhances a

participant’s mobility, through activities, such as shifting the body’s center of gravity, maintaining a standing position and arm movements.

This article describes medical information to support the health benefits of Ai Chi in several target populations.

Fall prevention: Falls in the elderly population is a leading cause of injury-related hospitalization. The aquatic medium can be used for elderly individuals to provide training on balance. Numerous studies have shown the benefit of aquatic therapy on elderly individuals with balance and coordination difficulties. [10, 11, 12, 13, 14]

Lambeck and Bommer [8] suggest several Ai Chi movements that can specifically be used for training elderly individuals in balance and posture control. Listed below are key points of consideration:

  • Ai Chi movements that involve changes in the center of mass, minimal support of upper extremities and balancing on a narrow base, may be encouraged.

  • A typical therapy regimen should incorporate at least 50 hours of exercise.

  • If desired, Ai Chi can be made more challenging by removing some of the static and stable movements from the program.

  • Ai chi can be designed to facilitate lateral stability and lateral stepping skills. These skills are encouraged while working in tandem and unipedal positions with asymmetric hand movements. Again, cross-step movements without pivots can be used for developing lateral stability. Finally, side-stepping movements without foot crossing can also encourage the same.

  • Long arm reaching movements help develop balance and stability. The range of arm movements can be explored, and the participant may be encouraged to hold the pose for few seconds to challenge a posture.

  • Limited knee and plantar flexions may be observed in the elderly population. This leads to difficulty stepping over an obstacle. Ai Chi anterior weight shift encourages knee and plantar flexion movements. This activity starts with plantar flexion of the hind limb ankle, and subsequently the swing leg is moved along with knee flexion.

  • In the elderly population, gait variability is reduced as a result of the decreased rotation of the spinal joints. During Ai Chi, participants may be encouraged to focus on rotations between the pelvis and thorax, and continue rotations till the end of the active range of motion. Following the hand movements with the eye may also be encouraged to facilitate cervical spine rotation.

  • Hip movements and balance are facilitated by Ai Chi. For example, hip extension and flexion could be encouraged during Ai Chi, along with lateral hip movements for the tandem stance or unipedal movements.

  • Ai Chi movements should be slow. The reduced pace of these movements encourage connective tissue mobility and also decrease musculotendinous stiffness.

  • The slow Ai Chi movement of Uplifting or abduction leads to muscular activation at a reduced intensity as compared with rapid movements as well as those performed on land. [15] Therefore, Ai Chi may be used for early active motion following shoulder injury or surgery.

Spinal Muscular Atrophy (type III, Kugelberg-Welander): Bauer et al [16] studied the effect of Ai Chi on three patients with spinal muscular atrophy. These patients were treated with conventional physiotherapy and hydrotherapy (1 session/week each). Ai Chi was introduced as a final complement to hydrotherapy. Ai Chi sessions were 20-minutes in duration, and were followed over a course of 1 year. There was improvement in the patients’ symptoms as measured by Barthel Scale. The patients reported a preference for Ai Chi over other forms of hydrotherapy, such as Watsu. The techniques of Ai Chi are easily followed and provide a relaxing effect, which may have contributed to its favorability.

Osteopenia / Osteoporosis: Devereux et al [17] studied the effect of water-based program combined with self-management program on elderly women diagnosed with osteopenia / osteoporosis. Fifty individuals, between ages of 65–83 years, living in a community-setting were enrolled in the study. They were randomly selected to participate either in the intervention or the control group. The intervention group received aquatic therapy for 1 hour, twice a week, for a total period of 10 weeks. The aquatic therapy incorporated Tai Chi movements. In addition, to the aquatic therapy, individuals in this group also received a self-management program. The control group did not receive any interventions during this time. Upon completion of the study, the intervention group showed improvements in their balance abilities as measured using the Step test. A questionnaire was developed to evaluate changes in the quality of life of these individuals. The test showed that the intervention group had improvements in physical function, vitality, social function and mental health. However, there was no difference between the two groups on the fear of falling.

