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 in 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 few 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 should be noted that from the beginning, the therapeutic aim of these exercises is difficult to separate from their use as a martial practice or combat 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 that has influenced the evolution of other martial arts, which have often given rise to the current sporting forms, such as Chinese or Vietnamese martial arts, or even modern Japanese karate-do.

 

If 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 a physical or sports activity to rehabilitate is of course not specific to the martial arts (see for example the use of gymnastic or swimming methods for vertebral 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)), both in patients and subjects with motor or mental disabilities (Adams, Daniel & Rullman, 1975; Terranova, 1986; Shepard, 1991).

 

But, as Lehmann (1981) reminded us, it is not self-evident to open up sports activities, even adapted ones, to people with motor disabilities, such as asking them to perform a one-legged strike of the mae geri type in karate, when they already have enormous difficulties in balancing on their two lower limbs.

 

On the other hand, whether the subject is an elderly person or a patient, in order to take account of his past experience, he will not be asked the same thing if he has never practised sport, or if he has already practised a sport, or even a combat sport, sometimes even at a high level (Delpech, 1996). Furthermore, functional rehabilitation, the aim of which is to prevent or reduce deficits, has been described as specific in the elderly because of the normal biological ageing of the individual (Ribeyre, Rabourdin, 1982), thus implying that the age of the subjects must be taken into account in the frequency, intensity, duration and warm-up of the adapted sports exercises proposed.

 

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).

 

This type of technique either derives from the adapted practice of so-called internal martial arts: "Nei-chia kung-fu" (qi-qong or tai chi chuan type) or external: "Wai-chia kung-fu" (karate type), or, in the case of slight impairment of the patients, uses the practice of these martial arts for beginners This classification between internal and external martial arts is not obvious and is subject to controversy (Dufresne and Nguyên, 1994; Itier, 1997; Raffort, 1997), to simplify (while knowing that this does not cover the whole phenomenon) some, the internal ones, would be rather supple and slow, others rather violent and jerky, some would be especially interested in the development of the internal energy, which is not very visible, others in the physical force in its visible external manifestations.

CLINICAL APPROACH

 

This practice of adapted martial arts constitutes a very convivial activity for young patients (ataxic, cerebellar, cranial traumatised, whose aetiology can be variable: multiple sclerosis...), because always in permanent presence of the reeducator and in interaction with this one, and being able sometimes to be carried out in group, including including nursing staff wishing to be initiated. These activities allow intensive work on balance and control of aggressiveness in a warm and motivating atmosphere (possibility of using appropriate background music, in particular to reduce the risks of stress or to normalise the speed of the exercises, which must follow the rhythm imposed by the music).

 

The activity and the exercises proposed must be adapted to the patient's personality and the degree of disability: punching, kicking, parrying (whether or not associated with forward and backward movements), rotations, learning to fall, etc. Thus, karate performed in a standing position is mainly suitable for subjects with an intermediate or mild disability (Vallet, 1995). Slow movement sequences from Chinese gymnastics such as qi-qong or tai chi chuan are more suitable for patients with spastic hypertonia who only need to do the exercises with a minimum of force (with the hypothesis that this avoids exacerbating the spasticity).

 

In deep damage, one should generally limit oneself to friendly struggles in low positions. Interest in static and dynamic balance: The work of balance is very important in martial arts and therefore for its use as a postural and locomotor rehabilitation technique (Tse, Bailey, 1992). Indeed, 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.

 

Orthopaedic interest: All exercises that are performed in the standing position are done with the spine in the correct position, insisting on axial self extension without stiffness. The position of each joint is also carefully controlled. Flexibility is not forgotten since the movements performed allow the stretching of the main musculoaponeurotic chains. Interest for the breathing: Among the various forms of breathing often associated with the exercises of qi-qong, we will insist on the reversed abdominal breathing. This technique is particularly interesting for patients and for the elderly. - It allows a massage of the intra-abdominal organs, by alternating pressure and depression at their level. - It also allows for an awareness and strengthening of the muscles of the perineal floor which are solicited with each inspiration, and which must be relaxed on expiration. This avoids distension of the perineum during the increase in inspiratory intra-abdominal pressure. As a result, this breathing can play an important role in the case of stress incontinence (this type of incontinence is particularly frequent in elderly people and in particular in former sportswomen).

 

It is also known that breathing influences postural balance (Jeong, 1991; Bouisset, Duchêne, 1994), hence the interest in knowing how to control it. The technique is very simple: - Inhalation is associated with an abdominal and perineal contraction (inhale by pulling in the belly and squeezing the anus and the perineum); - Exhalation is a time of relaxation (blow out by relaxing the belly and the perineum).

