In this podcast, Melanie Hamilton-Basich, chief editor of Rehab Management and Physical Therapy Products, talks with Karen Danchalski, PT, DPT, who has been practicing physical therapy for 25 years and has a special interest in mindful movement. They discuss how incorporating qigong and other types of mindful movement practice into physical therapy can benefit both patients and therapists.
For more information about mindful movement and physical therapy, read Karen Danchalski’s series of articles on the subject:
Karen Danchalski, PT, DPT, has been practicing physical therapy for 25 years. She currently practices in an outpatient orthopedic clinic and delivers outpatient level of care in the home setting. Karen is the education coordinator at Rehab at Home at Northwell Health where she organizes lectures for homecare therapists. She has a special interest in mindful movement and uses the practices of qigong and Pilates with her therapy clients. Karen has been a certified Stott Pilates instructor since 2013 and is a member of the National Qigong Association. She is the author of several articles written for therapists on the topics of mindful movement, pain, and personalized healthcare. She is pursuing a science writing certificate from University of California San Diego and is a member of the American Medical Writers Association.
This is Melanie Hamilton-Basich, chief editor of Rehab Management and Physical Therapy Products. For today’s podcast episode, I’m joined by Karen Danchalski, PT, DPT, who has been practicing physical therapy for 25 years and has a special interest in mindful movement. We’ll be talking about how incorporating Qigong and other types of mindful movement practice into physical therapy can benefit both patients and therapists. Thank you for being here today Karen. I know you’ve been practicing Qigong, which is a form of mindful movement, similar to Tai Chi for many years, and you’ve written a series of articles about your practice for us, but many people still might not be familiar with mindful movement or they might question whether it provides legitimate health benefits. With that in mind, how would you describe mindful movement and what place does it have in modern healthcare and physical therapy treatment? Well,
Mindful movement is actually an exercise modality, and it has some components to it that sort of tie all mindful movement practices together. So whether you’re talking about Tai Chi, Qigong, yoga, and then there’s other types as well, such as Pilates. Some people may have heard of the Feldenkrais Method, the Alexander method, and we can kind of think of many of these practices as falling under the umbrella of mindful movement. So what does that mean? So the three main components that tie these modalities together is, number one, there is a focus on body awareness. So that might mean the quality of your movement, the direction of your movement, how your body is moving in space, but it also can mean more internal awareness. And there’s a word here that they use called interoception, and that is the awareness of changes that are happening with our breath, maybe our heartbeat.
And so turning inward and being more aware of what is happening inside the body as we are doing the exercise. Number two is intention. So mindful movement practices have an intention to movement. So we’re not just going through an exercise just to get it done. We are rather finding a purpose in the movement. And sometimes that can be a mental thing. It could be like an imagery thing. So we could be thinking about moving gently, floating our arms up as light as feathers, or we can think about moving powerfully in the legs. And as though we are pushing up a mountain, for example, often, and I actually do Qigong, so even though I’ve mentioned that mindful movement encompasses several different modalities, I personally practice Qigong, so I can speak more specifically to that as we go forward. But in Qigong, a lot of the mental imagery is around nature and animals.
So we can imagine how it might feel to flow like water or how it might feel to move like a tiger or a bird, for example. So moving with intention. And number three is a focus on deep, slow, diaphragmatic breathing. Okay. So just to recap, the three main components that really tie mindful movement practices together are number one, body awareness, number two in intention. And number three, focus on the breath. And what happens is there is a goal that we have in mind when we are doing these practices, and that is to practice with a calm and focused mind, again, to become aware of the sensations in our body. And ultimately, this allows us to enter into a flow state, and it’s been shown through research that this flow state or this state where the mind is calm yet focused really provides a good place for healing. And so that’s where my love of doing Qigong with physical therapy patients comes in because I’m using it truly as a healing practice for my patients.
I’m glad you bring that up because there are probably some people out there who are thinking, oh, is this real? But as you say, research shows that it can be very helpful for so many things, including healing.
