The Chi of Water

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April 2004

By Ruth Sova, MS

Ai Chi is a water movement and relaxation program that has been created to help aquatic therapists and patients enjoy the water in a flowing yet powerful progression. It is an efficient exercise program that increases oxygen and caloric consumption simply with correct form and positioning in the water, it is a perfect relaxation technique for highly stressed, overchallenged patients, and it is ideal for creating improved range of motion (ROM), balance, and mobility.

Created in Japan by Jun Konno, Ai Chi is performed standing in shoulder-depth water using a combination of deep breathing and slow, broad movements of the arms, legs, and torso.

It is an technique that can be used with groups or one-on-one and will expand the therapists’ range. While some protocols can be used with only a specific population group, Ai Chi has been successfully used with: pain management, arthritis, fibromyalgia, COPD, diabetes, multiple sclerosis, amputation, paraplegia, neurological and orthopedic diagnoses, balance deficits, scoliosis, carpal tunnel syndrome, hypertension, cerebrovascular accident, fatigue, eating behaviors, weight control, breast cancer, cardiac and pulmonary rehab, congestive heart failure, prenatal therapy, menopause therapy, immunodeficiency disorders, migraine headaches, anxiety and depressive disorders, and anger management.¹

Patients are introduced to basic concepts of circular movement, breath control, and tranquility as they experience the upper-extremity trunk stability and lower-extremity movements and learn proper pelvic mechanics.

WHY OFFER AI CHI
The original purpose of Ai Chi was relaxation. In our hectic but sedentary world, we found that we needed to exercise, so we set aside the time. Now we find we have cumulative stress symptoms and diseases, and we have to set aside time to relax.

Since Ai Chi began in the United States, we have found anecdotal support for the following responses to the program:

Flexibility, range of motion, balance, coordination, and general mobility increase. There are increases in metabolism, caloric consumption, and blood circulation. The breathing technique massages vital organs and therefore improves liver efficiency. The water and movements are used to free the body of stress and to encourage a state of relaxed awareness, which in turn decreases stress, insomnia, depression, anger, fatigue, anxiety, and confusion. Increased mental alertness is another by-product of relaxed awareness. Finally, the slow, flowing movement creates design sense (a feeling that you are doing what the body was designed to do) and, therefore, improves proprioception.²

In body-mind healing, a level of total, deep relaxation is the most important precondition for curing any disorder. Ai Chi creates that relaxed state. Health and medical professionals are now recognizing that the integration of mind, body, and spirit is what allows us to best cope with life’s problems.³ This integration views the person from a perspective in which the energy flowing through us is more important than our bodies. Integration sees the body as a series of energy channels, the blockage of which is a fundamental cause of disease.⁴

Optimal health, then, is the integration and harmony of mind, body, spirit, and emotions.³ Yet for many health professionals, virtually all attention is placed on physical well-being because it is the most tangible aspect of health. Pain and disease are messengers of information not just of our physical being but of our overall being. Too often we depend on external forces to “fix” our bodies and minds because we are unaware of our own innate ability to achieve health.

THE BOTTOM LINE
Ai Chi postures are used and billed for under the current procedure code for aquatic therapy, which is 97113. If you are not reimbursed for your work with a client, try rebilling under a different code. For example, if an insurance carrier will reimburse for gait training but not for aquatic therapy, and you work with the client utilizing gait training in the water, bill under the gait training code 97116.⁵

Offering Ai Chi has proven to increase private pay clients (see sidebar, page 22) who can use an audiocassette that leads them through the progression or a poolside signboard with drawings of each posture. These clients bring in money, but generally take no extra manpower.

Liability has not been shown to increase; however, any facility with a pool should follow basic safety standards.

PREPARING FOR AI CHI
In preparation for offering Ai Chi, first check your pool: Water temperature recommended for Ai Chi is 88 to 94 degrees. Lower water temperatures can be used after an adequate warm-up. If patients become chilled, stop the program. Blood and oxygen must be moving to the extremities to allow for full ROM. If the patient is chilled, blood will be shunted to the vital organs (not the extremities) and muscles will tense. This is not conducive to relaxation and the full ROM Ai Chi movements. Keep in mind the following requirements:

Space requirements are about 25 square feet per person.
Appropriate depth is usually about 12 to 18 inches lower than the person’s height, or midriff to armpit depth.
A quiet environment has elicited the best results in terms of pain reduction, ROM, etc.
Be sure patients can access the pool easily via a ramp or stairs. There are portable stairs available.
Patients are sometimes unsure in the water. Have a pool edge they can hold on to until they gain confidence.
Equipment is not a part of the Ai Chi program but can be used as an assistive device for special needs. Patients should wear water shoes to protect the facility and themselves from a slip and fall accident.
Hire a therapist/instructor who is able to use Ai Chi from the deck and in the water. Because of the different goals of Ai Chi, any aquatic practitioner can use the program. Depending on billing, a therapist-extender can be used. The best practitioners will be those who understand both the body and its disease processes and the mind as it connects with the body.
Consider your client base: Review health history forms for possible contraindications to use of Ai Chi. There are a few populations who may have trouble with the traditional depth of Ai Chi. Patients with COPD may need to be shallower in the pool on some days because of breathing distress due to the hydrostatic pressure of the water. Bariatric patients may have difficulty with stability and may have to move to shallower water or use ankle weights. When patients are moved to shallower water, arm movements should be lowered.
Train your practitioner: Ai Chi is not a trademarked technique or name so you may use the program and name without licensing fees.
Ai Chi can be learned from a book, video, coworker, or in-person workshop. There are no educational requirements to be completed before using Ai Chi as a therapeutic technique. Konno believes that, after working with Ai Chi, therapists either will want to expand their knowledge or will stop using the technique.

