Intracerebral haemorrhage and
We report on a 65-year-old woman who presented with acute right-
sided weakness because of an intracerebral (thalamic) haemorrhage.
As a Qigong enthusiast with a long-standing history of hypertension,
she developed a stroke syndrome soon after practising Qigong one
morning. Following neurological recovery, the patient exhibited erratic
blood pressure responses while practising Qigong, despite the fact
that resting blood pressure was normal. The haemodynamic responses
to exercise are discussed and a review of the therapeutic implications
of practising Qigong is presented.
The incidence of stroke—usually the third most common cause of death inHong Kong—is estimated at approximately 1 to 2 cases per 1000 of popu-lation.1 Intracerebral haemorrhage occurs in approximately one third of thesecases and is two to three times more frequent in ethnic Chinese than inCaucasians.2 Cerebral haemorrhage is due to the irruption of blood into thebrain parenchyma, usually from the rupture of a small perforating artery.
Traditional therapeutic exercises are widely practised in China and
some, such as Tai Chi, have also gained popularity in the West. Literature
on Tai Chi has shown that there are no adverse haemodynamic effectsduring its practice.3,4 The haemodynamic effects of some other traditional
Chinese exercises, however, are not well documented. We report on a
woman who was a Qigong enthusiast and presented with an acute thalamic
The index case was a 64-year-old woman who presented with her first
Rehabilitation Unit, University Department
ever attack of acute right-sided weakness soon after practising Qigong
of Medicine, Tung Wah Hospital, Sheung
Wan, Hong Kong
one morning in September 2000. The weakness reached its maximum in
KP Leung, FHKCP, FHKAM (Medicine)
15 minutes and then gradually improved. She presented herself to an
LSW Li, FACRM, FHKAM (Medicine)
emergency department and was subsequently admitted to Queen Mary
Department of Physical Medicine and
Rehabilitation, Sun Yet-sun University of
Hospital for further management.
Medicine Sciences, Guangdong, China
T Yan, MSc, MD
This woman had a previous history of goitre and hypertension, which
Correspondence to: Dr KP Leung
were not receiving any medical attention. Her family history was
HKMJ Vol 7 No 3 September 2001 315
unremarkable. She did not smoke or drink. Both she
blood sugar were under optimal control. The patient
and her husband were Qigong enthusiasts and believed
even resumed practising Qigong, along with the usual
that they could regulate their blood pressure by practis-
physiotherapy and occupational therapy training.
ing Qigong regularly.
The type of Qigong that she practised consisted of alot of isometric elements. From the authors' experi-
Assessment a few hours after the onset of symptoms
ence, the injudicious practice of isometric exercise,
revealed mild grade 4/5 right hemiparesis. The
especially with breath-holding, can induce surges in
Glasgow Coma Scale score was 15. Cranial nerves
blood pressure. Hence, continuous blood pressure
were not affected, except that there were grade 2 hyper-
recording was conducted using a 24-hour ambulatory
tensive changes on fundoscopic examination. Speech,
blood pressure monitor while the patient practised
swallowing, sensory, and sphincter functions were not
Qigong. Blood pressure was recorded every 3 minutes
affected. A clinically euthyroid goitre was noted. Blood
after Qigong was commenced. The resulting blood
pressure level was moderately increased at 190/
pressure profile is shown in the Table and the Fig. The
110 mm Hg. The rest of the physical examination was
results demonstrate that within 3 minutes of starting
Qigong, both systolic and diastolic blood pressureincreased to a relatively high level, and remained
An urgent non-contrast computed tomography scan
elevated for about 35 minutes. The mean systolic blood
of the brain revealed a left thalamic haemorrhage. As
pressure was 162.3 mm Hg (standard deviation [SD],
there was no mass effect and the patient was improving
12.8 mm Hg) and the mean diastolic blood pressure
neurologically, she was managed conservatively. A
was 99.4 mm Hg (SD, 5.1 mm Hg). The findings were
laboratory investigation was normal, except that mild
presented to the patient and it was suggested that she
diabetes mellitus was confirmed. An electrocardiogram
avoid performing Qigong activities that caused blood
showed left axis deviation and left ventricular hyper-
trophy by voltage.
The patient was discharged 2 weeks after the
The patient remained neurologically stable after
onset of stroke, with full independence in daily living
admission, although blood pressure level was persist-
activities, including walking.
ently elevated (180/105 mm Hg). In view of the evi-dence of chronic hypertension, amlodipine was slowly
added to achieve a modest blood pressure control.
