Abstract
Introduction:
Although new COVID-19 cases have been decreasing globally, long-haul COVID-19 continues to present a challenge. Long-haul COVID-19 symptoms, such as dyspnea, fatigue, cognitive impairments, gastrointestinal distress, and mood changes, can remain for months after initial infection in 10-30% of individuals infected with COVID-19. These symptoms can limit daily function and decrease quality of life. Given the recency of the disease, very little literature exists on the causes of long-haul COVID-19 and few treatment options are available for afflicted individuals. This case report describes the use of the Eastern medicine practices of Tai Chi and Qigong as a possible technique to increase lung function and thus daily function in those with long-haul COVID. Both Tai Chi and Qigong were developed thousands of years ago in China and utilized as part of traditional Chinese medicine. They are forms of gentle, low-intensity exercise involving slow, continuous movements and stretches that focus on alignment, coordination, and breathing control. Previous studies have shown that Tai Chi and Qigong provide beneficial effects in those experiencing mood disorders, chronic pain, cardiovascular issues, fibromyalgia, and chronic obstructive pulmonary disease. Although practitioners have proposed the use of Tai Chi and Qigong in patients with COVID-19, no data exists on the outcomes.
Materials and Methods:
This case report presents a patient with pre-existing conditions of obesity, gastroesophageal reflux disease, cervical cancer, cataract surgery, and sinus surgery initially diagnosed with COVID-19 with symptoms of acute dyspnea, dizziness, cough, headache, chills, fever, rhinorrhea, and sore throat. She was later diagnosed with long-haul COVID-19 with symptoms of dyspnea, fatigue, and dizziness on exertion and gastrointestinal distress. The patient practiced Tai Chi and Qigong three to four times weekly for about 30 min on average.
Results:
The patient experienced decreases in resting heart rate and weight and an increase in oxygen saturation level (SpO2) from 83% to 96%, indicating that Tai Chi and Qigong may have the potential to restore lung function.
Conclusion:
Thus, we propose that Tai Chi and Qigong can be an easily accessible, low-intensity, and cost-effective technique to increase lung function and quality of life in patients with long-haul COVID-19.
Background
Long-haul Covid-19 symptoms are described as fatigue, dyspnea, and headache lasting for months after initial disease resolution; less typical symptoms include cognitive impairments, chest and joint pain, myalgia, smell/taste dysfunctions, cough, mood changes, gastrointestinal issues, and cardiac affects. 1 Presently, the literature is limited regarding possible treatments in long-haul COVID-19. Although recent articles have proposed the use of Tai Chi and Qigong in mitigating COVID-19 symptoms, none have reported quantifiable effects of Qigong and Tai Chi in patients with long-haul COVID-19.2–4
Qigong and Tai Chi are considered components of Eastern medicine practice using body position, controlled movements, deep rhythmic breathing, meditation, and mental focus to restore homeostasis and reduce stress. 5 Tai Chi is frequently considered a form of “medical or health Qigong.” 5 Tai Chi and Qigong have previously been shown to alleviate headaches 6 and mood disorders,5,7 increase aerobic capacity-maximum rate of oxygen consumption peak volume, 8 and decrease chronic pain. 9
With little research on the impact of gentle exercise on long-haul COVID-19 symptoms3–4 and after seeing improvements in a patient self-motivated to practice Qigong and Tai Chi, we decided to write this case report to present the Eastern practices of gentle exercise (Tai Chi) and controlled breathing (Qigong) as a technique with potential to moderate long-haul COVID-19 symptoms.
Case Presentation
Patient information
Mrs. X, a 62-year-old Caucasian female from Eastern European descent, was diagnosed with COVID-19 on January 7, 2022 and presented with acute dyspnea, dizziness, cough, headache, chills, fever of 100.9 F, rhinorrhea, and sore throat. Blood pressure was 159/85, pulse 97, respirations 16, and oxygen saturation (SpO2) ranged from 84% to 96%. She stated that she had been experiencing symptoms for the past 7-days but was too ill to come to the clinic.
The patient was previously immunized for COVID-19 with Moderna, red cap 0.5 mL primary dose on January 14, 2021, and received boosters on February 11, 2021, and September 10, 2021. She was also immunized for Influenza PF2y+ Quadrivalent (Flucelvax) on December 21, 2021.
Diagnostic assessment
The patient has a medical history of obesity (body mass index 37.2), gastroesophageal reflux disease, cervical cancer (>10 years), cataract surgery (>5 years), and sinus surgery on October 3, 2021 to retrieve dental implant foreign body. She is allergic to Cephalosporin, Penicillin, and Tetracycline. Current medications are Triamcinolone (Kenalog) 0.1% cream as necessary, and omeprazole 20 mg once daily. The patient was tested and negative for Point of Care Testing Influenza A/B and positive for Coronavirus Nucleic Acid Amplification Test.