Yeah, exactly. And I was actually really surprised to learn that there are thousands, thousands upon thousands of abstracts that are deal with studies that look at mindful movement and the benefits that they have in healing. There is the Qigong Institute that put out a report in 2022 that was a curated collection of research studies. And it’s really a wonderful document because you can go and pick and choose what ones you’re interested in looking at. And what is interesting is that it’s not so much the specific modality or the specific exercise like how many times did you do it and what exactly did you do with the patient? It’s more just looking at what ties all these modalities together, which is again, focusing the mind and paying attention to the breath and moving with intention. So you were asking about modern medicine and where this all fits in.
So it really has pervaded, I guess that’s the word, modern western healthcare. So the VA, for example, has a whole program called Whole Person Health where they are focusing on much more than just the physical problem with the patient, but rather including mental health and psychological, emotional, even spiritual components to a person’s wellbeing. And they specifically recommend things like Tai chi and Qigong and yoga as part of health. The Harvard Medical School also is a good proponent of doing Tai Chi for health. The American College of Sports Medicine clearly defines exercise as medicine, so moving our bodies and specifically Tai chi and other mindful movement practices as being beneficial. So when you really look at these big institutions, and I think it’s not hard to find, even if you go into large healthcare systems throughout the country, wherever you live, check out newsletters and what your large institutions are recommending. And I bet you’re going to find recommendations to do some mindful movement.
Right. And I think that has changed in recent years that it’s become even more accepted, it seems.
Right. And I guess too, I just want to point out the biopsychosocial model of healthcare is really the current model that we as healthcare providers use. So we’ve really gone away from this idea that we’re just treating a physical problem and we’re really including all these other dimensions into how we treat the patient. So I already mentioned a little bit about the mental and emotional psychological wellness, but there is also a spiritual component. There’s also relationships, so how your patients are relating to you as a provider belief system. So there’s all these things outside of just the injury or the person’s illness that really can help define whether or not they are healthy or whether their quality of life or how they perceive their health to be. So we are really starting to look at more than just pills, more than just medicine. And this is a type of exercise that can be really helpful. So
There are many aspects to mindful movement as you were talking about. What was it that really drew you to Qigong and the practice of mindful movement in general?
Sure. Well, if I really look back, I would say I was a dancer. I was not a professional dancer, but I danced all throughout my childhood and into college. And so the idea of moving to express emotion or intention always spoke to me. And Qigong and Tai Chi feels a lot choreography to me as a dancer. So even though we don’t practice these things for the purpose of looking good, I want to just emphasize that it’s really about how we’re feeling on the inside and the meditative component. I will not lie to you. I am drawn to the beauty of it and moving your body in such dynamic ways. I also have always just been interested in alternative forms of healthcare. So I did some reading on traditional Chinese medicine, and I found a book called Walking the Way, written by Robert Rosenbaum, who is a psychotherapist.
He’s a zen Buddhist and a Qigong instructor. And it was a beautiful book where he was recounting poems from the Tao Te Ching, 81 poems. And I was really moved by it. And lo and behold, I discovered he was teaching a week long retreat on Qigong and at a place that was just a couple hours from my house and I decided to go. And that was my first introduction to Qigong learning movements.
And honestly, I was more excited on learning about it, how Qigong could help my patients even more so than myself, because I immediately saw how movements could be broken down into simple chunks or simple exercises. They could be linked together in small routines. They required very little space, no equipment, there’s no cost, and it could really help a wide variety of patients. So I think I was just kind of drawn to those two things. The fact that it’s a beautiful art form, I feel, and it is used to enhance health. So it was kind of combining my two loves moving with physical therapy and helping patients. And then from there I found an online community that I still take classes with and attend lectures. And so I still do it and I still teach it with my patients.
So how do you use Qigong in your work? Can you share some more specifics about how it is helpful to your patients?
So as a therapist, I typically divide my time between manual work and exercise. So I work in a hands-on manual clinic that really focuses on pain management. So I usually do some sort of manual work. And then honestly, I often do traditional PT exercises, so I just want to be clear about that. It’s not like I’ve closed the door on everything I’ve learned about PT and I just do Qigong. That’s ridiculous. I don’t do that. But what I have found is that Qigong has really reached certain patient populations. And so I have one patient, she has dermatomyositis, which is a systemic autoimmune disease. It attacks the muscles and the skin. And she has repetitively told me that traditional PT exercises don’t work for her. And so I do Qigong with her. So I’ve taught her a lot of different routines, and she says that the meditative component really helps her pain, the fluidity of the movement really helps her pain.