Exercise and haemodynamic responses
Five days after the acute event, the patient was
Muscle contractions can be divided into two categories:
transferred for stroke rehabilitation. In the rehabili-
static and dynamic. Static or isometric contractions are
tation unit at Tung Wah Hospital, she gained almost
those in which there is no movement of the load on
full functional recovery. By now, blood pressure and
which the muscle is acting. Dynamic contractions, on
Table. Blood pressure and pulse profile
Blood pressure (mm Hg)
* SD standard deviation
316 HKMJ Vol 7 No 3 September 2001
Intracerebral haemorrhage and Qigong
viewed as placing primarily a pressure load on the left
ventricle, whereas dynamic exercise is viewed as
placing more of a volume load on the left ventricle.5
Qigong and health
Qigong for health maintenance and promotion has atherapeutic concept reliant on traditional Chinese
medicine and has been practised for hundreds of
years. It is estimated that 5% of the current 1.3 billion
Chinese population perform this traditional exercise6
which, broadly speaking, can be of either a dynamic
or static variety. Unfortunately, the therapeutic effects
of Qigong are seldom reported in the western litera-ture. Nevertheless, recent attention has focused on this
technique for treating chronic disorders, includingcardiovascular disease.7 A number of studies have
shown that properly practised, Qigong can reduce
blood pressure.8,9 Sancier10 conducted a review of the
evidence available and concluded that combiningQigong and drug therapy for hypertensive patients
Fig. Blood pressure and pulse profile
could reduce the dosage requirement for blood pres-
the other hand, involve muscle shortening or lengthen-
sure control, as well as the incidence and mortality of
ing. Many of the cardiovascular adjustments to dy-
namic exercise are regulated by changes in autonomicactivity outflow. Parasympathetic tone exists at rest,
The patient in this study, however, had a history of
and its withdrawal at the onset of exercise allows heart
hypertension lasting for some years and, in view of
rate to rise. When work intensity reaches the point of
the fact that she was not under medical attention for
50% of maximal oxygen consumption (VO ), para-
this, it was questionable whether her blood pressure
sympathetic withdrawal appears to be exhausted, and
control was optimal. There is a potential risk in
any further rise in heart rate is totally dependent on
practising Qigong under these circumstances.
increased sympathetic activity. Systolic blood pressure
Certainly, the results of her continuous blood pressure
progressively rises with increased dynamic workload,
monitoring support this point.
whereas diastolic blood pressure generally remainsrelatively unchanged. The net effect is a modest
The authors would like to point out that Qigong,
increase in mean arterial blood pressure (usually less
with its intrinsic exercise element, definitely has some
than 20 mm Hg). Total systemic vascular resistance
effect on blood pressure. For patients who are hyper-
declines progressively with increasing work intensity.
tensive, or at risk of cerebrovascular or ischaemic heart
The precise mechanisms leading to vasodilatation
disease, objective blood pressure measurement is
in active muscles remain debatable, but are likely to
thus desirable. O'Connor et al11 have shown that the
stem from changes in several local factors, including
Valsalva manoeuvre (breath-holding) is the prime
osmolarity, pH, potassium concentration, and levels
factor causing an elevation of blood pressure during
of endothelial relaxing factor and adenosine.
isometric exercise. Hence, proper instructions to avoidbreath-holding are important for susceptible patients
The haemodynamic responses (increases in VO ,
who wish to practise Qigong.
cardiac output, and heart rate) are typically modestduring static exercise compared with dynamic exercise.
Additionally, total peripheral vascular resistance doesnot decrease, and stroke volume usually fails to rise,
This report illustrates a case of intracerebral haemor-
as occurs with dynamic exercise. Mechanical and meta-
rhage related to suboptimal blood pressure control. In
bolic activation of skeletal muscle afferent nerve fibres
addition, it documents erratic blood pressure elevation
during static exercise evokes a pressor response that
in this patient while she was practising Qigong, which
leads to a significant increase in blood pressure,
is a very common form of Chinese therapeutic exer-
especially in mean arterial blood pressure and diastolic
cise. Disregarding the possible therapeutic benefits
blood pressure. For this reason, static exercise is often
of Qigong, one should remember that the exercise
HKMJ Vol 7 No 3 September 2001 317
component will undoubtedly have an effect on blood
pressure. We thus recommend that persons wishing to
5. Martin DH, Lois MS, William JK. Therapeutic exercise. In:
DeLisa J, Gans BM, Bockenek WL, et al. Rehabilitation
practise Qigong have a general body and blood pressure
medicine: principles and practice. 3rd ed. Philadelphia:
check before embarking on this, or any other form, of
Lippincott Williams & Wilkins;1998:697-743.
vigorous exercise. For those with hypertension, we
6. Lee S. Chinese hypnosis can cause qigong induced mental
recommend that they have meticulous blood pressure
disorders. BMJ 2000;320:803.
control and undertake proper breathing instructions.
7. Luskin FM, Newell KA, Griffith M, et al. A review of mind-
body therapies in the treatment of cardiovascular disease.
Part 1: implications for the elderly. Altern Ther Health Med
8. Mayer M. Qigong and hypertension: a critique of research. J
1. Statistical report 1995/96. Statistics and Health Information
Altern Complement Med 1999;5:371-82.
Section, Hospital Authority; February 1997.
9. Lee MS, Kim BG, Huh HJ, Ryu H, Lee HS, Chung HT. Effect
2. Kay R, Woo J, Kreel L, Wong HY, Teoh R, Nicholls MG.
of Qi-training on blood pressure, heart rate and respiration
Stroke subtypes among Chinese living in Hong Kong: the
rate. Clin Physiol 2000;20:173-6.
Shatin Stroke Registry. Neurology 1992;42:985-7.
10. Sancier KM. Therapeutic benefits of qigong exercises in
3. Fontana JA. The energy costs of a modified form of Tai Chi
combination with drugs. J Altern Complement Med 1999;5:
exercise. Nurs Res 2000;49:91-6.
4. Young DR, Appel LJ, Jee S, Miller ER 3rd. The effects of
11. O'Connor P, Sforzo GA, Frye P. Effect of breathing instruction
aerobic exercise and Tai Chi on blood pressure in older
on blood pressure responses during isometric exercise. Phys
people: results of a randomized trial. J Am Geriatr Soc 1999;
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