Journal of Exercise Physiologyonline

100 Journal of Exercise Physiologyonline April 2018 Volume 21 Number 2 Editor-in-Chief Official Research Journal of Tommy the American Boone, PhD, Society MBA of Review Exercise Board Physiologists Todd Astorino, PhD Julien Baker, ISSN 1097-9751 PhD Steve Brock, PhD Lance Dalleck, PhD Eric Goulet, PhD Robert Gotshall, PhD Alexander Hutchison, PhD M. Knight-Maloney, PhD Len Kravitz, PhD James Laskin, PhD Yit Aun Lim, PhD Lonnie Lowery, PhD Derek Marks, PhD Cristine Mermier, PhD Robert Robergs, PhD Chantal Vella, PhD Dale Wagner, PhD Frank Wyatt, PhD Ben Zhou, PhD Official Research Journal of the American Society of Exercise Physiologists ISSN 1097-9751 JEPonline The Intensity of Qigong Exercise Suphannika Ladawan 1, Martin Burtscher 1, Panakaporn Wannanon 2,3, Naruemon Leelayuwat 2,3 1 Department of Sport Science, Medical Section, Faculty of Psychology and Sport Science, University of Innsbruck, Innsbruck, Austria, 2 Department of Physiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, 3 Exercise and Sport Sciences Development and Research Group, Khon Kaen University, Khon Kaen, Thailand ABSTRACT Ladawan S, Burtscher M, Wannanon P, Leelayuwat N. The Intensity of Qigong Exercise. JEPonline 2018;21(2):100-115. The purpose of this study was to investigate the intensity of Qigong exercise by measuring absolute energy expenditure (METs) and relative indicators [i.e., percentage of rate of maximal heart rate (HR max), peak oxygen consumption (VO 2 peak), oxygen consumption reserve (VO 2 R)]. Ten healthy sedentary female subjects aged between 50 to 60 yrs randomly performed two visits of exercise; VO 2 peak test and Qigong exercise on 3 to 4 separate days. Expired air and heart rate (HR) were recorded for 5 min at rest, throughout the test and Qigong exercise. During Qigong exercise, mean energy expenditure, HR, and VO 2 during Qigong exercise were 1.78 ± 0.20 METs, 80.1 ± 5.97 beats min -1, and 6.2 ± 0.69 ml kg -1 min -1, respectively In addition, average %VO 2 peak, %HR max, and %VO 2 R were 40.8 ± 10.2%, 48.5 ± 3.45%, and 53.8 ± 18.6, respectively. The findings indicate that Qigong exercise is a very light- to predominately light-moderate-intensity exercise. Key Words: Cardiorespiratory, Effort, Energy Expenditure, Qigong

101 INTRODUCTION Qigong is a form of mind-body exercise that originated in ancient China. Currently, Qigong exercise is defined as a meditative movement involving four elements: (a) movement; (b) focus on breathing; (c) meditative state of mind; and (d) relaxation (11,17). Previous studies have reported the beneficial effects of Qigong practice such as reduced blood pressure (12,13,15), improved ventilatory function (12), improved cognitive function (16), and reduced mental stress (6), depression (1), and anxiety (19). Nevertheless, exercise intensity of Qigong is still unclear even though it is one of the important factors affecting physical responses to training and useful for exercise prescription. A previous study by Chao et al. (2) found that it is a light-intensity exercise; whereas, Kjos and Etnier (8) reported that it is a moderate-intensity exercise. This may depend on the style, posture, and duration. The present study is focused on Qigong 18 movements because this style comprises the simple movements that are easy to learn with low joint impact and suitable for all age groups, particularly for beginners. Hence, everyone should be able to benefit from practicing Qigong exercise. Exercise Intensity can be estimated by absolute and relative intensity. Absolute intensity is defined by rate of energy expenditure during exercise, which is expressed in metabolic equivalents (METs). Relative intensity is defined by several terms that include the percentage of maximal oxygen consumption (VO 2 max), maximal heart rate (HR max) (4,5), or rating of perceived exertion. Presently, percentage of oxygen consumption reserve (VO 2 R) has been recommended for prescribing exercise intensity (5,18). The present study was designed to evaluate the intensity of Qigong in both absolute and relative intensity. We hypothesize that Qigong exercise would be predominately a lightintensity to light moderate-exercise intensity. METHODS Subjects Ten healthy sedentary female subjects were recruited to participant in this study. They were between 50 to 60 yrs of age. All subjects were healthy, although they did not engage in daily exercise. Also, they did not take part in training at an athletic level for at least three months prior to enrolling in the study. Exclusion criteria consisted of the following medical conditions, such as cardiovascular diseases, respiratory diseases, orthopedic problems, neuromuscular disorders, and infectious conditions. All subjects were informed of the experimental protocol and possible risks before signing the consent form. Ethical approval was obtained from the Ethical Committee of Khon Kaen University, reference number HE591225.