The fact that there’s a lot of attention to breathing really helps. So I think chronic pain syndromes can do really well with this sort of thing. Just a couple other examples. Patients nearing the end of their rehab, I had a shoulder patient who had been coming to me for a while, I think she was a shoulder replacement, and she was almost done with pt. And she asked me, “Karen, do you have anything new? Do you have anything kind of fun and different? Just I’ve been doing the same exercises for a while now.” And so Qigong has given me more tools. It’s like more repertoire in your toolbox. So I said, “Sure, I’ll show you some new stuff.” So certain arm movements, yes, it’s a shoulder patient, but certain arm movements incorporate forearm and hand twisting and things like that. And so I showed her some things that were new and different.
Let me just throw out a couple more at you. Elderly patients with dementia. I’m not sure. This is just my opinion. I can’t tell you that this is proven, but I feel like when I do a Qigong routine with a patient like that, I’m incorporating a lot of things that challenge them. So getting them up in standing, building their stamina up, challenging their coordination, because a lot of movements, you have to move the arm with the leg or you’re twisting the body while you’re weight shifting to one side. And it’s also challenging their focus because they have to really pay attention.
So I use it with that, balance, any diagnosis that has a balance component to it. A lot of exercises work on weight shifting, so that single leg stance exercises and finally, arthritis patients. So there are a lot of warmup routines where you’re doing either hip circles or back circles. And some of these things may have funny names to them, but really when you boil them down to their components, you’re moving the body body in ways that PTs really can understand, whether it’s a circular movement with a hip or you’re flexing or extending, bending the knees, reaching up and extending the shoulders. So any arthritis patient I think can have fun with some of these movements.
Right. It sounds like it can be great for engaging certain patients who are looking for something additional, something more, something different to compliment what you’re already doing.
Yeah, and I will say this though, I wouldn’t say that this is awesome for every single patient you have, and you should just force it on everyone. Of course not. You will know as a therapist. I think therapists are excellent at reading people’s emotions and energy levels and kind of meeting patients where they’re at, I think that’s one of our strengths as therapists. So you know there are going to be some patients that they don’t have the patience for this, because it does require a certain level of stillness, a certain level of slowness and patience to really get into your body and feel what’s going on. And there are some people that have just no time for that, and that’s just the reality. And that’s okay, but you’ll know who those patients are and who really loves it.
So what are the benefits that therapists can get out of practicing mindful movement themselves?
Well, I think that’s a good question. And honestly, it’s the same as what your patients can get out of it, because I often do the exercises with my patients, so I’m leading them through a routine or I’m demonstrating the routine, and I kind of get into it with them. So I’m benefiting right alongside with them. And so I think that that’s good. And I think that also learning just a whole new set of cues, we didn’t really get into that too much yet. I don’t know if we will, but there’s lots of ways that we can practice Qigong with our patients. So I don’t know if it’s okay if I could just jump into that now, but-
Okay, great. I’ll kind of go through them relatively quickly, but I think this is important because therapists can really kind of sink their teeth into how they can use Qigong with their patients with this.
So you can practice on six or seven different levels. And honestly, I kind of just do the first three levels with my patients, or actually the first four. So the first one is physical. There’s just the physical level, we’re just moving. So think of it as I’m stretching my muscles, I’m moving my joints, I’m bending, I’m going moving this way or that way. And a lot of the chigong exercises are very repetitive. So once you learn the routine, it kind of gets ingrained in your mind and in your body, and you’re just showing the patients how to move. And it’s very physical. The second level is more… Well, actually there’s a second level that is kind of considered physical, and that is the elasticity level where you’re getting into a little more of a stretch, feeling the end ranges of your tissues. And in fact, there’s a typo Qigong called muscle tendon changing.
That is, that’s actually the name of it. And so it feels very much like neural tension principles. So therapists are aware of different neural tension exercises. So that’s what this type of Qigong feels like, so you can practice on that level. Third is the mental level, which is where we’re getting more into imagery, which is fun. And also just changing the quality of how you move. And I think I already mentioned that that can be cues about moving in a powerful way, in a gentle way. Things like relating it to different animals and nature can really get the patient to feel the quality of the movement. And then there’s also cues for direction of movement, which is nice because it allows the therapist to think about moving in several different ways, up and down, in and out. And so in and out has a compressive kind of feeling, and out has an expansive or expansion kind of feeling.
