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Martial Arts and Physical Therapy:
Exploring the Connections

Americans are discovering the physical and mental benefits of martial arts. What is the role here for the physical therapist? To answer that question, PT presents three aspects of the martial arts/PT relationship. 

By Ellen Woods 

Special Needs Karate:
The Dojo Becomes Inclusive 

With the help of a dedicated PT, kids with special needs are kicking and punching their way to fitness and higher self esteem. 

Amanda Carter is a spunky pint-sized 17-year-old. An 11th grader with a red belt in karate, Amanda participates in baseball, bowling, skiing, gymnastics, and choir. She just got her learner's permit, loves to write, and is starting to prepare for college applications. Amanda also has cerebral palsy, which she says is "not really any big deal. It's just the way I am." Amanda says that much of what she has accomplished stems from a decision she made 7 years ago. At the age of 10 she watched her cousin practicing karate. It looked like fun, so she told her parents she wanted to learn karate. "I nagged my mother until she knew that I was serious." However, Amanda's mother couldn't find a karate studio that would accept Amanda. "They were afraid she would get hurt and that she would not succeed. But we kept looking because she had had to hear 'No, you can't participate' one too many times," recalls Mrs Carter.

Then Amanda's physical therapist heard about the Karate Program for Children with Special Needs offered through the St Barnabas Medical Center in Livingston, New Jersey. Amanda has been a student in the program ever since. She used to be the scorekeeper in gym class. Now she kicks and punches her way through one-hour workouts that test her endurance and strength. "Karate changed my life. It is my favorite thing to do in the whole world," she says.

Sue Wissen, PT, a pediatric physical therapist at St Barnabas, says that Amanda's success story is one of many. "She is exactly the kind of child we developed this program for," says Wissen, who has been with the karate program almost since its beginning. "We wanted a recreation program for children who, because of cognitive and/or physical disabilities, didn't fit into community extra-curricular programs. What we liked about karate is that it is an individual sport. The children could progress at their own pace and, therefore, had greater opportunity to succeed." 

When Amanda started at St Barnabas, the program had just finished a rocky first year. "It didn't work out with the first karate studio we went to. We needed to find ways to individually adapt the program for each child, while still presenting them with real challenges offered through martial arts. For instance, in a traditional karate program, the dojo (karate floor or mat) is sacred ground. You must bow to it and always take your shoes off. Some kids had to wear their orthotics and braces. Others were in wheelchairs. It was hard for that studio to make such accommodations," explains Wissen. 

Enter Paul Del Sordo, third-degree black belt instructor and owner of Hwang Karate of Springfield, New Jersey. Del Sordo had no experience working with students with disabilities. But, intrigued by the challenge, he met with staff in the physical therapy and occupational therapy departments at St Barnabas. They showed him a video of the special needs karate class. He immediately had ideas for improving the program. 

A physical therapist and an occupational therapist are present at every class. Wissen was at Del Sordo's first class 7 years ago, and she has been at nearly every class since. Del Sordo says, "From the beginning, Sue helped me feel comfortable with the various disabilities. And more important, she told me which kids to push harder and which ones had issues that I had to pay particular attention to or be extra careful with." 

The Special Needs Karate Program is open to children ages 4 to 18. The classes may have up to 18 students and are held twice a week. The "special needs" are wide ranging and may include autism, attention deficit disorder, cerebral palsy, Down Syndrome, and spina bifida. A medical release is required before starting, and participants enroll through the St Barnabas Medical Center. 

Structure is an important component of the program. After group warmup and stretching led by Del Sordo, the students break up into three groups based on their needs and abilities. Each group has at least one aide to work with them, with Del Sordo, Wissen, and the occupational therapist floating among the groups. 

Success in the class is measured on an individual basis, says Wissen. "For one it might be the ability to stay focused in the class for just 10 minutes. For another, it might be tournament competition. Some children have 'mainstreamed' to non-special needs classes, and others are advancing through the belt ranking system. We also developed a stripe system that recognizes advancement in skills for those students who may not be able to advance through the traditional ranking system." 