102 Procedures All subjects performed Qigong and VO 2 peak test on 3 to 4 separate days. They had at least 8 hrs of sleep, and were not allowed to have meals or severe exercise for at least 2 hrs before the test. Qigong Exercise The subjects performed 18 movements of Qigong exercise for 40 min (refer to Figure 1 for specific movements). Expired air and heart rate (HR) were recorded for 5 min at rest in a seated position and throughout the Qigong exercise. VO 2 Peak Test Each subject performed an incremental exercise test on an electromagnetically braked cycle ergometer. The test began with a warm-up by cycling at 0 watt, then workloads were increased by 25 watts every 2 min until they reached the following criteria: 85%HR max (220 age); could not maintain the required pedaling frequency of 60 rev min -1 ; highest VO 2 or respiratory exchange ratio (RER, 1.15). Electrocardiogram and expired air (measured by Oxycon Mobile; BD Biosciences, Franklin Lakes, NJ, USA) configured in the breath-by-breath model) were recorded throughout the test. Statistical Analyses Means ± standard deviation (SD) were calculated for all variables by descriptive statistic, SPSS version 17. Metabolic equivalents (METs) were calculated from each subject s oxygen -1 consumption (VO 2 ) during the Qigong exercise, of which 1 MET is equal to 3.5 ml kg -1 min (7). Oxygen consumption reserve (VO 2 R) was calculated as the difference between the subject s maximum and resting VO 2 (18). The mean value of VO 2 during the Qigong exercise was used to calculate %VO 2 peak and %VO 2 R. The mean value of HR during the Qigong exercise was used to calculate %HR max.

103 Figure 1. Eighteen Qigong Movements. --------------------------------------------------------------------------------------------------------------- 1. Lift Hands - Raise the arms up (breathing in) - Slowly lower the arms, sink body down with knees slightly bent (breathing out) 2. Opening the Chest - Raise arms to shoulders and draw hands away from each other (breathing in) - Draw hands together to shoulder width apart then draw arms down to thighs, sink body down with knees slightly bent (breathing out) 3. Rainbow Dance - Stand naturally and relaxed with your feet slight wider than shoulder width apart - Raise arms over the head - Turn to the left: transfer body weight to right leg (breathing in) - Turn to the right: transfer body weight to left leg (breathing out)

104 4. Separating Clouds - Crossing the hands and draw arms up fully extended above head(breathing in) - Separate the hands and lower the arms down in an arching motion on the outside of the body, sink body down with knees slightly bent (breathing out) 5. Rolling Arms, knees slightly bendand the back straight - Turn to right:turn body from waist toward right keeping knees and feet in alignment, left arm forward and right arm back (breathing in). Push right arm forward and draw the left arm back (breathing out). - Turn to left: Turn body from waist toward left keeping knees and feet in alignment, right arm forward and left arm back (breathing in). Push left arm forward and draw the right arm back (breathing out) 6. Rowing the Boat - Draw arms up fully extended above head (breathing in) - Sink body down with knees slightly bent and draw arms down to thighs(breathing out)