There’s also turning, which is rotation movements. There’s circling, which is literally just creating the shape of a circle. There’s also spiraling movements, which are kind of multi-directional movements. So when you start to learn these different cues, it kind of opens up a whole new world for you on how you can cue your patients. But I just want to just quickly go back. So we were just talking quickly about the levels. So we talked about the physical level, the elastic level, the mental level. And I do want to mention just one more level, which is the level of energy or so people may not know, well, what the heck is Qigong? What does that even mean? So in traditional Chinese medicine, chi is means energy. So gun, it’s spelled Q-I, and then the word G-O-N-G means energy work or just the moving of energy through the body.
So this fourth level is practicing more at that energetic level. And once you learn the physical components of the movement, you can get into more the feeling of the movement. And so sometimes that can feel like tingling. Some people will say, “Oh, I feel like a warmth sensation in my body,” or “I feel a little bit of tingling in my hand,” or “I feel a release of muscle tension.” So we’ve all had patients talk about feeling those things from time to time. And so according to Qigong, or according to traditional Chinese medicine, this is actually the feeling of chi or a greater flow of energy through the body.
And then the last two levels, which honestly I do not really get into at all with my patients, but patients can certainly move on and do these levels on their own, would be more of a spiritual level, which again, yes, that is definitely part of health and wellness, but as a PT, it’s a little bit out of my realm of my personal focus. And then the last level is emptiness, which is really a high level skill, if you will, of learning to really meditate on really just the feeling of emptiness. So I’m not even going to really get into all that, but that would be for people that are interested. It’s interesting, it’s kind of a more advanced way to practice
For people who are interested. Do you have advice for physical therapists and rehab professionals looking to get started practicing mindful movement? Are there any specific resources you suggest?
Sure, sure. So first of all, we have at our fingertips so many resources can online, you can find a whole bunch of websites and people that are offering classes online, sometimes YouTube videos. You can look for lots of free stuff, and sometimes you’ll find something that really interests you, and you might be able to become a member of an online community. For example, I’m a member of Qigong for Vitality, which is founded by a man named Jeffrey Chan. He actually lives in British Columbia, but I love his work. And he offers monthly lectures, and we talk about different Qigong topics. There’s a forum so you can meet other people practicing. And it’s funny, whenever people find out you’re a physical therapist, they get super excited, “Oh. Which exercise should I practice for arthritis? And what should I do to cure my frozen shoulder?”
And so I really want to emphasize, since I know this is a PT audience and probably an OT audience as well, is that you really do have the foundation if you’re interested, to incorporate this sort of practice into your life and into your professional career and into help your patients. So in addition to websites, you can probably find in your community adult education classes. I’ve done that. I’ve found different people offering Tai Chi or Qigong. There are retreat centers around the country. I live in the Northeast. So in Massachusetts, there is a wonderful retreat, it’s called Kripalu. Now it is much more heavily yoga based, but that is actually where I got my start with Qigong. So I’m sure there’s places all over the country that you would be able to find. I want to just emphasize that there really are no standards for certification currently.
So I don’t want therapists to feel like they have to be experts to start teaching this sort of thing with their patients because it’s not true. You don’t have to be an expert. Like I said, you have the foundation to start. You understand the body, you understand movement, you understand posture, you understand balance. So this is just providing you a new set of tools, a new set of routines that are very dynamic. They incorporate whole body movements, they incorporate relaxation, they incorporate meditation, and they can really help your patients in their healing process. So you could pursue a certification. They do exist. For example, The National Qigong Association will give a certification out if you have a certain amount of hours. And maybe that appeals to you if you wanted to maybe round out your bio or your resume, but you shouldn’t feel like you have to be an expert to start using it.
So again, I just want to… Well, I should say this one last thing about that, although you can start learning things and teaching them, in my opinion, relatively quickly, of course, the more engaged you become in the practice, the more you study, the more you do it yourself, you will become more authentic, of course. But that’s up to you how deep you want to go into it. And likewise, you’ll find your patients might be different. Some patients might be okay with just practicing on that very physical level, and some might be very curious and want to go deeper. So there’s lots of things out there for you to find a teacher locally, online, et cetera.