This control is important for patients who tend to be aggressive. In addition, these exercises help to maintain a taste for effort (photo 2). Provisional conclusion: motivation, conviviality, improvement of balance, personal development in respect of others. With all these characteristics, is it any wonder that the adapted use of martial arts can play a role in the physical and psychological development of patients? Finally, because of the relative specificity of each learning, it is important to understand that internal and external martial arts do not pretend to replace the functional rehabilitation of these patients which remains essential: rehabilitation of standing, walking, climbing stairs, dressing, washing....

 

EXPERIMENTAL APPROACH

 

It is under the aspect of the psychomotor development of the individual that it was tried to demonstrate the effect of the practice of qi-qong, qi gong or chi-kung (qi = energy, qong = discipline), a medical and martial activity which would have been born under the reign of the Yellow Emperor Huang Di between 2690-2590 B.C. or more probably (Voranger, 1988) at the time of the Han (200 years before J.C.) It was necessary to identify the neurophysiological and neuropsychological aspects specific to this practice.

 

Complex mechanisms underlie the essential postural and balance activity in qi-qong. It is important to realise that "the postural reference is used by the nervous system to calculate the trajectory of the voluntary movement in the pericorporal space" (Biguer et al., 1988). Posture is a referent around which the anti-gravity, axio-proximo-distal reactions, the postural organisation of the head and the segments are organised. A notion directly linked to that of posture is that of balance, which itself underlies that of adapted movement. Equilibrium means the state of rest of a body solicited by several forces that cancel each other out.

 

There are 4 main elements that underlie the maintenance of balance during posture (Massion, 1993): - The control of the projection of the centre of gravity on the ground within the sustentation polygon, - The error-detecting signals or sensory reafferences, - The 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 diagram.

 

Qi-qong exploits these mechanisms through 3 classes of postures (sitting, lying and standing) and its practice tries to bring the practitioner towards an internal work of tonic regulation, relaxation, breathing, tactilo-kinesthetic and topographical knowledge of the body, spatial knowledge, knowledge of the static and dynamic properties of the body in order to optimize the various coordinations leading to the adapted movement. It is essential to place Qi-Qong in its practice of slow movement under predominant proprioceptive control.

 

Indeed, the slow practice makes us enter the possibility of controlling the movement, of correcting the errors at each moment by feedback loops concomitant with the task, and requires a very fine, continuous control of the posture. According to the theories of Adams (1971) and Schmidt (1975) the subject would compare his present act to an internal model or memory of reference of the gesture, with in pathology the hypothesis of a reduction or disappearance of this reference. Thus qi-qong is an internalised and slow motor activity (internal kung fu) but which can, by extension, be actualised in external and rapid martial practices (external kung fu).

METHODS

 

It is within the framework of the psychomotor rehabilitation of the old person that was engaged an experimental protocol aiming at checking if the qi-qong could improve the performances of the subjects. The aim of the re-education was to allow a slowing down of the appearance of psychomotor deficits (gestural coordination and praxis, representation of space, fine motor skills, muscular reinforcement, memory and calculation...) caused by natural ageing, or an improvement with a reduction of these deficits.

 

Two groups (drawn from an elderly mutualist population with no neurological antecedents), of 5 subjects each, were evaluated at a time T0 by a test derived from the Lincoln-Oseretski originally composed of 36 items (Roger, 1984), adapted to the adult 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 possibility and the manner (with more or less oscillations, movement of the arms...) to stand for 10 to 15 seconds with the feet aligned, the balance on the tiptoes, the balance on one foot with the eyes open and closed.

 

For G2 we find walking backwards, tapping rhythms with feet and hands at the same time while sitting... Each group had two psychomotor re-education sessions per week, identical in content, one of a normal duration of 2 hours and one of 1 hour. One of the two groups practised, during the 2-hour session, qi-qong for 1/2 to 3/4 of an hour, under the direction 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 about 40 to 50 hours of qi-qong which were spread over a period of 7 to 8 months. The duration of psychomotor rehabilitation for the test group was on average 1 year 2 months, and for the control group 4 years and 4 months.

RESULTS

 

The statistical study carried out by analysis of variance after re-assessment at a time T1 showed that the difference in results between the T0 test and the T1 retest 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], this being in the direction of a positive effect of the training for the 2 groups of subjects.