Taking Special Needs to the National Level 

The Hwang Karate studio is a certified member of the United States Soo Bahk Do Moo Duk Kwan Federation, Inc, and Del Sordo is a Federation-certified instructor. The studio teaches the traditional martial art style of Moo Duk Kwan, a highly disciplined form of karate. It was developed in 1945 by Grand Master Kee Hwang, who continues an active involvement in the worldwide practice of Moo Duk Kwan. His son, Master HC Hwang, works within the US Federation headquarters, which is located in Springfield, NJ, in the same building as Hwang Karate. This close affiliation with the US Federation has been a key factor in Del Sordo's ability to foster special needs karate programs throughout the country. 

Wissen and Del Sordo broke new ground 6 years ago when they took several students from the special needs class, including Amanda Carter, to the Federation's national championship tournament. "They didn't compete but did a small demonstration. People were impressed and proud that their Federation was embracing such a program. Other members were asking how they could start a program at their studios," remembers Wissen. "The kids were so excited. But what I'll remember most is the reaction of the parents. There was a not a dry eye among them. It means so much to these parents to see their children in a situation of accomplishment that has nothing to do with disability." 

After that tournament, Del Sordo and Wissen set out to develop a division within the Federation's tournaments that allowed students with special needs to compete. As they developed guidelines, they sought the help of Federation Chairman John Johnson, PhD, who brought several important perspectives to the process. He is a professor of special education at San Diego State University, has a sixth degree black belt, and has spina bifida. Johnson says without martial arts he surely would be in a wheelchair full-time. 

Today, the Federation has a formal division for tournament competitors with special needs. Four years ago, Del Sordo hosted a conference on special needs karate that was attended by about 50 instructors. "We've made it a mission to share what we've learned, and what we know works. I always tell other instructors to get the guidance of physical therapists and occupational therapists. We work as a team," says Del Sordo. 

"With Sue looking over, I have a level of confidence that we are not going to hurt any of these kids. When you are not worried about the risk of injury, it frees you up to accomplish so much," Del Sordo says. Not the least of which, he says, is treating them like other kids. "Once I understand the individual constraints of each child's disability, I can push them beyond what they think they can accomplish. That is one of the most valuable lessons I've learned from Sue." 

Among the trophies displayed in Amanda Carter's room are two pieces of wood. They were once one board that she broke in half with one swift kick, something she didn't think she would ever be able to do. It was quite an accomplishment for a kid with cerebral palsy. Actually, it would be quite an accomplishment for any kid. 

Tai Chi:
An Option for Therapeutic Exercise 

Tai chi is a Chinese martial art that involves controlled movement. Its origin goes back several thousand years. Explaining its origin, Steven L Wolf, PT, PhD, FAPTA, says, "Using tai chi, the warrior welcomed the attack, sidestepped it, and threw the attacker off balance, essentially using the attacker's own energy against him." Tai chi, as we know it today, involves a series of fluid movements. Each pattern of movement is known as a form. Each form progresses through a sequence of postures.

Several studies have shown that tai chi can improve balance and fitness in older adults. Physical therapists have taken note, incorporating the martial art form into therapeutic exercise programs. Jennifer Bottomley, PT, PhD, has practiced the ancient Chinese martial art of tai chi every day for 17 years. Having studied with tai chi grand masters, she credits her devotion to this martial art form with significant improvements in her strength, agility, flexibility, and mental balance. As tai chi became so positively integrated into her life, Bottomley couldn't help but wonder what its impact might be on her elderly patients. Thirteen years ago, she began to incorporate the low-impact, purposeful movements of tai chi into her therapeutic exercise programs. Her patients loved it, and she noticed many of them getting stronger and more physically fit. Still, she recalls, there was a level of discomfort because what she was doing was not evidence based. 

That was about to change. In the early 1990s, results from the National Institute on Aging's (NIA) FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) Project were published. Wolf, one of the profession's most highly respected and honored researchers, was a primary investigator on the project. 

The FICSIT Project looked at creative options in therapeutic exercise to reduce frailty and falls. Eight interventions were studied. "Tai chi proved to be the most potent intervention in preventing falls-delaying the onset of falls by 47.5%," says Wolf. "We were very excited about the study results, especially when we considered the potential implications for greater independence and quality of life for people as they age." 