It seems like it’s also very adaptable that depending on what you want to use, what your patients are interested in using, what they could benefit from, it could be adapted to people of all ability levels.
Oh, yes. Thank you so much for bringing that up. Of course. Yes, absolutely. So because if we go back again to the principles of this practice of being just focused, intentional movement and breathing, you can adapt the actual physical movement to really any position. So even bedbound patients, believe it or not, could engage in some type of Chigong, whether it be extending the legs in the bed, stretching through the toes, paying attention to the breath. It can be done sitting, standing, absolutely. You can adapt to any type of disability or injury. And that’s where I think physical therapists are also have a lot of strength is being creative. And so this offers a lot of creativity. So it can definitely be used for various, yeah, definitely a lot of patients. Actually, Melanie, I wanted to just mention one key thing, just going back to the research, because there’s a concept called the relaxation response.
Is it okay if I just mentioned that quickly?
Yeah, please enlighten us.
Okay, good. Okay, good. So there is something called the relaxation response. And a lot of the research really focuses on the relaxation response being what is helping our patients in their healing and their perception of their wellness and their quality of life and their pain level, et cetera. And what that is therapists are very aware of the autonomic nervous system. We have sympathetic nervous system, parasympathetic nervous system, the former being the fight or flight response, and the latter being more of what we call rest and digest. So there is a theory called polyvagal theory, which is talked, and this is my understanding of it, so not an expert in this, but this is my understanding, is that polyvagal theory talks about us being in various states of dominance. So it’s not really like a seesaw, it’s not like, “Oh, when our sympathetic goes up, our parasympathetic goes down and vice versa.”
But rather we have sort of a dominant state. And what mindful movement does is it puts us into a ventral vagal state or a dominant ventral vagal state. So the parasympathetic system, again, is more of the rest and digest system, but we don’t want to be practicing in such a relaxed state that we’re near falling asleep, right? It’s not about being so relaxed that we are so zoned out. That is so not what we’re aiming for. So that is considered more a dorsal vagal state. So the ventral vagal state is where we have the perfect balance, if you will, of sympathetic and parasympathetic sympathetic activity where we’re calm, yet relaxed, we’re focused, and yet we’re not amped up. And this is the optimal state of healing. And so that’s where if we can be functioning in this ventral vagal state where we have what’s called the relaxation response, we are just in a better state for healing our bodies.
And there is a lot of research that mindful movement practices help a lot of different diagnoses. So this is not just speculative, but rather studies that show it builds bone density. That seems clear because a lot of Chigong is done in the standing weightbearing position. It can help like MS, CVA Parkinson’s falls, it’s been shown to reduce fall risk. So I think that’s an important takeaway from this for therapists who work with patients who are at risk for falls, it lowers anxiety, it lowers depression, it can improve mood, it can improve sleep. What else? It can be used for cancer care help, hypertension, lower blood pressure, lower heart rate, osteoporosis, again, because there’s a lot of weightbearing in it, arthritis we already talked about. So yeah, it’s research out there that shows that it can work on a lot of these different conditions. And not to repeat myself, but just again, the relaxation response is a big component of where that healing is coming from,
Right. Why it’s beneficial. All right. Was there anything else that you wanted to touch on that you wanted to share with physical therapists and occupational therapists that you think they could use in their work?
I guess just to make sure that I do understand that there are limitations that we have as therapists in time and how much time we can spend with a patient. I don’t want people to think I lead this glorious work life where I can just do Chigong for an hour with every patient, and that is not true. That is not realistic. I just want to be honest about that. So I have a lot of enthusiasm with it. But like I said, I don’t use it with everyone, but I use it when I can. So for example, my patient I mentioned before with dermatomyositis, she is my last patient of the evening. So guess what? I have time. I have a little extra time with her. And she’s extremely grateful. And it builds, I believe, the patient therapist relationship. I think that relationship that our patients have with us is very important.
That’s going back to the biopsychosocial model, how our patients perceive the people that are helping them. So I think it really strengthens the bond when you can do new and different things for them. So I also do home care where I do have one-on-one uninterrupted time. So it’s also a bit easier for me to do Qigong with patients in the home setting because it’s just me and the patient. So again, I pick and choose who and when I can use it for, if I have a very busy day in outpatient, but suddenly I get a few cancellations and I just happen to have the perfect patient comes in, I have an a little block of time after they say, “Okay, Karen, my back’s really bothering me today. Can you show me any new stretches?” I say, “Oh, okay. Let me show you something new. Let’s get off the table and let’s try a few new things.”