 

Furthermore, a comparison of the scores of the two groups showed that the difference between the results of the initial T0 test was not significantly different [F(1, 8) = 1.11; p < 0.32].

 

On the other hand, the difference between the results of the T1 retest of the 2 groups was significantly different [F(1, 8) = 8.44; p < 0.019], thus objectifying the differential effect due to qi-qong.

 

Figure 1 shows this evolution of the test/retest results more important for the qi-qong subjects than for the control subjects. The study of the interaction shows a significant difference between the evolution of the results obtained between test and retest situations for the qi-qong group compared to the control group [F(1, 8) = 6.08; p < 0.04]. Figure 2, which shows the individual results of the 5 elderly qi-qong subjects, shows that the effect is obtained in all subjects, although to varying degrees.

 

There was no negative effect of practising qi-qong, and a satisfaction questionnaire showed the subjects' interest in the exercises practised.

 

CONCLUSION

 

From the results of this study, and from a work on tai chi (Tse, Bailey, 1992), we can deduce that qi-qong and tai chi have a therapeutic effectiveness in psychomotricity of the elderly which seems probable, in particular on postural balance, but it would be necessary to ensure this by a study on a larger sample of subjects, and to compare with other reeducational methods.

 

It should also be asked whether and how the practice of slow movement (using control and execution mechanisms distinct from fast movement) can actually provide 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 of slow movement in that of quality and precision of the gesture leading to a better management of the effort on the part of the individual, as well as obtaining a true economy of gesture in the elderly person. In addition to the physiological effects of Qi-Qong, one should not dismiss its possible psychological benefits (effect of dynamic relaxation for example).

 

From there, the qi-qong seems to constitute a practice being able to bring the individual to a true search for physical, physiological and psychological balances.

GENERAL DISCUSSION

 

If, from an empirical point of view, it seems that the use of adapted sports or martial arts practices is interesting for the psychomotor rehabilitation of patients, it would only be from the point of view of their psychology by the pleasure of the patients to participate in these activities, which brings them closer to the practice of healthy people as it is conveyed by the image of sport in our society.

 

This result would also seem to be based on more than 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 works that do support these criteria, it has been possible to prove the effect of Qi Qong training on cortical activity (Zhang, Li and He, 1988; Zhang, Zhao and He, 1988) and on the resistance of subjects to the increase in gravity due to centrifugal force (Guo et al., 1988 and 1991).

 

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 the use in rehabilitation of all sports (Gabel, 1986). It also arises for the quantification of 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 arises for any technique for the general evaluation of motor disorders and their evolution over time (e.g. the Tinetti test, 1986, which analyses the balance of subjects in different motor activities by separating static and dynamic balance) for which there is no consensus on a universally recognised method (Berg et al., 1989; Fugl-Meyer et al., 1975; Gatev et al., 1996; Sanford et al., 1993). The same applies to the quantification of the subjective state of fitness of patients who have undergone these adapted sports exercises. In his review of research on 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), which reflects rather different forms of work; tai chi chuan itself differed from wing chun in the sense that tai chi had a better respiratory efficiency (Schneider, Leung, 1991).

 

But it is difficult to link these quantified results of the effects of the practice and what can be called the state of form 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 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 of use of these methods, we recall that they are not intended to replace traditional rehabilitation techniques but to complement them.

BIBLIOGRAPHY

 

