The use of therapeutic exercises to maintain or improve people's health is not a new concept (Licht and Johnson, 1965). Historians describe their use in Greece as well as India long before the birth of Jesus (Licht, 1965).

But what is covered by the generic term cong fou (gongfu or kung fu depending on the spelling used to translate the Chinese (Florence, 1995)) described by Amiot as early as 1779 in the West, and including the use of a set of postures, movements and breathing exercises, is one of the only types of exercise (along with yoga), which has survived the ages, from its use in ancient China (Adams, Daniel & Rullman, 1975), while evolving to reach us.

It's worth noting that, from the outset, the therapeutic purpose of these exercises is difficult to separate from their use as a martial practice or fighting art (Despeux, 1981, Jwing-Ming, 1997 for taiji quan (or tai chi chuan); Habersetzer, 1991, Jwing-Ming, 1995 for qi-qong (or chi-kung)), a practice which has influenced the evolution of other martial arts, often resulting in today's sporting forms, such as Chinese or Vietnamese martial arts, or even modern Japanese karate-do.
While the use of this type of exercise is classic in the practice of Chinese medicine, it is much less so in the practice of Western medicine (Réquéna, 1991; Voranger, 1988) and its introduction there is much more recent, although often influencing the development of new therapies (e.g. May-Ropers, 1996). The use of physical activity or sport to rehabilitate is of course not unique to the martial arts (see, for example, the use of gymnastic or swimming methods for spinal rehabilitation by Efther and Préau (1991) or the rehabilitation of cerebellar patients by Sultana (1981) ; or the various activities proposed in the proceedings of the IXth congress on adapted physical activities, Minvielle, Caillaud, Ramanantsoa (1997)), for both patients and subjects with motor or mental disabilities (Adams, Daniel & Rullman, 1975; Terranova, 1986; Shepard, 1991).
But, as Lehmann (1981) reminds us, it's not a matter of course to open up sporting activities, even adapted ones, to people with motor disabilities, such as asking them to perform a mae geri-type single-leg strike in karate, when they already have enormous difficulty balancing on their two lower limbs.
On the other hand, whether the subject is an elderly person or a patient, to take account of their past experience, they will not be asked the same thing if they have never practised sport, or if they have already practised a sport, or even a combat sport, sometimes even at a high level (Delpech, 1996). In addition, functional rehabilitation, whose aim is to prevent or reduce deficits, has been described as specific to the elderly, due to the normal biological ageing of the individual (Ribeyre, Rabourdin, 1982), implying that the frequency, intensity, duration and warm-up of the adapted sports exercises proposed must take account of the age of the subjects.
We present here, in the first part, a descriptive, clinical approach to the use of this type of technique derived from the martial arts (Sultana et al., 1997), and in the second part, an attempt to experimentally quantify the effect of their use on a population of elderly people (Gorgy, 1996).
These techniques either derive from the adapted practice of so-called internal martial arts: "Nei-chia kung-fu" (such as qi-qong or tai chi chuan) or external martial arts: "Wai-chia kung-fu" (such as karate), or, in the case of mild impairment of patients, use the practice of these martial arts intended for beginners. This classification between internal and external martial arts is not self-evident, and is the subject of controversy (Dufresne and Nguyên, 1994; Itier, 1997; Raffort, 1997). To simplify (although we are aware that this does not cover the entire phenomenon), some internal martial arts are more supple and slow, others more violent and jerky; some are more concerned with the development of internal energy, which is not very visible, others with physical strength in its visible external manifestations.
CLINICAL APPROACH
The practice of adapted martial arts is a very user-friendly activity for young patients (ataxic, cerebellar, cranial trauma sufferers, whose etiology may vary: multiple sclerosis, etc.), as it is always present and interactive with the rehabilitator, and can sometimes be carried out in a group, including nursing staff wishing to be initiated. These activities enable intensive work on balance and aggression control in a warm, motivating atmosphere (with the possibility of using appropriate background music, in particular to reduce the risk of stress or to normalize the speed of the exercises, which must follow the rhythm imposed by the music).