Treatment
The patient was prescribed Promethazine-dextromethorphan 6.25–15 mg/5 mL liquid, 5–10 mL by mouth four times daily as needed for cough, azithromycin (ZITHROMAX) 250 mg tablet two tablets by mouth on day 1 and one tablet by mouth every day after, and albuterol (PROAIR HFA) 90 mcg/puff inhaler inhale two puffs into the lungs every 6 h as needed for wheezing. Patient was advised to monitor her SpO2 levels and go to the Emergency Room if the levels dropped into the low 80%. At the follow-up visit 10 days after the initial visit, the patient was experiencing acute dyspnea, fatigue, and dizziness with exertion. A chest X-ray (CPT 71046) was ordered but the patient has not complied.
At day 10 post-diagnosis, the patient was self-motivated to start a 22-min Tai Chi gentle exercise program every morning. The patient did not have prior experience of Tai Chi and Qigong but was motivated to start the practice to improve her quality of life given limited relief of symptoms with medication. The patient began to experience symptom mitigation with Tai Chi and decided to add Qigong because of the focus on controlled breathing.
The Tai Chi exercise program was discussed with the patient's primary care physician and she was told to go ahead with a gentle movement yang-style Tai Chi program designed for seniors. After 2 months of Tai Chi exercise, the patient decided to increase the morning Tai Chi routine to 35 min and added a 10-min Qigong breathing practice nightly to increase benefits. The exercise programs were self-found by the patient from YouTube (https://www.youtube.com/watch?v=pa_I5NAOW4k&t=956s), and the practices were completed at the patient's home. The patient monitored her SpO2 levels nightly (Table 1).
Change in SpO2% and Resting Heart Rate with Tai Chi and Qigong Practice
SpO2, oxygen saturation.
The patient's SpO2 levels increased from 83% at the beginning of the exercise regimen to 93%, whereas resting heart rate decreased. Patient's weight also decreased (Table 2). The patient experienced a 9-pound weight loss from February 9, 2022 to February 16, 2022 partly due to taste side-effects from COVID-19; the patient stated that food had a pungent putrid odor and taste with gastrointestinal discomfort.
Change in Weight During Tai Chi and Qigong Practice
Follow-up and outcomes
During the follow-up visit with the patient on February 15, 2022, the patient was able to demonstrate that with controlled breathing exercise for only 5 min in clinic, she could increase her SpO2 levels by 4–5%. The patient discussed the change in taste perception, which led to diet changes with a reduction in carbohydrate intake of sweets and starches; the gastrointestinal symptoms occurring after consuming sweets and starches were nausea, intestinal cramping, and diarrhea.
Follow-up visit with the patient on April 12, 2022 revealed that the patient was seen with a diagnosis of long-haul COVID-19 manifesting chronic dyspnea with exertion. The following vitals were recorded during the visit: Blood pressure 127/78 | Pulse 74 | Temperature 36.7°C (98°F) | Resp 18 | SpO2 96%. Chest X-rays were ordered, but the patient has not complied.
The patient has not resumed her pre-COVID-19 diet because of taste alteration with the resulting gastrointestinal discomfort. However, the patient stated her symptoms began to mitigate: Breathing became easier after Tai Chi practice (i.e., there was almost immediate relief that she could fill her lungs with air), she was able to walk progressively longer distances without struggling for breath (i.e., initially she could barely walk 10 feet across a room and was now able to walk 0.5 miles outside), and dizziness upon exertion was becoming more infrequent (i.e., initially, she was dizzy after even mild exertion but after a week of Tai Chi her balance rapidly improved along with the dizziness).
She also reported that she now starts the Tai Chi or Qigong breathing exercises at the first sign of dyspnea, and she is able to resolve symptoms without resorting to the albuterol inhaler. The patient still has fatigue and tires much more quickly than before COVID-19 infection but the patient's perspective was that the practice of Tai Chi and Qigong provided a pathway back to a more normal activity level. Figure 1 provides a concise timeline of patient-care and interventions.
Timeline of patient care and interventions. F/U, follow-up; Dx, diagnosis; Rx, prescription.
Discussion
The SARS-CoV2 (COVID-19) pandemic had a huge impact on the world. It has produced 80,938,963 total cases in the United States from March to April 2022 and continues to produce 48,692 average daily new U.S. cases. 10 Although extensive research has been performed on COVID-19 pathophysiology, treatments, and immunization, there is a lack of information about the long-term effects of post-COVID-19 infection. Long-haul COVID-19 presents symptoms similar to active infection, 1 but there are a few treatment options available and understanding of disease progression is difficult.
