Tai chi rehabilitation - using Tai Chi in rehab

Mark Sheppard introduces a surprising addition to the sports injury rehabilitation toolkit

The prevailing image of Tai Chi today is of groups of elderly people in parks, waving their arms in a slow dance. The attraction is that of a moving meditation and relaxed exercise that can be done by all ages without too much effort, an escape from the stresses of today’s modern lifestyles. However, it is likely to come as a surprise to many sports therapists to learn that this ancient martial arts discipline may have something to offer the world of sports performance, conditioning and rehabilitation.

Origins of Tai Chi

Tai Chi as an exercise modality has emerged out of Chinese culture, Taoist philosophy and experiential history. Tai Chi Ch’uan (translated literally as ‘the supreme ultimate fist’) has been traced back at least to the 13th century, attributed to a Taoist priest Zhang San-feng. There are several family styles (different movement forms): Wudang, Chen, Yang, Wu and Sun to name a few. Some of these patterns of choreographed movements can be as short as five minutes from start to finish, while others take an hour to complete.

In the Chinese tradition of healing, the physician was paid if his patients remained well; their payments to him stopped when they fell sick. The emphasis on wellness and balance throughout all the body’s systems was also reflected in one’s lifestyle and habits. This is the rock on which traditional Chinese medicine is still based. The approach can be summed up in the following formula: Practice + Intention = Inner Harmony = Chi Flow = Health and Longevity

Today Tai Chi is China’s national health exercise, practised by more than 200m people as a callisthenic workout. It is a low-cost way to keep an ageing population healthy and requires no special equipment, clothing or space. It can be done by all ages, all levels of fitness and is part of China’s varied and wide mix of martial art forms.

The arts that were once passed down by acknowledged Masters are now taught in traditional Chinese medicine universities. Mao’s Cultural Revolution in the 1960s forced the best of a generation of legendary teachers to leave or go underground. Those of that generation who remain are well into their eighties. Fortunately, some did find their way to the West and the students they taught have had half a century to integrate western thinking into the practice and philosophy of Tai Chi. If an actor who lost his voice can give us the Alexander Technique and a boxer with a bad back and no room to swing a dumbell could develop Pilates, then I am sure there is a lot we can learn from this Chinese art.

Tai Chi movement

The forms (Tai Chi routine movement patterns) cover ranges of movement that are coordinated through the hips and core muscle groups, deploying studied weightshift patterns and single leg balance where foot placement and knee alignment are key. An awareness of posture through rotational movement makes Tai Chi a functional system to experience and understand biomechanical sequencing and kinetic chain relationships.

Each of the postures within the different moves of Tai Chi has an application in selfdefence; holds, blocks, neutralisations, locks, punches, kicks, throws, pulls and strikes. The steps are in all directions, with the upper body moves covering up-down, left-right, in-out, expand-contract, split, spiral and rotate. The joints and soft tissues are continually and gently moved through their ranges.

A practitioner of Amatsu (Japanese bodywork system) I met recently, described the body as one muscle with hundreds of attachments. This concept is useful to feel and appreciate the effects of movement that link the whole body. This ripple effect can be seen in experienced practitioners, with the wave of movement clearly travelling from the feet to the hands.

Peter Ralston was the first non-Asian to win the World Championship full-contact Martial Arts tournament in the Republic of China in 1978. He bases his system of Cheng-Hsin (Body-Being) on the use of the intrinsic compression and stretch reflex of the muscles to deliver effortless power. On the occasions I have been on the receiving end of such ability, the feeling is unnerving. The force is both powerful and soft at the same time: one is definitely flying through the air but the impact point feels like being on the end of a released spring which you can feel coming but can do nothing about. Having played contact sports, the collision force is a completely different experience. It is the unlearning of this force/tension modality that is the first challenge of using Tai Chi, and what also makes it effective in injury prevention and recovery.

Foot movement in Tai Chi

When practising Tai Chi walking, the foot is placed heel to toe and the legs have a sense of filling and emptying, as in a sand-filled egg timer: once tipped over, it fills from the base up. The emptying leg only moves when the transfer is complete. Tai Chi walking also follows the principle of avoiding any ‘double weighting’ (even weight distribution) between the feet. Two-footed postures should always end with a 70:30 or 60:40 distribution between the two legs (this is an important defensive precaution in martial arts to avoid being caught out flat-footed).