The authors make recommendations for similar studies in the future. A comparison of water-based and land-based exercises may be performed with a similar patient population. A longer follow-up could be implemented to study optimal therapy times for adequate improvements. It is known that Modified Falls Efficacy Scale (MFES) scores reach a ceiling effect for high-functioning individuals. Therefore, studies can be designed to incorporate subjects with varying MFES scores to evaluate the effect of water-based therapy on the fear of falling.

Teixeira et al [18] studied the effect of Ai Chi on balance and the fear of falling in elderly individuals. Thirty adults, between the ages 77-88 years, were enrolled for a study spanning 6-weeks. They were randomly placed in two groups—experimental and control. All individuals displayed a high or a medium risk of falling, as measured by the Tinetti Performance-Oriented Mobility Assessment (POMA) scores. The experimental group received 16 Ai Chi sessions based on the sequence suggestions by Sova and Konno. [19] The control group did not receive any interventions. According to the study’s findings, the experimental group had a significant improvement in balance (as measured by POMA) following the intervention. In addition, the fear of falling tended to decrease in the experimental group (as measured by falls Efficacy Scale [FES]). The control group did not show any improvement in balance during the same time period; in addition the fear of falling increased in this group.

Parkinson Patients: Ribero Queroz et al [20] evaluated the effect of Ai Chi on 10 Parkinson’s disease patients. These individuals were between the ages of 30–50 years. A series of 9 Ai Chi movements were performed in each 30-minute sessions, for a total of 10 sessions. According to video recordings, the authors concluded that Ai Chi sessions led to a significant improvement in postural tremor, dynamic balance, static balance and gait. However, the authors did not perform any Parkinson-specific tests, and Hoehn & Yahr stages were not provided.

Stroke survivors: Noh et al [21] evaluated the effect of Halliwick-concept and Ai Chi swimming programs on stroke survivors. Twenty five stroke survivors were selected, and randomly divided into two groups. One group (13 individuals) was involved in aquatic programs (Halliwick and Ai Chi), while the other group (12 individuals) received land-based gym therapy. The total period of therapy was 8 weeks, with 3 sessions every week, for 1 hour each. According to this study, the aquatic therapy group demonstrated significant improvements in Berg Balance Scale scores, forward and backward weight-bearing abilities of the affected limbs and knee flexor strength, as compared with the conventional therapy group. There were no significant changes in the other measures between the two groups.

Multiple Sclerosis: Castro-Sanchez et al [22] evaluated the effect of Ai Chi on multiple sclerosis patients. Seventy three patients were randomly placed in two groups—experimental and control. The experimental group received 40 sessions of Ai Chi, while the control group received 40 sessions of land-based abdominal breathing and contraction-relaxation exercises. The total study period was 20-weeks long, with 2 sessions/week. This study found a significant decrease in pain intensity over baseline in the experimental group. This decrease in pain was maintained up to 10 weeks following the last session. The experimental group also had significant improvements in spasm, fatigue, disability and autonomy.

In this study, pain was measured using VAS, the Pain Rating Index (PRI) and the Present Pain Intensity (PPI) from the McGill Pain Questionnaire (MPQ). Stability and disability were measured using the Roland Morris Disability Questionnaire (RMDQ). The secondary measurements were spasm VAS score, Multiple Sclerosis Impact Scale-29, Modified Fatigue Impact Scale, Fatigue Severity Scale, Becks Depression Inventory and Barthel Index. The authors noted that Ai Chi exercises offer neural and musculoskeletal benefits that are not possible by passive water immersion techniques, such as balneotherapy. Since exercise-based therapies alleviate the symptoms of multiple sclerosis, clinicians may use aquatic programs to encourage a more active lifestyle. In addition, this study incorporated ambient music together with the Ai Chi sessions, which might have enhanced the patient’s positive experience. In future, individualized Ai Chi sessions, wherein the participant can choose their own music, may be explored.

In another study, Bayraktar et al [23] evaluated the effect of Ai Chi on Multiple Sclerosis patients. Twenty three patients were randomly divided into two groups—experimental (n=15) and control (n=8). The experimental group performed Ai Chi sessions, while the control group performed home-based active arm and leg exercises along with abdominal breathing. The study found improvements in static standing balance (as measured by the duration of one-leg stance), functional mobility (as measured by Timed-up-and-Go and 6-minute walk tests), upper and lower extremity muscle strengths (as measured by hand-held dynamometer) and fatigue (as measured by Fatigue Severity Scale). No improvements were observed in the control group in these selected outcome measures.

