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CASE REPORT
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.
Key words:
Blood pressure;

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 Case report
HKMJ 2001;7:315-8 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- pressure elevation.
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) Pulse (beats/min) * 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 Pulse (beats/min) 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; Instructions for Letters to the Editor
Letters discussing a recent article in the Hong Kong Medical Journal are welcome and shouldbe sent to the Editorial Office by e-mail to <hkmj@hkam.org.hk> within 6 weeks of thearticle's publication. Original letters that do not refer to a Journal article may also beconsidered. All letters that relate to a Journal article will be posted on the Journal website<http://www.hkmj.org.hk> and will be eligible for publication in the paper version.
Letters should not exceed 500 words, have no more than five references (in the Vancouverstyle), and contain only one illustration if appropriate. There should be no more than twoauthors; a greater number requires justification. Authors should quote their two highestqualifications and give full contact details, as well as an e-mail address for the correspondingauthor. Financial associations or other possible conflicts of interest should always be disclosed.
Letters may be edited before publication.
318 HKMJ Vol 7 No 3 September 2001

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