Chapter 15 Qigong

Penelope is a 55-year-old female sculptor who had a myocardial infarction followed by a triple coronary artery bypass graft 1 month ago. She has completed phases I and II of a cardiac rehabilitation program. Penelope has developed low back pain (LBP) and has been referred for outpatient physical therapy to address her pain and progress her home exercise/walking program.

Initial Examination

Client Report: The client reports mild panic attacks when needing to go to the hospital or social gatherings and complains of LBP. She is concerned that she may not be able to continue to work on large sculpture pieces because of her cardiac status and back pain.

Client Goals: To eliminate back pain, increase activity level, and reduce her situational anxiety

Medications: Inderal, Coumadin, Lipitor, Xanax

Cardiovascular and Pulmonary: Vitals: HR: 82; BP: 130/80; RR: chronic hyperventilation (26 breaths/minute at rest); walks 2½ mph × 45 minutes without cardiac symptoms. Reports breathing is much more rapid during panic attacks. Demonstrates high thoracic respiration—unable to demonstrate diaphragmatic respiration despite verbal and tactile cues. Blood values: cholesterol 280, triglycerides 206, HDL 22 and LDL 150.

Musculoskeletal: Upper extremities: limited shoulder elevation (130 degrees) bilaterally; lower extremities: positive Thomas test bilaterally, which indicates psoas tightness; posture: excessive thoracic kyphosis and forward head, hyperlordotic lumbar spine; palpation: moderate myofascial dysfunction noted in quadratus lumborum, scalenes, upper trapezius, and pectorals

Neuromuscular: Strength: 5/5 throughout except quadriceps, hamstrings, dorsiflexor, and gluteus medius strength 4-/5, abdominals 3+/5, short neck flexors 3-/5; back pain: sitting 1/10, standing 4/10, walking level ground 4/10, walking uphill 3/10, walking downhill 5/10, reaching overhead 5/10.

Affect: an affiliated psychologist suggested the Beck Anxiety Inventory to track progress of the client’s anxiety symptoms (score=38/63).

Reevaluation

Based on the pain behavior (worse with extension) and palpation, the LBP appears to be generated (primarily) by facet joint arthritis. This is exacerbated by thoracic and scapular immobility, myo-fascial dysfunction, impaired abdominal strength, poor posture, hyperventilation, mental stress, and improper body mechanics.

Plan of Care

Penelope attended six physical therapy sessions, which included (1) manual therapy to gently mobilize the thoracic spine to increase extension and address limited scapular mobility and myofascial dysfunction; (2) therapeutic exercise to strengthen the quadriceps, hamstrings, dorsiflexors, gluteus medius, abdominals, and short neck flexors; and (3) neuromuscular reeducation to facilitate diaphragmatic respiration, correct posture, and relaxation.

Reevaluation

After eight sessions over a period of 4 weeks the client demonstrated a reduction of anxiety (Beck Anxiety Inventory=27/63) and reduction of back pain (pain sitting 0/10; standing 2/10; walking level surface 2/10; walking uphill 1/10; walking downhill 3/10; reaching for objects overhead 3/10) in addition to improvements in posture and strength.

Although the client felt that the diaphragmatic breathing facilitation had helped the pain and panic attacks, allowing her to use the Xanax less frequently, she still found herself reverting to shallow, rapid chest breathing when pressured. Her respiration rate at rest is now 19/minute (down from 26). The client’s friend recommended she try qigong with a local teacher to further address her pain and anxiety, and so she asked the therapist’s opinion regarding the safety and efficacy of this therapy.

Incorporating Cam into the Plan of Care

The therapist, completely unfamiliar with qigong yet intrigued by the idea of incorporating qigong into the client’s plan of care, decides to investigate and evaluate qigong’s safety and efficacy before he gives recommendations to his client.

INVESTIGATING THE LITERATURE

The therapist uses two strategies to investigate the literature. The first is a detailed approach in which he does preliminary background reading of qigong and consults with a qigong instructor. This is followed by a search of the databases and evaluation of the literature using reviews and primary sources for qigong, in addition to meditation and breathing. The second strategy is the use of the PICO format for a focused search to answer the clinical questions generated by the case. In this case two PICOs are generated: one for LBP and the other for anxiety.