A young player at the tennis academy where I work, was moving and playing off his toes. He had been trying to apply the unhelpful coaching injunction to ‘get on your toes and bend your knees!’ As a result he was failing to drive through his glutes and hips on delivery and recovery. On impact he was loading on only half of his foot, and this imbalance meant he had to do more from the arm, causing scapular instability. The bouncing movement created through the calves and ankles meant his footwork looked busy but ineffective. He was not taking the ground laterally, and spent too much time in the air, which made him slow to the wide or short balls.

Peter Ralston describes the loading of compression through the legs as the ‘squish’. I have found this a great concept to use with the kids at the tennis academy to describe the need to go down in order to come up, instead of hopping or jumping into the move. The base becomes easier to maintain and the shoulder girdle is relaxed, staying engaged with the muscles of the back.

The tennis player practised Tai Chi walking with a bean-bag on his head (to make him aware of bobbing as he stepped); he quietened and relaxed into his legs. We also addressed his tendency to let his knee extend beyond his foot. The sitting into his leg made him more aware of aligning his second toe to the centre line of his knee when stepping. He came back to beat the player who had previously beaten him in national qualifying.

A wonderful 75-year-old Tai Chi student found the drive from the legs particularly useful when opening the heavy Victorian sash windows of her apartment.

Moving meditation

Tai Chi teaches participants to place their focus in the tan-tien. This is the most important of the three energy centres, located in the centre of the abdomen, three to four finger-widths below the navel. The other two energy centres are heart and head. A recent article by Robert K Cooper(1)speaks of neuroscience’s discovery of the intelligence centres of the heart and gut: ‘The enteric nervous system of the gut has more neurons in the intestinal tract than the entire spinal column’; while ‘the electrical energy within every heartbeat and the information contained therein, is sent to every cell in the body’.

The placing of focus in the tan-tien links the centre of gravity with the core stability muscle groups and moves one’s mental focus away from the interference of ‘internal dialogue’ – a concept discussed by the author and life coach Tim Gallway in his Inner Gameseries. Gallway talks about ‘self-one’ and ‘self-two’ and how one interferes with the other to create doubt which undermines performance. By focusing on the process, outcome takes care of itself. This self-awareness of attention to what one is doing and how it feels, helps the athlete (or patient) to manage the technical or physiological adjustments they are being asked to make.

In a combat situation, the value of being thus ‘centred’ is to remain calm and make effective responses, to master mental and emotional reactions in order to overcome the fight-or-flight response and allow the body’s trained experience to manage the situation. This is also true of someone coping with the trauma of injury or the pressure of match play. And the ability to stay calm and focus effectively also transfers readily into everyday life to offload any number of daily lifestyle stresses.

But ‘centring’ is about more than simply relying on a catalogue of previously rehearsed patterns. The ‘open learning style’ of Taoism – of not falling back to the default position of learned responses – provokes a more appropriate response to finding oneself facing a similar but new event.

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Many people are attracted to martial arts practice by the ‘Bruce Lee fantasy’. They believe that if they train in a particular style in class, they will be ready to make their moves in a street situation. In real life, before they get the chance to go into their ‘flying fox, third dan defence’, their attacker has knocked them out and is back in the pub. The attacker’s style was learned on the street and shaped by that environment.

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The Taoist philosophy that developed Tai Chi at first sight can appear both esoteric and poetically vague, which can be frustrating for those more familiar with learning the facts and agreed knowledge of a subject. Taoism observes the principles and nature of change and moves in harmony with them. Dogma is inflexible and creates conflicts. So be more like the water than the rock.

Clinical use

The ‘no pain, no gain’ maxim – still widespread in sporting endeavour – creates physiological, emotional and mental overloads that have to be paid for. For the young athlete who has to manage a constantly changing and evolving body and mind, or for someone recovering from a trauma, this is not a healthy approach. Tai Chi has a maxim of the ‘70% rule of practice’. This applies to an individual’s ability and comfort level at the time to maintain the postures and the intensity of the training. It is a good guide to prevent overtraining stress.