Enjoy it. No two Ai Chi programs will be the same and that is as it should be. Every practitioner will have variationsaccording to what she or her patient needs that day. It is fine to eliminate movements, put them in a different order, and change the tempo or the number of repetitions. Because all patients are different, Ai Chi will serve each of them individually, and they will all perform Ai Chi differently. Experiment with offering the Ai Chi program at your clinic—it may be wonderful or it may not work for you. The basic Ai Chi premise holds: however it turns out is exactly the way it was meant to be.

Ruth Sova, MS, Port Washington, Wis, is president of the Aquatic Therapy & Rehab Institute, is on the Wisconsin Governor’s Council on Physical Fitness; received the Governor’s Entrepreneurial Award, the IDEA Outstanding Business Award, the first Presidential Sports Award in aquatic exercise, and AEA’s 1994 Contribution to the Industry Award; and has authored 15 books.

REFERENCES

Sova R, Konno J. Ai Chi—Balance, Harmony and Healing. Port Washington, Wis: DSL, Ltd; 1996.
Konno J, Sova R. Ai Chi—Flowing Aquatic Energy. Port Washington, Wis: DSL, Ltd; 1996.
Moyers B. Healing and the Mind. New York: Doubleday; 1993.
Chopra D. Quantum Healing, Exploring the Frontiers of the Mind/Body Medicine. New York: Bantam Books; 1989.
Meyer R, Taucher G. Aquatic therapy reimbursement. Aquatic Therapy Journal. 2003;5(2):15-20.

Ai Chi In Action
Here are three examples of Ai Chi programs already in place:

Central DuPage Hospital (suburban Chicago area) has a therapy pool and rehabilitation facility. PTs work in the rehabilitation facility and also [work] in the water...Ai Chi pleases our [clients], and others in the pool area will enjoy the peaceful atmosphere and benefit from the energy flow. Ai Chi is unique—resulting in people talking about it and where to get classes, which is good for the facility. It increases revenue, and people learn more about the facility and pay for classes.

We sell Ai Chi as a therapeutic/wellness class, and those with special needs are the ones who try Ai Chi and stay with the class. Instructor reimbursement is $25 for a 45-minute Ai Chi and preparation time. Program fees are $6/class, and the program runs 6 to 8 weeks. We offer two classes per week. The attendance is consistent, and we allow 12 participants in the therapy pool due to space.
—Patti Crimer, COTA, Aquatic Exercise Specialist

Good Shepherd (Allentown, Pa) is a rehabilitation hospital that provides inpatient and outpatient services. Recreational therapy implements the Ai Chi program, and there are Ai Chi instructors. Our pool is able to accommodate 8 to 10 people. The water temperature for our pool is 95-96 degrees.

Ai Chi:

Offers an alternative program to the traditional exercise programs in the pool.
Provides income to the facility.
Provides a relaxation program for clients once they have completed their traditional therapy programs. It is very beneficial for clients in our Pain Management Program.
Since the program is offered to anyone in our facility, it is also a benefit to the employees.

We offer two group sessions of Ai Chi per week. Each group meets one time per week. We incorporate Ai Chi in our one-on-one therapy sessions in the pool. For reimbursement, group sessions are $80 for an 8-week session. Our clients pay out of pocket. Attendance is about equal to our other group programs.We did not need to change our insurance [to provide Ai Chi].
—Allison Ghorm, CTRS, Senior Recreational Therapist

The Capper Foundation in Topeka, Kan, is a private nonprofit organization that serves people with physical disabilities, primarily children. We have a beautiful warm-water therapy pool. We were looking for a way to increase revenue, so we began to offer Ai Chi to adults in the community.

Our facility has benefited from offering Ai Chi by bringing a new population into the facility. The participants see what we offer to children and become possible future donors. Several have donated beyond the Ai Chi course fees.

The classes are also a good revenue source. We charge $48 for an 8-week session, one time per week. Sessions are 45 minutes long. We have a maximum enrollment of 15. We are currently offering five classes, so the dollars add up quickly. It is a very effective use of staff time since the ratio of instructor to participants is high. We are currently offering only group Ai Chi, but someone could go one-on-one for a $50-per-hour fee. Our attendance is good compared to other programs. A few participants come twice a week.

Since Ai Chi was something new to Topeka, a local TV station contacted us. They featured our Ai Chi program on a ‘Health Matters’ segment for their news. They did a beautiful job and showed a several-minute feature during three different newscasts. We received great free publicity, and our phones rang off the hook with people wanting to enroll.
—Nan Gatewood, CTRS, Recreation Coordinator

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