Preliminary Reading

Qigong (pronounced chee-gung and also known as chi kung or chi gung) is one of the five pillars of traditional Chinese medicine along with herbology, nutrition, acupuncture, and manual therapy. This tradition is based on the concept of qi. The word qi usually is translated as “vital energy” or “breath” and is closely related, if not identical, to the yogic concept of “prana,” the Greek “pneuma,” the Hebrew “ruach,” the Native American “great spirit,” and the Judeo-Christian “breath of life.” This concept of vital energy is multifaceted and pervades traditional Chinese culture, including medicine, martial arts (wushu), and environmental design and placement (feng shui). When qi is sufficient and flows harmoniously in the mind-body, respiratory, cardiovascular, orthopedic, metabolic, and emotional health is optimal. Indeed, traditional Chinese medicine, unlike allopathic Western medicine, does not segregate psychological problems from physiological in evaluation and treatment, because both are manifestations of disordered qi flow (see Chapter 4).¹ Correct biomechanical function allows qi to flow properly and that qi flow, in turn, allows ideal body mechanics and posture. Meanwhile, skeptics criticize the concept of qi as a worthless construct consistent with magical thinking.² This skepticism is supported by the plethora of ways that the word qi is used, which makes it a hard concept for the Western mind to accept.

The first written record of qigong, defined as the science of vital energy accumulation, balance, and circulation, dates back to the Zhou dynasty, which ruled China from 1122 to 934 bc. Written during this era, the classic Tao Te Ching refers to breathing techniques that “concentrate Qi and achieve softness.” Over centuries of development, emperors, philosophers, scholars, clergy, martial artists, and doctors have contributed to the broad field of knowledge encompassed by the term qigong. Yoga practices from India and Tibetan practices were gradually cross-pollinated with qigong indigenous to China.³

Qigong, true to its substantially Taoist heritage, resists the scientific and scholarly impulse to reduce it to neatly defined categories. It can be categorized as an energy-based system, as a mind-body approach, or more accurately as belonging to both categories. In the same way, it is impossible to break qigong into mutually exclusive subcategories. However, several ways do exist to group similar practices together to help analyze the field.^4,⁵

Qigong can be differentiated by the purpose for which it has been developed. Spiritual qigong, for example, focuses primarily on attainment of enlightenment, yet it can take different forms. Practice in a Buddhist tradition emphasizes the achievement of Buddhahood or cultivation of the ability to see through illusion and relinquish attachment, whereas Taoist qigong tradition emphasizes longevity and harmony between the practitioner and the environment.

Martial qigong assumes that harmonious qi flow is facilitated and in turn allows for movement that minimizes excess muscle tension and effort. Martial qigong practices such as tai chi and bagua seek to develop “internal power,” whereas Iron Shirt was developed to make the body impervious to blows. The Iron Palm Technique conditions the hands and other parts of the body to improve striking ability and decrease sensitivity to pain. Medical qigong emphasizes healing and regulates the energy circulation to prevent illness and cure diseases.

Another way to categorize qigong is by the dichotomy of internal versus external. Internal qigong seeks to accumulate and circulate qi in a the practitioner’s own body through static meditation, breathing exercises, and movement. External qigong includes healing emission qigong and martial emission qigong. Healing emission qigong is thought to involve the exchange of energy from the practitioner to the client to address energetic deficiency and harmonize qi flow, whereas martial emission qigong is meant to train the practitioner to discharge qi to cause pain or subdue an opponent.

A third way to classify qigong is under the heading Nei Dan or Wai Dan.⁴ In Nei Dan (internal elixir), vital energy is gathered in the dantien (abdominal area) via breathing practices, movement, and mental focus and then lead by the mind to other parts of the body, especially the extremities. In Wai Dan, qi is drawn to the extremities and flow is stimulated by mental focus and muscular activity. When the qi flow is sufficient, it is thought to overflow into the rest of the meridian system to invigorate qi flow in general.

A fourth way to categorize qigong is by whether the body is still or moves (static versus dynamic) or what position is assumed (supine, sitting, or standing).

Again, these categories are by no means mutually exclusive. For example, tai chi chuan, a practice primarily focused on building martial prowess, is also considered to improve health. In fact, many practice this martial art only for health purposes and therefore have no idea of its martial application. In the same way, the spiritual qigong path includes a focus on health and longevity to improve the practitioner’s chance of achieving enlightenment in the present lifetime. Those who practice any style report tingling sensations, heat, or a flow of warm water through the body, thought to be manifestations of qi flow. It is thought that qi can be led to any part of the body for the purpose of healing. According to qigong theory, many qigong practitioners believe that the will leads the mind, the mind leads the qi, and the qi leads the blood. At the functional level, qi leads strength.