The activity and exercises offered must be adapted to the patient's personality and degree of disability: punching, kicking, parrying (with or without forward and backward movements), rotations, learning to fall... For example, karate performed in the standing position is mainly suitable for people with intermediate or mild disabilities (Vallet, 1995). Slow movement sequences derived from Chinese gymnastics, such as qi-qong or tai chi chuan, are more suitable for patients with spastic hypertonia, who only need to perform the exercises with a minimum of force (on the assumption that this will avoid exacerbating the spasticity).
In the case of deep-lying spasticity, the exercises should generally be limited to friendly wrestling in low positions. Interest in static and dynamic balance: Balance training is very important in the martial arts, and is therefore used as a postural and locomotor rehabilitation technique (Tse, Bailey, 1992). It is used to hold certain uni or bipedal positions, associated with various movements of the upper limbs, trunk and head, as well as to ensure transfers of body weight from one foot to the other, changes in posture and voluntary and involuntary falls.
Orthopedic benefits: All exercises performed in the standing position are performed with the spine in the correct position, insisting on axial self-expansion without stiffness. The position of each joint is also carefully controlled. Flexibility is not forgotten either, as the movements performed stretch the main musculoaponeurotic chains. Benefits for breathing: Among the various forms of breathing often associated with qi-qong exercises, we'd like to highlight inverted abdominal breathing. This technique is particularly interesting for patients and the elderly. - It massages the intra-abdominal organs by alternating pressure and depression. - It also raises awareness and strengthens the perineal floor muscles, which are called upon with each inhalation, and which must relax with each exhalation. In this way, we avoid distension of the perineum during the inspiratory increase in intra-abdominal pressure. As a result, this type of breathing can play an important role in the treatment of stress incontinence (which is particularly common in the elderly and in former sportswomen).
Breathing is also known to influence postural balance (Jeong, 1991; Bouisset, Duchêne, 1994), hence the importance of knowing how to control it. The technique is very simple: - Inhalation is associated with abdominal and perineal contraction (inhale while drawing in the abdomen and squeezing the anus and perineum); - Exhalation is a time of relaxation (blow out while relaxing the abdomen and perineum).
Psycho-socio-relational benefits of martial arts: The discovery of a new activity, as well as the playful and aesthetic aspect of these exercises, explains the high level of patient motivation. They develop cooperation and solidarity with the teaching team. They have a positive effect on patients' zest for life, and are therefore particularly useful for sad or withdrawn patients. Martial arts ethics advocate self-control and respect for others in all circumstances;
This control is important for patients who tend to be aggressive. What's more, these exercises help maintain a taste for effort (photo 2). Provisional conclusion: motivation, conviviality, improved balance, personal fulfillment while respecting others. With all these characteristics, is it any wonder that the adapted use of martial arts can play a positive role in the physical and psychological development of patients? Finally, because of the relative specificity of each learning process, it is important to understand that internal and external martial arts are not intended to replace functional rehabilitation for these patients, which remains essential: rehabilitation of standing, walking, climbing stairs, dressing, toileting....
EXPERIMENTAL APPROACH
It was from the point of view of the individual's psychomotor development that an attempt was made to demonstrate the effect of the practice of qi-qong, qi gong or chi-kung (qi = energy, qong = discipline), a medical and martial activity said to have originated during the reign of the Yellow Emperor Huang Di between 2690 and 2590 BC, or more probably (Voranger, 1988) during the Han period (200 BC). We had to identify the neurophysiological and neuropsychological aspects specific to this practice.
Complex mechanisms underlie the postural activity and balance essential to qi-qong. It is important to realize that "postural reference is used by the nervous system to calculate the trajectory of voluntary movement in pericorporal space" (Biguer et al., 1988). Posture is a referent around which anti-gravity, axio-proximo-distal reactions and the postural organization of the head and segments are organized. Directly related to posture is the notion of equilibrium, which in turn underlies that of adapted movement. Equilibrium means the state of rest of a body subjected to several forces that cancel each other out.