105 7. Lift the Ball - Turn left: turn the body from waist toward left, raise the right arm up, left arm move slightly back (breathing in). Draw the right arm down to thigh and sink body down with knees slightly bent. Turn the body from the waist back to center (breathing out) - Turn right: turn the body from waist toward right, raise the left arm up, right arm move slightly back (breathing in). Draw the left arm down to thigh and sink body down with knees slightly bent. Turn the body from the waist back to center (breathing out) 8. Looking at the Moon - Turn left: turn the body from waist toward left, extend the arms up towards the left (breathing in). Draw arms down to thigh and sink body down with knees slightly bent. Turn the body from the waist back to center (breathing out) - Turn right: turn the body from waist toward right, extend the arms up towards the right (breathing in). Draw arms down to thigh and sink body down with knees slightly bent. Turn the body from the waist back to center (breathing out) 9. Pushing Palms, knees slightly bend and the back straight. - Push to the left: turn the body to the left from the waist and push the arm forward at chest level (breathing out). Turn the body back to center from the waist and draw the right arm back to the side (breathing in) - Push to the right: turn the body to the right from the waist and push the arm forward at chest level (breathing out). Turn the body back to center from the waist and draw the left arm back to the side (breathing in)

106 10. Cloud Hands, knees slightly bend and the back straight - Raising the left arm to face level and drop the right hand to waist level with both palms facing the body. Turn the body to the left from the waist, allow the arms to follow the body as turning (breathing in) - Raise the right arm to face level and drop the left arm to waist level. Turn the body to the right from the waist, allow the arms to follow the body as turning (breathing out) 11. Touch the Sea, Look at the Sky - Stand with feet approximately shoulder width wide and the left foot forwards. - Transfer the weight onto the left foot and bend at the waist. Draw both arms downwards and towards the knee. Cross the hands over the knee (breathing out) - Transferring the weight onto the right leg whilst gradually straightening the body upright. Bringing the crossed palms up above the head (breathing in) 12. Pushing the Waves - Stand with feet approximately shoulder width wide and the left foot forwards - Pushing both arms out whilst transferring the weight onto the left foot (breathing out) - Pulling both arms back to chest leveland transferring the weight back onto the right foot (breathing in)

107 13. Flying Dove - Stand with feet approximately shoulder width wide and the left foot forwards - Transfer weight onto the left foot, curve arms and palms to center until fingers almost touch (breathing out) - Transfer weight from left foot onto right, open arms out to shoulder height (breathing in). 14. Punching, knees slightly bend and the back straight - Right punch out: punch out (breathing out), draw right fist back to waist and turn the fist palm facing up (breathing in) - Left punch out: punch out (breathing out), draw left fist back to waist and turn the fist palm facing up (breathing in) 15. Flying Wild Goose - Raise both heels, gently raise the arms up and out above the head shoulder width apart(breathing in) - Sink body down with knees slightly bent and heels downwards, move both arms downwards to thighs (breathing out)

108 16. Rotating the Wheel,knees slightly bend - Raise the body and slowly swing the arms to left side, allowing right arm to cross in front ofthe body. Continue this circular movement out to left side until the arms come above the head with the fingers pointing up to the sky (breathing in).sink body down and continue the movement down to the other (right) side (breathing out). - Repeat in the other direction 17. Marching Whilst Bouncing the Ball - Shift the weight to right foot, raise left knee, foot and right arm (breathing in). Bring the right arm down, put left toes down then left heel down (breathing out). - Shift the weight to left foot, raise right knee, foot and left arm (breathing in). Bring the left arm down, put right toes down then right heel down (breathing out). 18. Balancing the Chi - Gently raise the arms up to chest height (breathing in) - Sink body down and gently push the arms down (breathing out)