Long-haul COVID-19 presents in 10–30% of the infected patients with unspecified symptoms, lack of objective diagnostic tests/biomarkers, and no clearly delineated consensus in exactly what constitutes a long-haul COVID-19 case. 11 Long-haul COVID-19 is “a range of symptoms that can last weeks or months…[that] can happen to anyone who has had COVID-19… symptoms may affect a number of organ systems, occur in diverse patterns, and frequently get worse after physical or mental activity”(p.577). 11 Thus, there has been considerable reticence in suggesting exercise to improve lung capacity in these patients. However, Tai Chi and Qigong may have the potential to lead to improvements.
Tai Chi involves a series of slow, continuous movements that shift weight from foot to foot and includes rotational movements of the head, trunk, and extremities. Tai Chi practice involves flexing the hips and knees to create a low center of gravity to strengthen the lower extremities and flexing the neck, trunk, and arms to improve alignment and coordination. The movements are combined with controlled breathing and concentration on the breath to provide awareness of breathing rate and lung capacity. 8
Qigong is a form of meditative movement along with breath control that can result in greater body awareness. 12 Qigong practice also includes either static or dynamic movements combined with breath regulation, mental concentration, and self-massage. Self-massage techniques include tapping along meridians and bones, stroking muscles to relieve tension, foot massage through weight shifting and stretching compression of organs and soft tissue. 12
Several studies have reported improvements in lung function and increased tidal volume following Tai Chi and Qigong practice.13,14 In another study, Tai Chi and Qigong demonstrated improved respiratory function and activity capacity in patients with chronic obstructive pulmonary disease who completed two sessions of 1 h each week for 3 months. 15 Due to Tai Chi's beneficial effects on several complex diseases, such as cardiovascular, multiple sclerosis, chronic pain, and fibromyalgia, some practitioners have suggested its use while recovering from COVID-19. 2
In the current case, we are able to provide quantifiable results with the patient's SpO2, resting pulse rate, and weight. The patient's SpO2 started at 83%, which greatly limited her ability to perform daily activities. After 10 weeks of Tai Chi and Qigong, her SpO2 increased to 93%. This indicates that Tai Chi and Qigong may be able to alter lung physiology and alleviate dyspnea in long-haul COVID-19 patients. It is postulated that Tai Chi improves lung function by counteracting the fibrotic scar formation, which could then decrease long-term COVID-19 fatigue and dyspnea. 2
A chest X-ray was ordered to determine presence of lung scarring, but the patient has not complied. However, the results of this case study are congruent with recent clinical trials showing that inspiratory muscle training and manual diaphragmatic muscle technique can aid in recovery post-COVID-19.16,17 Considering that Tai Chi and Qigong also involve a breathing component that engages the diaphragm, it is likely that Tai Chi and Qigong improve symptoms of dyspnea in a manner similar to yoga and other breathing exercises by increasing oxygen utilization and diaphragmatic muscle strength.
Further, recent articles have found that IL-1beta, IL-6, and TNF are elevated in patients experiencing long-haul COVID-19.18,19 Considering that high exercise amounts of Tai Chi can reduce IL-6 and TNF in patients with chronic illnesses such as diabetes mellitus type 2 and chronic pulmonary obstructive disorder, 3 it is also possible that the sustained Tai Chi practice improved lung function by lowering inflammation. However, a limitation exists in that limited data are present on the exact biological mechanisms by which Tai Chi and Qigong affect lung function in long-haul COVID-19, so a direct connection between these exercises and lung function cannot be established.
The improved symptoms could be related to improvement of other pre-existing conditions, diet alterations because of COVID-19, medications prescribed with the Tai Chi and Qigong, or simply a placebo effect as the patient was self-motivated to try this method. The patient lost weight during the time period that corresponds to previous reports demonstrating that Tai Chi can reduce waist circumference. 20 Decrease in weight has previously been shown to correlate with increased lung function, 21 so it is likely that Tai Chi and Qigong may have led to better lung function by impacting weight.
It is also likely that the weight loss is in part due to the gastrointestinal distress caused by COVID-19. Under this circumstance, an increase in lung function should be present in most individuals who experience weight loss due to COVID-19 as it is a common symptom of COVID-19, but this is not true as most patients with COVID-19 exhibit decreased lung function.
Conclusion
We suggest the use of Tai Chi and Qigong to improve lung function and quality of life in individuals with long-haul COVID-19. Tutorials for these exercises can be found from a wide variety of online sources, such as YouTube, making them freely available to self-motivated patients.
Future Research
With this case study being limited to one patient, we recommend future studies to focus on larger cohorts of patients with long-haul COVID-19 to further understand the connection between Tai Chi and Qigong and lung function.
Footnotes
Authors' Contributions
L.S.G. collected the patient data. L.S.G. and R.P. were the major contributors to writing the case report. B.T. served as editor. All authors read and approved the final manuscript.
Declarations
Funding Information
No funding was received for this article.