There are 4 main elements underlying the maintenance of balance during posture (Massion, 1993): - control of the projection of the center of gravity on the ground within the sustentation polygon, - error-detecting signals or sensory re-afferences, - various regulations during movement or coordinations between posture and movement (which include postural reactions, anticipatory postural reactions), during coordinations between posture and breathing, and coordinations between movement and breathing, - the body schema.
Qi-qong exploits these mechanisms through 3 classes of postures (sitting, lying and standing), and its practice aims to lead the practitioner towards an internal work of tonic regulation, relaxation, breathing, tactilo-kinesthetic and topographical knowledge of the body, spatial knowledge, knowledge of the body's static and dynamic properties, with a view to optimizing the various coordinations leading to adapted movement. It is essential to place Qi-Qong's practice of slow movement under predominant proprioceptive control.
Indeed, slow practice allows us to control movement, to correct errors at every moment through feedback loops concomitant with the task, and requires very fine, continuous control of posture. According to the theories of Adams (1971) and Schmidt (1975), the subject compares his or her present action to an internal model or reference memory of the gesture, with the pathological hypothesis of a reduction or disappearance of this reference. Qi-qong is therefore a slow, internalized motor activity (internal kung fu) which can, by extension, be actualized in fast, external martial practices (external kung fu).
METHODS
In the context of psychomotor rehabilitation of the elderly, an experimental protocol was initiated to verify whether qi-qong could improve the subjects' performance. The aim of the rehabilitation was to slow down the onset of psychomotor deficits (gestural coordination and praxis, spatial representation, fine motor skills, muscle strengthening, memory and calculation, etc.) caused by natural aging, or to improve and reduce these deficits.
Two groups (drawn from an elderly mutualist population with no neurological antecedents), of 5 subjects each, were assessed at a time T0 by a test derived from the Lincoln-Oseretski originally composed of 36 items (Roger, 1984), adapted to adults and the elderly with 16 items.
This test is composed of 4 groups of motor items
(G1: balance, G2: general dynamic coordination, G3: fine motor skills, G4: neurological).
For G1, we find, for example, the ability and manner (with more or less oscillation, arm movement, etc.) of standing for 10 to 15 seconds with feet aligned, balancing on tiptoe, balancing on one foot with eyes open and closed.
For G2 we found walking backwards, tapping rhythms with feet and hands at the same time while sitting... Each group attended two psychomotor re-education sessions per week, identical in content, one lasting 2 hours and the other 1 hour. During the 2-hour session, one of the 2 groups practised qi-qong for 1/2 to 3/4 of an hour, under the guidance of one of the authors of the article, who was trained as both a psychomotor therapist and a qi-qong teacher. The total duration was around 40 to 50 hours of qi-qong, spread over a period of 7 to 8 months. The average duration of psychomotor rehabilitation for the test group was 1 year 2 months, and for the control group 4 years 4 months.
RESULTS
Statistical analysis using ANOVA after re-assessment at time T1 showed that the difference in results between test T0 and retest T1 was highly significant for the qi-qong group [F(1, 8) = 34.9; p < 0.0004] and significant for the control group [F(1, 8) = 5.9; p < 0.041], suggesting a positive effect of training for both groups of subjects.
A comparison of the scores of the 2 groups showed that the difference between the results on the initial T0 test was not significantly different [F(1, 8) = 1.11; p < 0.32].
On the other hand, the difference between the 2 groups' T1 retest results was significantly different [F(1, 8) = 8.44; p < 0.019], thus objectifying the differential effect due to qi-qong.