Many clinical studies looking at the benefits of tai chi have followed. "The research has increased exponentially. Today, you could easily find up to 70 articles on tai chi in the health care literature," says Wolf, who has continued to be a contributor to such literature, as has Bottomley. Wolf says that after the findings of the FICSIT study, he felt compelled to continue his study of the health implications of tai chi. He recently completed an ambitious 4-year study (which has not yet been published) that looks at the effects of tai chi in older adults transitioning to frailty. As to why tai chi is so successful in reducing falls, Wolf says we don't yet know for sure, but he speculates: "The visual imagery makes you much more aware of your surroundings. The concentration required for each movement enhances your ability to divide your attention. It has repetitive practice, and you experience postural movement slowly." 

Other clinical studies support the use of tai chi in reducing blood pressure and stress and increasing fitness, strength, and aerobic capacity. 

Bottomley, who is president of APTA's Section on Geriatrics, says the findings on tai chi are among the most exciting developments in geriatrics in recent years. "I've been in geriatrics for 30 years. I remember when it was difficult to even talk about rehabilitation for this population within the medical model. The philosophy in medicine was, 'They are at the end of the lifespan. Why spend time returning them to full function?' But physical therapists didn't accept that. And now, we're concentrating on not just rehabilitation, but improved fitness, independence, and quality of life. This is a very exciting time for geriatrics." 

In light of research on the effectiveness of tai chi as therapeutic exercise for older patients, can it be incorporated into a PT's practice? 

Wolf urges physical therapists to be cautious in encouraging patients/clients to sign up for tai chi classes. "If your patients take classes with tai chi instructors who are not experienced in working with older adults, they can get hurt. For instance, one form requires rotation of the body with feet planted on the ground while twisting above the knee joint. That move has potential for causing a knee injury in an older adult. The stance can be easily modified. Many instructors are purists and will not be willing to make modifications. But there are several styles of tai chi that have been developed and practiced in China for the last 400 years and that are specifically modified for the older student. Look for an instructor who has experience in these styles." 

A physical therapist who is serious about incorporating tai chi into his or her practice should consider studying the martial art, says Wolf. "A one-day course is a great way to learn more about the art and to consider its potential use with your patients. But to take the next step and actually instruct patients, physical therapists should consider studying tai chi for several months," says Wolf. Another option is to team up with an experienced tai chi instructor. "This is what we did in all of our studies. By bringing your skills and knowledge together with an experienced instructor, you can provide a safe and positive experience for your patients," says Wolf. 

Physical Therapist Black Belts:
Making the Connection 

What happens when physical therapists study human movement from an Eastern perspective? PT Magazine looks at the experience of three PT black belts. 

George Davies

 Like many sports physical therapists, George Davies, PT, MEd, SCS, CSCS, ATC, is an athlete. A typical day for him might include a 5-mile run, a circuit weight-training program, a stretching session, and teaching a karate class. This 54-year-old grandfather has regularly and successfully competed in marathons, ultramarathons, triathlons, and Iron Man competitions. He has a black belt in karate and is a Sensei (karate instructor).

Davies' interest in martial arts dates back more than 30 years ago when, as an active US Marine, he was learning hand-to-hand combat routines that included some martial arts styles of defense. He has been training ever since. Davies says, "The years of dedication and training it takes to get to the black belt level carry over in terms of self discipline in everything else you do in life." 

A clinician, teacher, and researcher, Davies served as president of the Sports Physical Therapy Section for 6 years, is widely published, and has received many research grants and professional awards. 

Davies is also a Specialist in Martial Arts Conditioning, a certification awarded through the International Sports Science Association. He says it was relatively easy to acquire the certification given his background as a physical therapist. "With this certification, I work with martial artists in the karate studio to help them train effectively," explains Davies. Martial arts training is complementary to most aerobic sports, notes Davies. And it is "complementary to a lot of the principles we use every day in physical therapy," he says. "Martial arts programs can improve balance, coordination, agility, strength, power, and flexibility. As a physical therapist, it would be hard for me not to relate my knowledge of physiology, biomechanics, and kinesiology to what I do in the karate studio." 

And while the interrelationship of physical therapy and martial arts is clear to Davies, he says he would not use martial arts as a formal part of a rehabilitation program for a client, but he does use variations of martial arts forms as part of his therapeutic exercise programs. "Once a client has completed a rehab program with me, I may also recommend a martial arts class as a way to stay fit, to continue to develop strength and flexibility, and to prevent re-injury. 