And it just gives me new stuff to do. I do want to just mention what we talked already talked a lot about queuing and how Qigong can offer a lot of new and different cues for your patients. So if I can just throw out just a couple more because maybe it’ll be helpful to therapists that are not real sure what exactly this is all about. Yeah we talked about how it can be very adapted, adapted to different positions and different disabilities. You can really cue the breath in the movement. So often the breath can be cued in for slow diaphragmatic breathing, but it can also be cued just to be natural. So you can teach the movement and just say, “Just breathe naturally,” or you can coordinate the breath.
So now suddenly you’re bringing that mindfulness and that focus to the breath and can say, “”When we stand up and we lift our arms, we’re taking a breath in, and when we squat down and lower our arms, we’re exhaling.” So we can cue the breath in different ways. It’s important to remind patients that they’re unique and that they bring with them to each Qigong routine, like their own injuries and their own sort of problems, their own asymmetries. And the focus really is on how it feels and not how it looks because some of the movements can, maybe you could call them a little complicated, some of them. And it’s important that patients know it’s not about how good they look doing it.
I bet that’s helpful to therapists as well to think of it that way.
Yeah, exactly. Yeah, don’t, not about that, because you’re going to get a patient maybe with a scoliosis and one arm doesn’t go up as high as the other, or they can only balance on one side and the other side they’re not so good at. So there’s going to be all kinds of asymmetries to it. A couple more things to mention. Number of repetitions and how long you do it for. There’s no right or wrong, so it can vary even from one session to the next. So patients can come to a session with a lot of energy and maybe they feel like they can do a movement more vigorously, or they might come to the session feeling low energy and maybe they need to just not use as much energy in the movement, and it can change from day to day and session to session.
So I give a lot of Qigong as a home exercise program, and I definitely tell that to patients, it’s not about doing it three sets of 10. It could mean do it for for one minute or do it for 10 minutes. Do it for a half hour. And it’s really cool when you start to see patients figure out what feels good and what doesn’t. And I guess lastly would just be this concept of effortless effort. So there’s definitely this concept in Qigong where you’re queuing patients to use about 70% of effort. That number is not strictly written somewhere. It’s just kind of what I’ve heard tossed around. But it’s this idea of not using so much effort that you are exhausted. You need to practice and do your exercise in such a way that you leave some room for this and this, remember we talked about this, what was called interoception or this awareness of changes in our body.
So we want to work and exercise in such a way that we can tune into some of those changes and that we don’t feel exhausted. So this is not a power workout. It’s really like a 70%. That’s a nice way I think of it, or I call it effortless effort. Another way I think of it is using just enough tension to hold a posture or to move through a posture without, at the same time being able to let go of unnecessary tension. So again, I’m throwing out at you all these different cues and all these different ways of thinking about movement. And so the more you learn, the more you get comfortable with it. And it’s been fun. It’s kept me less bored. I will tell you, I don’t know, I can’t speak for everyone, but after 25 years, I still love what I do, and I still go back to the basics.
And I still, I’m still doing range of motion exercises and rehabilitating patients in ways that I always have. It’s just that sometimes it can get a little stale. And learning these types of modalities just brings in a beautiful, another way to move. And patients are usually very appreciative and they’re really excited and they think it’s so cool because it’s something new and keeps them motivated, and it keeps you motivated as a therapist. So that’s the biggest thing. I want to just sort of impart on those listening, that it can be fun and not to be scared of it because you could start doing it right away to be honest, and just learn one thing and teach it to your patients.
All right. Well, thank you so much for sharing your insights with us, Karen.
Thank you. Thank you for having me.
And thank you to our listeners. For more about mindful movement and physical therapy, you can find Karen Danchalski’s series of articles about Mindful Movement on the Rehab Management website, rehabpub.com, along with other great content. And check out our content on the Physical Therapy Products website, ptproductsonline.com. Also be on the lookout for more podcast episodes from Physical Therapy Products and Rehab Management, wherever you listen to podcasts.