Figure 1 shows that the change in test/retest results was greater for qi-qong subjects than for control subjects. The study of interaction shows a significant difference between the evolution of results obtained between test and retest situations for the qi-qong group compared to that of the control group [F(1, 8) = 6.08; p < 0.04]. Figure 2, showing the individual results of the 5 elderly subjects practicing qi-qong, shows that the effect was obtained in all subjects, albeit to varying degrees.
There were no negative effects from practising qi-qong, and a satisfaction questionnaire showed the subjects' interest in the exercises practised.
CONCLUSION
From the results of this study, and of a study on tai chi (Tse, Bailey, 1992), we can deduce that qi-qong and tai chi have a therapeutic efficacy in the psychomotricity of the elderly that seems probable, in particular on postural balance, but we would need to verify this with a study involving a larger sample of subjects, and compare it with other rehabilitative methods.
The question should also be asked whether and how the practice of slow movement (involving control and execution mechanisms distinct from fast movement) can really bring about better management of speed, for example in combat sports and martial arts, or better management of everyday actions. In particular, it is essential to place this work on slow movement within that of quality and precision of gesture, leading to better effort management on the part of the individual, as well as achieving a genuine economy of gesture in the elderly. In addition to the physiological effects of qi-qong, its potential psychological benefits should not be overlooked (the effect of dynamic relaxation, for example).
From this perspective, qi-qong seems to be a practice that can lead the individual to a genuine search for physical, physiological and psychological balance.
GENERAL DISCUSSION
If, from an empirical point of view, the use of adapted sports or martial arts practices is indeed interesting for the psychomotor rehabilitation of patients, it would only be from the point of view of their psychology by the pleasure patients derive from taking part in these activities, which brings them closer to the practice of healthy people as conveyed by the image of sport in our society.
This result would also seem to be supported by over a thousand references on the therapeutic virtues of these practices, with all the difficulties encountered in understanding these studies based on references from traditional Chinese medicine (Ribaute, 1987; Gascoigne, 1997). Unfortunately, most of these references do not meet the criteria for publication of scientifically proven results.
Among the few studies that do support these criteria, the effect of qi-qong training on cortical activity (Zhang, Li and He, 1988; Zhang, Zhao and He, 1988) and on subjects' resistance to increased gravity due to centrifugal force (Guo et al., 1988 and 1991) has been demonstrated.
On the other hand, quantifying the general improvement in motor functions poses a completely different problem, even if the results obtained are encouraging.
This problem naturally arises for use in the rehabilitation of all sports (Gabel, 1986). It also applies to quantifying the effect of sports training in general (Crémieux et al., 1995; Durny and Avanzini, 1998), or the effect of exercise on postural balance in the elderly (Lichtenstein et al., 1989). It also applies to any technique for the general assessment of motor disorders and their evolution over time (e.g. the Tinetti test, 1986, which analyzes the balance of subjects in different motor activities, separating static and dynamic balance), for which there is no consensus on a universally recognized method (Berg et al., 1989; Fugl- Meyer et al., 1975; Gatev et al., 1996; Sanford et al., 1993). The same applies to quantifying the subjective state of fitness of patients who have undergone adapted exercise. In his review of research into combat sports, Pieter (1994) found that the Chinese styles studied (tai chi chuan, wing chun) had a lower aerobic demand (measured by VO2 Max) than the Korean or Japanese styles (tae kwon do and karate), reflecting rather different forms of work; tai chi chuan itself differed from wing chun in that tai chi had a higher respiratory efficiency (Schneider, Leung, 1991).
But it is difficult to link these quantified results of the effects of practice with what we might call the state of fitness felt by the subjects (Buestel, 1982), the improvement of which is also one of the aims of the therapeutic exercises proposed in rehabilitation (Yardley, Hallam, 1996). We can see that in this field, much remains to be done in terms of scientific validation of the use of these methods derived from combat sports and martial arts, even if empirically they seem to bring interesting results. In all cases where these methods are used, it is important to remember that they are not intended to replace traditional rehabilitation techniques, but rather to complement them.
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