"One of my goals is to look at the scientific basis of martial arts. It is exciting to follow the research that has been done with tai chi. I have seen martial arts programs offer many benefits to individuals who are recovering from injury and to those who have disabilities-ranging from improved balance and strength to improved self confidence and self esteem. I believe the possibilities for people with disabilities are particularly great. But we don't know this for sure because we haven't scientifically documented such outcomes," says Davies. 

Trudy Goldstein 

Thirteen years ago, Trudy Goldstein, PT, was looking for a new fitness option after giving birth to her second child. She tried martial arts and ended up with a lifetime passion. In 1998, Goldstein earned her second-degree black belt. "I fell in love with martial arts and immediately saw a relevance to physical therapy," says Goldstein, who is skilled in the arts of kung fu, tae kwon do, and tai chi. 

"Applying my understanding of how the body moves, I was delighted to see how very posture oriented the training is. You work on balance and weight shifting, with your eyes always following the movement. In martial arts, the whole body is working as one unit, a concept that has become so important in physical therapy in the last decade as we shifted our focus to functional training. And like physical therapy, martial arts is about ability. The focus is on what you can do, not what you can't do. Today, I can do things that I could not do 14 years ago. I am fitter, stronger, more flexible, and in better cardiovascular condition." 

In the early '90s Goldstein became seriously ill with an unknown diagnosis. "I got worse and worse. I was in severe pain. I was tested for everything, and in retrospect I believe it was a viral form of arthritis. It lasted for about 6 months before dissipating. My martial arts instructor told me to come back to the studio to do tai chi, which I had never tried before. I was so weak I couldn't hold a pencil. But I went every other day. I got stronger and came back 100 percent. Tai chi has remained my favorite martial art form." 

At about the same time landmark research was being published on the therapeutic benefits of tai chi (see Tai Chi). "It was so exciting. I began integrating tai chi into my practice. And I was seeing the same improvements that had been documented in the literature: improvements in blood pressure, strength, balance, range of motion, mood, and aerobic capacity." 

Goldstein--founder and director of Quest Seminars, Burlington, Massachusetts--is an author, educator, and clinician in the areas of orthopedics and geriatrics. She was so excited about the value of tai chi as therapeutic exercise that she began offering classes to well elders as a community service. 

Wade Baskin 

"I'm 5 feet 7 inches on a good day," says Wade Baskin, PT. "At tournaments, I'm often the smallest guy out there. I have to be a little faster and more flexible." 

But that doesn't mean training harder or longer. Baskin says he simply can't. He has other priorities in his life. "Spending time with my wife and two children is an absolute priority, as is my dedication to my profession and my patients," says Baskin. So then, how did the Baskin manage to take top honors in the 2000 Tae Kwon Do World Championship? 

"I used my physical therapy background to train smarter and more efficiently," says Baskin, who placed number one in the forms division (an individual competition in which participants perform a set of compulsory movements). "I evaluated myself and came up with a plan. I broke up my training into short intervals addressing speed, flexibility, cardio, and strength. I trained in the early morning, at lunch time, and sometimes in the evenings. Once a week, I did sport-specific training." 

Baskin's results were not lost on his fellow martial artists who have come to him for training advice. He now offers private performance enhancement programs for martial artists. "One may come to me with the goal of improving his kicks, another might want to have more speed. I assess their movement patterns in the karate studio, and we develop a plan." Baskin says he is having fun, but he isn't about to quit his day job. He cautions his patients who are interested in starting a martial arts program. "If not done correctly, you can hurt yourself. Look for an instructor who is affiliated with a national organization and has completed some type of certification process to be an instructor." Baskin is certified through the American Tae Kwon Do Association. 

Known as the PT of choice in his rural Louisville, Mississippi, community where he has a general musculoskeletal and orthopedic practice, Baskin says his greatest satisfaction is in working one-on-one with patients and helping them return to full function. Sometimes, he will teach a martial arts movement pattern to a patient. "If I've got a patient who needs to strengthen a bad knee, I may teach him a mini form that has him perform a kicking-like maneuver with his good leg. That's a lot more interesting than balancing on your bad leg for 15 seconds, but, in effect, that is what he is doing."
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Ellen Woods is a freelance writer.

_{PT Magazine - May 2002}