Immediate and Long-Term Effects of Qigong on Cold Intolerance in Patients with Post-Poliomyelitis Syndrome

Post-poliomyelitis syndrome (PPS) is a disorder in individuals who have had poliomyelitis, characterized by new muscle weakness and often associated with other symptoms, including cold intolerance (CI). Qigong is a Traditional Chinese Medicine technique to adjust energy and blood circulation. Objec-tive: To verify the effects and late repercussions of Qigong on CI complaints in PPS patients. Methods: PPS patients (n = 22, 14 females, 8 males; ages 35 60) performed Qigong exercises in 40-minute sessions, three times per week, for three consecutive months. They were evaluated at baseline, the end of treatment and every three months for a year using a visual analogue scale adapted for CI (VAS-cold). Results: The systemic VAS-cold scores exhibited significant differences between the baseline, the end of treatment and throughout 12 months of follow-up. Conclusion: The CI scores were low and bearable at the end of intervention and for the following 12 months without activity.

weakness added to the residual manifestations of poliomyelitis and is often associated with other symptoms, including muscle fatigue, muscle and/or joint pain, cold intolerance (CI) and sleep disorders [1] [2] [3] [4] (see Table 1). Approximately 69.8% of individuals with PPS in Brazil exhibit CI. On clinical examination, the affected limbs are abnormally cold due to affected sympathetic nerve cells [5]. The etiology of CI has not yet been established, and there is no specific treatment for it; the affected individuals are advised to wear appropriate clothes, perform distal/proximal massages and apply local heat over short periods of time [6].
From the clinical and histological point of view, the pathophysiology of PPS involves dysfunction of the lower motor neurons. Overtraining and dysfunction of the surviving motor neurons causing disintegration of the axon terminals are the main mechanisms that cause PSS. However, compensatory mechanisms are also activated to induce muscle reinnervation, increasing the size of the motor unit. This phenomenon occurs in partially damaged axons. Exposure to stress contributes to electrophysiological changes that reduce the speed of nerve conduction, which favors early degeneration [7].   [8].
Traditional Chinese Medicine (TCM) is an Eastern healthcare practice that takes the patient's physical, mental, spiritual and environmental features into consideration, as well as his or her health-disease process [3].
In 1973, some objects were unearthed from Han (漢朝) dynasty tombs in Mawangdui (馬王堆), Zhangsha (長沙), Hunan (湖南) province, including a series of 44 gravures depicting exercises known as Daoyin. That finding represented a milestone in the history of the Chinese self-care-centered corporal arts. In 1984, excavations in Hubei (湖北) province found, among other objects, one book entitled Yinshu, written on bamboo slips and dated 186 BC, that made reference to Daoyin. Furthermore, 110 gravures were found at that site, of which 9 were duplicated, 85 provided instructions for the movement, and 50 were used as a method of treating disease [9].
The gravures described exercises performed lying down, sitting and standing.
The book comprised five chapters devoted to the following subjects: 1) recovery of health under the four climates (heat, dampness, wind and cold); 2) description of the theory and practice of Daoyin; 3) the use of 45 exercises for the recovery of health; 4) the use of 24 exercises to strengthen the body; and 5) the pathophysiology, treatment and prevention of diseases [9]. This study is justified by the paramount importance of follow-up in individuals with neuromuscular disease after the end of treatment to assess the interference of treatment in the natural history of disease.
The aim of this study was to investigate the effects and late repercussions of Daoyin Qigong (DQ) relative to CI in individuals with PPS.

Patients
The study included 22 patients (8 males, 14 females) aged between 35 and 60 years with clinical diagnoses of PPS, according to criteria developed by Mulder

Allocation
Patients were randomly selected according to their record numbers. The patients signed a consent form after being informed about the study.

Inclusion Criteria
We included all patients who fulfilled the definition of PPS-morbid condition in consequence of the poliomyelitis disease-and complained of CI.