109 RESULTS A total of 10 healthy female subjects completed the study. The average age was 55 ± 4.84 yrs. Referring to the adult Asia BMI classification, the subjects were generally in Class 1 obesity (n=7) and 3 subjects were at risk of being overweight (n=3) (20) with a high percent of body fat. The anthropometric and physiological characteristics are shown in Table 1. Table 1. Baseline Characteristics of the Ten Women. Characteristics Value Age (yrs) 54.8 ± 4.84 Height (cm) 149.2 ± 0.04 Body Mass (kg) 57.8 ± 5.60 Body Mass Index (kg m -2 ) 25.1 ± 2.82 Waist Circumference (cm) 82.0 ± 6.07 Hip Circumference (cm) 98.1 ± 4.15 Waist to Hip Ratio 0.84 ± 0.05 Body Fat (%) 34.6 ± 3.09 Values are expressed as mean ± SD VO 2 at rest and during the Qigong exercise are shown in Figure 2A. VO 2 at rest was 3.43 ± 0.29 ml kg -1 min -1, then increased to 5.28 ± 0.59 ml kg -1 min -1 during the first movement of the Qigong exercise, after which VO 2 fluctuated slightly and reached the highest level of 7.72 ± 1.02 ml kg -1 min -1 during the 17th movement, followed by a decrease to 6.17 ± 0.81 at the 18th movement. The mean VO 2 of all 18 movements was 6.2 ± 0.69 ml kg -1 min -1 and 40.8 ± 10.24 %VO 2 peak. This indicates that the intensity of Qigong was light to moderate, but predominately light (4) (refer to Table 2 and Figure 2A). VO 2 R was 12.5 ± 3.13 (ml kg -1 min -1 ), and the mean VO 2 of the 18 movements was 53.8 ± 18.6 %VO 2 R. This indicates that the intensity of Qigong was moderate (5). A similar trend was found for energy expenditure, which was 0.98 ± 0.08 METs at rest, then rose to 1.51 ± 0.17 METs at the first movement. Energy expenditure fluctuated slightly during the 2nd to 16th movement before increasing to the highest level of 2.20 ± 0.29 METs during the 17th movement, after which it declined to 1.76 ± 0.23 METs during the 18th movement.

The mean energy expenditure for all 18 movements was 1.78 ± 0.20 METs. This indicates that the intensity was very light (4) (Table 2 and Figure 2B). HR at rest was 65.3 ± 6.0 beats min -1, which increased to 77.1 ± 5.82 beats min -1 at the 1st movement. After that, HR increased to the highest level at 84.1 ± 8.75 beats min -1 during the 3rd movement followed by a decrease to 80.0 ± 6.69 beats min -1 at the 4th movement. HR tended to remain steady from the 4th to the 18th movement. The mean HR during all 18 movements was 80.1 ± 5.97 beats min -1 and 48.5 ± 3.45 %HR max. This indicates that the intensity of Qigong exercise was light (4) (Table 2 and Figure 2C). 110 Table 2. Intensity of Qigong Exercise Determined by VO 2, HR, and Energy Expenditure during the Qigong Session and VO 2 Peak Test. Variables Maximal Mean Value Percentage of Intensity Value (Qigong) Maximal Values Level VO 2 15.9 ± 3.28 a 6.2 ± 0.69 40.8 ± 10.24 Light to (ml kg -1 min -1 ) (ml kg -1 min -1 ) Moderate Heart Rate 165.2 ± 4.87 b 80.1 ± 5.97 48.5 ± 3.45 Light (beats min -1 ) (beats min -1 ) Energy Expenditure 1.78 ± 0.20 Very Light (METs) Data are expressed as mean ± SD; n = 10 women. a from V O 2 peak test, b from predicted HR max (220 age), VO 2 = Oxygen Consumption Rate; METs = Metabolic Equivalents

Figure 2. (A) Oxygen Consumption Rate (VO 2 ) (ml kg -1 min -1 ), (B) Energy Expenditure (METs), and (C) Heart Rate (L min -1 ) (C) at Rest and during the Qigong Exercise. The data are expressed as mean ± SD; n = 10 Women; VO 2 = Oxygen Consumption; METs = Metabolic Equivalents; Mvt = Movement 111