Case 1: A client at the physiotherapy clinic suffered a severe whiplash injury which impacted on her motor skills and balance. In cases similar to this the reaction to loss of control is to tighten up and lock down. In this instance I used the standing postures to help. Her 70% was at a low threshold and the exercise needed to reflect that.

Beginning standing posture:

The beginning standing posture of Tai Chi is centring the weight in the feet, softening the backs of the knees, noticing how much is needed from the thighs to maintain one’s stance, imagining a light weight on the end of the coccyx, gently pulling the tail underneath and engaging the lower abs. The feeling is one of sitting into the pelvis and relaxing into the hips, so from the waist down the sense is of ‘rooting’ into the ground.

To prevent the upper body from losing length and lightness, the head is suspended from the crown and floating on the top of the spine. The throat is softened to slide the chin back and up and create the length in the neck. The ‘three smiles’ are across the forehead, lips and chest. The tip of the tongue is placed on the hard palate, rolled behind the front teeth to stabilise the jaw, teeth gently closed. The place between the shoulder blades is open and relaxed, so softening the chest and releasing the arms and shoulders through an awareness of weight and gravity.

The arms are by the sides with space under the armpits, as though a tennis ball were placed there. The back of the hands are facing forward with the palms open and the fingers relaxed. There is a constant feel of opening and relaxing, noting the place where tension is held and melting the area, using the image of ice to water, water to steam and steam to evaporation.

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I would then focus on the diaphragmatic, nasal breathing and centring the mind to manage the whole feeling of the held posture. In Tai Chi, before we move, stillness is the neutral point of action.

Case 2: A client who was hypermobile had started to develop arthritic pain in her left hip. She used Tai Chi to manage the condition until it got to the stage when a resurfacing operation was needed. The goal was to keep the hip mobile and stop the body going into a management of the pain that would impact on her posture. Here the Tai Chi Swings were extremely useful. After the operation the kinetic/proprioception skills that she’d learned helped her back to work and on to the golf course.

Tai Chi Swings

A shoulder width position of the feet in parallel is taken, with the weight 80% to 90% in one leg. From the waist one turns into the loaded leg, rotating the trunk (navel and nose inline). The first move is to sit back into the empty leg and, turning from the waist, rotate with the weight transfer. The weight shift should feel as though it has travelled down the starting leg below the surface of the ground and into the other leg. This ‘sit back and turn’ creates a figure of eight move through the hips and pelvis. (Since we have stopped squatting to sit or defecate in the west, hip/pelvic mobility has become restricted. The figure of eight move uses bodyweight to work the joint like a rusty doorhinge being worked lose.) Using the spine as the vertical axis, the arms swing and rotate, wrapping themselves around the body like limp spaghetti. Here core muscle activation and in particular use of the obliques rather than the shoulders to manage the turning are key.

Conclusion

Tai Chi empowers the individual through the sensitivity and awareness that the practice of this art demands:

* movement from the ground up

* alignment through the joints and postural awareness

* relaxing the body and releasing tension

* quieting the mind and centring

* breathing to support movement and mental focus

* rhythm and flow to link coordination

* spatial awareness and timing.

All these facets combine to make sense of the complex systems that make us human beings. Tai Chi does it in an elegant and simple way, through the experience of doing. There is a Confucian saying, ‘I hear and I forget, I see and I remember, I do and I understand’. The proof is in the practice. We know in sports medicine that when an element is out of sync with the body’s systems, we get breakdown in technique that can lead to injury. Tai Chi is a model for harmony.

Reference

1. Robert K Cooper Jan 2001Strategy & Leadership Journal)

Further reading

Chungliang Al Huang and Jerry Lynch.Thinking Body, Dancing Mind. Bantam Books. 1992

Bruce Frantzis. The Big Book of Tai Chi . Thorsens, 2003.

Bruce Kumar Frantzis. The Power of Internal Martial Arts. North Atlantic Books, 1998.

Roger Jahnke, OMD The Healing Promise of Qi. Contemporary Books, 2002.

Peter Ralston. Cheng Hsin The Principals of Effortless Power. North Atlantic Books, 1989

Peter Ralston and Laura Ralston. Zen Body Being.Frog Ltd, 2006

Lao Tzu. Tao Te Ching. Penguin Books,1963.