Adams, J.A. (1984). Learning of movement sequences. Psychological Bulletin, 96/1, 3-28. Adams, R. C., Daniel, A. N. and Rullman L. (1975). Games, sports, and exercises for the physically handicapped. Lea & Febiger (Eds), Philadelphia, 308 p. Amiot, J.M. (1779). Notice du Cong-Fou des bonzes Tao-sée. In Mémoires concernant l'histoire, les sciences, les arts, les mœurs, les usages, des chinois par les missionnaires de Pe-Kin. Paris, vol. 4, 441. Berg, K., Wood-Dauphinée, S., Williams, J.I. and Gayton, D. (1989). Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada, 41/6, pp. 304-311. Biguer, B., Donaldson, I.M., Hein, A., and Jeannerod, M. (1988). Neck muscle vibration modifies the representation of visual motion and direction in man. Brain, 111, 1405- 1424. Bouisset, S. & Duchêne, J.-L. (1994). Is body balance more perturbed by respiration in seating than in standing posture? NeuroReport, 5, 957-960. Buestel, C. (1982). Estimation of fitness using chronaxis, rheobase, achilles reflexogram and VO2 max measurements. Cinésiologie, XXI, 267- 273. Crémieux, J., Perrin, P. and Mesure, S. (1995). Posture, balance and physical and sports activities. In " Abrégé de biologie et pratique sportive ", Masson (Paris), pp 98-113. Delpech, E. (1996). Early sport and patients with brain injury. Kinésithérapie scientifique, 35, 14-17. Despeux, C. (1981). Taiji Quan, martial art, technique of long life. Guy Trédaniel, Paris, 316 p. Dufresne, T. & Nguyên, J. (1994). Dictionary of Chinese martial arts. Budostore, Paris. 287 p. Durny, A. & Avanzini, G. (1998). Aptitudes psychomotrices et performance: étude en boxe française. in Recherches sur les sports de combat et les arts martiaux: Bilan et perspectives. Audiffren M., Brisswalter J., Crémieux J., Fouquet G. & Terrisse A. Dossiers E.P.S., forthcoming. Efther, G. & Préau, J.P. (1991). Gymnastic methods of vertebral rehabilitation. Encycl. Méd. chir, (Paris, France). Kinésithérapie-Réducation fonctionnelle, 26050 A10, 1-20. Florence, R. (1995). The importance of romanizing chinese martial arts terms. Journal of asian martial arts, 4/1, 10-31. Fugl-Meyer, A.R., Jääskö, L., Leyman, I., Olsson and S., Steglind, S. (1975). The post stroke hemiplegic patient. 1. A method for evaluation of physical performance. Scand J. Rehab. Med, 7, 13-31. Gabel, A. (1986). Falls in the elderly: will dance reduce their incidence? J. Human Movement Studies, 12, 119-132. Gascoigne S. (1997). The chinese way to health. Hodder and Stoughton, London, 160 pp. Gatev, P., Thomas, S., Lou, J-S., Lim M. & Hallet, M. (1996). Effects of diminished and conflicting sensory information on balance in patients with cerebellar deficits. Movements disorders, 11/6, 654-664. Gorgy, O. (1996). Introduction of slow movement in psychomotor rehabilitation of the elderly through the practice of qi-qong. Evolutions psychomotrices, 8/31, 39-49 Guo, H-Z., Zhang, S-X., Jing, B-S. and Zhang, L-M. (1988). A preliminary report on a new anti-G maneuver. Aviation, Space and Environmental Medicine, 59, 968-972. Guo, H-Z., Zhang, S-X. and Jing, B-S. (1991). The characteristics and theoretical basis of the Qigong maneuver. Aviation, Space and Environmental Medicine, 62, 1059- 1062. Habersetzer, R. (1991). Chi-Kung. The mastery of internal energy. Amphora, Paris, 197 p. Itier, R. (1997). The art of Chinese combat: presentation of wushus. Generation Tao, 1, 54-61. Jeong, BY. (1991). Respiration effect on standing balance. Arch. Phys. Med. Rehabil, 72/9, 642-645. Jwing-Ming Y. (1995). The roots of Chinese chi kung. Budostore (Paris). 351 p. Jwing-Ming Y. (1997). Superior Tai Chi Chuan. Internal energy: Principles and theories of chi and jing. Budostore (Paris). 273 p. Lehmann, R. (1981). Le sport pour les grands handicapés physiques. La démarche pédagogique de l'éducateur sportif. Cinésiologie, 82, 441-451. Licht, S. (1965). History. In: Therapeutic exercise, Licht S., Johnson E. (Eds.), The Williams & Wilkings Company, Baltimore, pp. 426-471. Licht, S. & Johnson E. (1965). Therapeutic exercise. The Williams & Wilkings Company, Baltimore, 937 pp. Lichtenstein, M.J., Shields, S.L., Shiavi, R.G. & Burger, M.C. (1989). Exercise and balance in aged women: a pilot controlled clinical trial. Arch. Phys. Med. Rehabil, 70, 138-143. May-Ropers, C. (1996). NOWO balance, a movement and balance therapy or playing with your body. Publicity document, Kreuth/Tegernsee (Germany), 9 p. Massion, J. (1993). Major anatomical-functional relationships in the cerebellum. Rev Neurol, 149/11, 600-606. Minvielle, G., Caillaud, C. & Ramananstoa, M-M. (1997). Actes des IXe journées francophones des activités physiques adaptées. Poitiers, 95 p. Pieter, W. (1994). Research in martial sports: A review. Journal of Asian Martial Arts, 3/2, 11-47. Raffort, P. (1997). The art of Chinese combat: "Tai ji" in the internal styles. Generation Tao, 1,