Rheumatoid Arthritis: Lambeck and Bommer [8] describe the effect of Ai Chi on a 59-year old woman with rheumatoid arthritis. This individual had secondary osteoarthritis of knees, ankles and hip. A 5-week Clinical Ai Chi regimen was selected for her, based on the American College of Sports Medicine (ACSM) guidelines for arthritic patients. Her low-level workout sessions comprised of 20-minute of workout at 40% VO 2 max, or RPE 11/20. The program was designed to present a high number of repetitions with a low external load in order to build muscle endurance. The slow movements of Ai Chi were incorporated to reduce connective tissue stiffness. The individual’s balance training was facilitated by selecting Ai Chi movements with frequent changes in center of gravity. Stabilization of postures, without the use of hands and with narrow support bases, was encouraged. Upon completion of the program, the woman showed improvements in the range of motion of hip, knees and ankles. Her MRC muscle strength (as measured by MRC scores) and functional balance (as measured by Timed Up and Go test) had improved. In addition, the woman reported to be able to better handle the activities of daily living.

Fibromyalgia: Calandre et al [24] evaluated the effect of pool-based Tai Chi in fibromyalgia patients. Eighty one patients, in their 40s and 50s, were randomly placed in two groups—one receiving Tai Chi (n=42) and the other group receiving stretching exercises (n=39). All interventions were carried out in a heated water environment. A total of 18 sessions were implemented for each group, which spanned a total period of 6 weeks (3 sessions/week). The study found significant improvements in fibromyalgia symptoms (as measured by Fibromyalgia Impact Questionnaire [FIQ]) and sleep quality (as measured by the Pittsburgh Sleep Quality Index [PSQI] in the Tai Chi group, which was not observed in the stretching group. This study’s unique strength was that the sustained benefits on fibromyalgia symptoms and sleep were even observable 3 months post-study. The study also found decreased Trait-anxiety scores for both the groups. The stretching group also showed reduced Beck Depression Inventory (BDI) scores and increased Short Form-12 Health Inventory (SF-12) scores; however, a similar trend was not observed in the Tai Chi group.

Kelley et al 25 evaluated the effect of Ai Chi on salivary cortisol levels in fibromyalgia patients. Increased cortisol levels are associated with stress conditions. A total of three patients were enrolled for the study, which implemented a single-patient alternating treatment design. Walking on a treadmill was compared with Ai Chi (aquatic exercise) in this study. The study spanned a total period of 7 weeks. According to the study findings, both aquatic and land-based exercises reduced salivary cortisol levels in these fibromyalgia patients; most noticeable benefits were observed during moderate-pace walking on treadmill. The authors suggest that the positive effect on cortisol levels of treadmill-walking could be partly due to the social interactions during these exercise sessions. The participants could talk to one another while walking on a treadmill, as opposed to concentrating on deep breathing during Ai Chi sessions. This social interaction could have helped lower cortisol levels in these patients.

For fibromyalgia patients, continued adherence to an exercise regimen is a critical factor to consider, especially because these individuals tend to easily discontinue. Future studies may be designed to evaluate the favorability of adherence to an Ai Chi program in this patient population.

Gangaway [26] reported the case study a 58 year old female fibromyalgia patient. An Ai Chi program was implemented that lasted a total 20 weeks (a 4-week baseline period, an 8-week pool period and an 8-week post-treatment period). The first 16 positions of Ai Chi were performed, consisting of 19 specific positions repeated on both sides. The study found significant improvement in the subject’s FIQ scores along with a marked decrease in depression, pain severity and anxiety. There was some observable improvement in balance and decrease in sensitivity of tender points. In addition, the woman showed great improvement in 6-minute walking distance.


In conclusion, the studies detailed above provide encouraging evidence for the health

benefits of Ai Chi on several patient populations.


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