DQ Exercises Used
Five exercises form Yinshu (引書) [9], a book that presents 50 exercises that recover health, were selected and adapted for the sitting position. These exercises were performed along with a specific breathing technique designated as "the small circle," which consists of abdominal breathing. The exercises were applied in sessions of 40 minutes, 3 times per week for 3 consecutive months.
The first exercise, called "Seed Harvest," is an adaptation of the Mang Zhong (芒種), see Figure 1. The therapeutic aim is to encourage the decompression of the spine's intervertebral structures and specifically strengthen the adjacent muscles that promote vertebral stabilization.
The second exercise, entitled "Leading the Waist," is adapted from the exercise Yinyao (引腰), see Figure 2. Its therapeutic purpose is the decompression of the spine's intervertebral structures by relaxing and stretching and by strengthening of the adjacent muscles that promote vertebral stabilization.
The third exercise is called "Summer Solstice" and is an adaptation of the exercise Xiazhi (夏至), see Figure 3. Its therapeutic potential is to mobilize and strengthen the deep posterior muscles, including the multifidus, intertransversarius, interespinalis and rotators. These muscles lie bilaterally to the spine. In stretching, both sides are activated, whereas in rotation or lateral flexion, they are unilaterally activated.
The therapeutic aim is to mobilize and strengthen the rotator muscles.
The fifth and last exercise of the series is called "Closure" and is based upon   2) With your torso erect, shrink it as much as possible.
3) Lift the torso and stand erect, feeling the spine straightening and your hands above your head holding up the sky.   3) Move your hands back towards the ribs and repeat the sequence.

Description of the Visual Analog Scale
The Visual Analog Scale (VAS) is a psychometric response scale for use in questionnaires. In this case, it has been used to evaluate intolerance to cold. It consists of a 10-centimeter sliding scale on a horizontal or vertical line, with categories from "no complaint," referring to a score of zero, to "intolerant," referring to a score of ten.
The patient will draw a cross or a line (perpendicular to the scale) marking the point that represents the intensity of his/her complaint. Therefore, the intensity of sensitivity to cold and the mark position on the scale are equivalent.
Afterwards, the distance in centimeters is measured from the beginning of the scale (which corresponds to zero) to the mark, thus obtaining a numerical rating, which is recorded on the record sheet.

Statistics
The t-test, Levene's test, the General Linear Model and the Bonferroni post hoc test were used. The 95% confidence intervals of the means were calculated, and the significance level was established as a p-value of 0.05. The analysis was performed using the software SPSS V20 and Excel Office 2007.   Table 3 and

Discussion
We found that following DQ training, the complaints of CI exhibited statistically significant improvement in all the participants, and the sensitivity to cold exhibited low scores and bearable levels at the end of intervention and in the evaluations performed during the following 12 months. In the study by Ramos et al.    [11], the participants were trained in eight exercises; however, as a function of the difficulties in memorization reported by the participants, this study trained the participants in only the five simplest and most easily reproduced DQ exercises. The results of the two studies agree. Barbosa and Stewien (1980) analyzed the records of 1305 individuals affected by the poliovirus from 1967 to 1977 in the city of São Paulo and found that 75.3% of the cases of polio corresponded to children within the two first years of life, while 0.5% corresponded to individuals aged 15 years old or older [12]. In this study, most cases of polio had occurred within the first two years of life and the smallest fraction at age 15 years old or older (see Table 4).
There is universal agreement that systematic, planned physical activity helps to improve and restore physical functioning and to optimize the global state of the health of individuals. For patients with PPS, the practice of exercise for therapeutic or sport-related purposes requires particular attention. Low-impact activities and/or exercises performed under personal instruction, beginning with relaxation and combining free isometric exercises with resistance training and appropriate breathing processes, are indicated for most motor neuron diseases, as they are favorable for the neuroplasticity induced by functional or motor tasks [13] [14], increase the body temperature as a function of the muscle activity and trigger the release of adenosine triphosphate into arterial circulation [15]- [20].
Notwithstanding those benefits, the particularities of each individual should be considered.
Following up individuals with neuromuscular disorders after the end of treatment is of paramount importance for assessing the effect of the investigated therapy on the natural history of the disease, as well as of its residual effects as a function of inactivity time, to determine the need to repeat the intervention or interruption. In this study, the cold sensitivity scores remained low and were  [23]. The gradual loss of the effects of exercise over time is also relevant, as it impairs the ability to perceive the environmental temperature and the efficacy of thermoregulation against cold. The results of this study suggest that physical activity should be resumed at approximately the time when the fifth evaluation was performed to prevent complaints related to CI from increasing to the level found at the first assessment.
We suggest that DQ exerts positive effects on CI. Following up individuals with neuromuscular disorders after the end of treatment is of paramount importance for assessing the interference accomplished by the investigated therapy in the natural history of the disease. Therapeutic decision-making should consider the possible interference of the environment, especially in the case of individuals with PPS and CI. Therapeutic programs should incorporate preventive goals, monitor the patients to establish the moment when activity should be restarted and particularly stimulate self-care. Low-impact exercises contribute to the maintenance and conservation of the patients' energy and global wellbeing.
DQ exercises exhibited positive effects on the CI complaints of individuals with PPS. VAS scores relative to cold sensitivity remained low and associated with bearable levels at the end of intervention and in the evaluations performed throughout the following 12 months without activity. The results of the fifth evaluation indicate the need to resume intervention.