112 DISCUSSION This study found that the 18 movements of Qigong exercise, which are simple and slow were a very light- to predominately light to light-moderate-intensity exercise. These results partially support our hypothesis that the exercise intensity of Qigong was predominately light to very slightly moderate. The findings of this study are consistent with a previous study in Tai Chi Qui Gong in the elderly, which is a combination of Tai Chi Chuan and Qui Gong. This exercise included 54 postures that were divided into 3 sets of 18 postures. Each posture was a structured body movement pattern including rhythmic limb and trunk movements. The results showed that the intensity of Tai Chi Qui Gong was about 3 METs and the authors suggested that Tai Chi Qui Gong was a low-intensity exercise (2). On the other hand, Kjos and Etnier (8) demonstrated that Qigong was moderate-intensity exercise. In addition, Lan et al. (10) reported that classical Tai Chi Chuan, which consists of many complex postures was of moderate-intensity, indicated by 58% of the heart rate reserve and 55% of VO 2 max. The discrepancy in the results suggests that the intensity of Tai Chi Chuan depends on training style, posture, and duration. Swain and Franklin (18) suggested that training at 45 %VO 2 R was a minimal effective training intensity for subjects who had higher fitness (i.e., initial VO 2 max >45 ml kg -1 min -1 ) while 30 %VO 2 R was effective training intensity for subjects whose initial VO 2 max <45 ml kg -1 min -1. Regarding VO 2 R, Qigong is an alternative exercise for improving cardiorespiratory fitness. However, the intensity of Qigong in the present study was varied by the estimation method. Exercise intensity of Qigong, which was estimated by %VO 2 peak and %VO 2 R was higher than %HR max and METs. Fortunately, Qigong exercise is a combination of meditative movement patterns that incorporate gentle movement with meditation, breathing, and relaxation (11). Control of breathing, synchronized breathing with slow movement during the Qigong exercise that increases in ventilation, which contributes to the higher VO 2 during the exercise while HR is slightly increased. Lan et al. (9) have indicated that Qigong produces an increase in the subject s breathing efficiency due to training effect of diaphragmatic breathing. Clearly, the intensity of the Qigong exercise was very light, as indicated by METs. While the use of the MET method is practical and easily understood procedure to quantify the energy cost of activities, it is important to remember that METs vary according to body size, percent of body fat, and lean body mass (7). This may provide different intensity of exercise from other indicators. As mentioned earlier, Qigong includes four essential elements (i.e., movement, focus on breathing, a meditative state of mind, and relaxation) (11), thus the effect of Qigong is a combination of the effects of each element that could generate more benefits than a single element. To investigate the effects of Qigong, its characteristics should also be considered. Although the intensity of Qigong is still unclear, several studies showed positive effect of Qigong on cardiorespiratory system. Lee and colleagues (14) demonstrated that a 10-wk Qigong exercise program had a significant antihypertensive effect in hypertensive patients. The study suggested that Qigong may improve blood pressure by stabilizing the sympathetic system. Synchronized breathing with movement and control of breathing during the Qigong exercise may alter autonomic nervous system activity (3). In addition, Lan et al. (9) reported

that Qigong practitioners had a higher tidal volume than the sedentary control group. This finding tends to show that Qigong training improves parasympathetic and pulmonary function. Limitations of this Study Although there were no data of subjective assessment of rating of perceived exertion (PRE) in the present study, the indicators (%VO 2 peak, %HR max, and % VO 2 R) that were used in the present study are valid enough to assess the intensity of Qigong. 113 CONCLUSIONS Regarding the healthy sedentary older female subjects, the findings indicate that the Qigong exercise is a very light- to predominately light to light-moderate-intensity exercise. ACKNOWLEDGMENTS This study was supported by the Exercise and Sport Sciences Development and Research Group, Khon Kaen University, Thailand, and a grant from The ASEAN European Academic University Network (ASEA-UNINET). We also thank the subjects for their excellent participation. Address for correspondence: Naruemon Leelayuwat, PhD, Department of Physiology, Faculty of Medicine, Khon Kaen University, Email: naruemon.leelayuwat@gmail.com REFERENCES 1. Chan JS, Ho RT, Wang CW, Yuen LP, Sham JS, Chan CL. Effects of qigong exercise on fatigue, anxiety, and depressive symptoms of patients with chronic fatigue syndrome-like illness: A randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:485341. 2. Chao YF, Chen SY, Lan C, Lai JS. The cardiorespiratory response and energy expenditure of Tai-Chi-Qui-Gong. Am J Chin Med. 2002;30(4):451-461. 3. Chow YW, Tsang HW. Biopsychosocial effects of qigong as a mindful exercise for people with anxiety disorders: A speculative review. J Altern Complement Med. 2007 ;13(8):831-839. 4. Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B, Eckel R, Fleg J, et al. Exercise standards for testing and training: A statement for healthcare professionals from the American Heart Association. Circu. 2001;104(14):1694-1740. 5. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise

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