Although many forms of qigong exist, most, if not all, styles seek to cultivate a calm and quiet mind and the ability to release unnecessary muscular tension. They also teach correct posture, with the meaning of “correct” dependent on the style. Qigong also is meant to facilitate balance and stability and emphasizes, at least in initial training, breathing into the lower dantien. The dantien or sea of qi is located below (caudal and deep to) the navel and is meant to be the source of all movement. The lower dantien also is known as the hara in Japanese and as the navel chakra in Ayurvedic mind-body energetics. Broadly defined, qigong can encompass mental imagery, supine/seated/standing meditation, breath work, self-massage, intense shaolin-based practice,⁶ and exercises associated with internal martial arts, including tai chi chuan. Qigong styles that emphasize relaxation and equanimity, minimal to moderate exertion, and regulated breathing are thought to address stress-related problems, including mild to moderate hypertension. Qigong on the gentle end of the spectrum seems well suited for phase III and IV cardiac rehabilitation because of its apparent low risk of inducing myocardial ischemia or musculoskeletal injury. Because qigong healers may use a variety of practice approaches and employ a wide spectrum of techniques, some of which may be potentially dangerous (Figure 15-1) for Penelope,⁵^–⁷ the therapist decides to contact the qigong instructor for a description of a typical qigong session before proceeding with a more specific search of the scientific literature. She obtains written permission from Penelope to discuss her issues with the qigong teacher and arranges a meeting with him.

Figure 15-1 A potentially dangerous qigong technique.

(From Liang S, Wu W: Qigong empowerment: a guide to Medical Taoist Buddhist Wushu and energy cultivation, East Providence, Rhode Island, 1997, Way of the Dragon.)

Consulting with the Qigong Instructor

The qigong instructor explained and demonstrated how he would work with Penelope using several types of qigong exercise.

Sitting Meditation

The training would start with sitting meditation on a chair to begin the process of calming the mind and bringing moment-to-moment awareness of the body and breath (Figure 15-2). This instructor would encourage slow, continuous, diaphragmatic breathing through the nose. He would also teach her to be aware of her sitting posture and continuously adjust it according to qigong principles. By promoting physical relaxation and correct alignment, sitting meditation facilitates the circulation of blood and qi. Penelope would be instructed to focus on the breath and, when the mind wanders (as it is sure to do), gently return the focus to the sensation of respiration and spinal elongation. When the mind is calm and the posture is correct, qi flows more smoothly, evenly, and continuously.

Figure 15-2 Sitting meditation.

(From Mantak Chia, Iron Shirt Chi Kung I, Huntington, NY, 1983, Healing Tao Books.)

Self-Massage

This part of the program would consist of self-applied massage to help relax the muscles, move lymph and blood, disperse qi stagnation, and stimulate smooth energy flow (Figure 15-3). Special attention would be given to certain acupuncture points, where qi flow can be manipulated easily, and the major channels through which qi flows.

Figure 15-3 Self-massage.

Rights were not granted to include this figure in electronic media. Please refer to the printed book.

(From Jahnke R: The healer within, San Francisco, 1997, Harper.)

Medical Qigong

This part of the qigong program would consist of exercises to help address the more specific qi stagnation and imbalance that Penelope’s history suggests is likely in her heart, kidney, and lung organ meridian system. Certain qigong movements, breathing, and mental awareness techniques promote the release, circulation, and balance of qi in these organs (Figure 15-4). The movements also apply gentle pressure and relax the organs and surrounding fascia, which provides a gentle massage that promotes circulation, increases respiratory efficiency, and balances function. All of these stretching and twisting movements would be performed gently and slowly. An example of these types of qigong movements would be forward and backward swing arms, in which she would swing her arms forward (shoulder flexion) while extending her thoracic spine and then swing her arms back (shoulder extension) while flexing her spine. Some of these qigong exercises also use sounds to help relax and nourish the organs. The heart sound (“Hawwwww”) is repeated subvocally as a mantra to help the heart be open and balanced.

Figure 15-4 Medical qigong.

Rights were not granted to include this figure in electronic media. Please refer to the printed book.

(From Yang JM: Back pain, YMAA, Jamaica Plain, MA.)

Standing Meditation

The purpose of this practice is to gather and enhance circulation of qi while building strength and endurance, especially in the lower half of the body (Figure 15-5). This practice also teaches the practitioner to “root” herself to the ground to build stability and balance. This is a way to stimulate and regulate the function of the viscera, muscles, ligaments, and bones. Various processes, such as blood circulation, heart rate, breathing, and functioning of the nervous system, are thought to be optimized.