Ai Chi (Konno)

1. Introduction

Version followed: the Ai Chi posture sequence as described by Jun Konno's programme and its English-language co-developer Ruth Sova, as published by the Aquatic Exercise Association (AEA, which runs the Ai Chi International instructor certification), together with the "Clinical Ai Chi" version described by Lambeck and Bommer in Comprehensive Aquatic Therapy. A shortened clinical set used in a multiple sclerosis trial (Castro-Sánchez et al., 2012) is noted where it differs. [source: AEA Ai Chi General Info; Lambeck & Bommer, Clinical Ai Chi chapter; Castro-Sánchez et al. 2012]

What it is. Ai Chi is a water-based programme of slow, broad, continuous movements of the arms, trunk and legs, performed standing upright in water to about shoulder or neck depth and coupled with deep, abdomen-focused breathing. It was developed in Japan in 1993 by Jun Konno, founder of the Aqua Dynamics Institute in Yokohama, who drew on his background as an Olympic swimming coach. It began as a preparation for Watsu (a hands-on aquatic bodywork form) and now stands alone as aquatic exercise and relaxation. AEA states that Konno created the postures and the mental concepts, while Ruth Sova worked with him to finalise the concepts, suggested the posture names and the name "Ai Chi", and proposed adding the "Cultivating the Chi" postures. [source: AEA Ai Chi General Info; Wikipedia, Ai Chi; Lambeck & Bommer] The meaning of the name is not explained in the sources consulted [uncertain: not verified].

Roots and attributed concepts. Sources describe Ai Chi as combining elements of qigong (the earlier, more static and symmetrical arm postures) and tai chi (the later postures with continuous weight shifting), and as drawing on Shiatsu and Watsu. Lambeck and Bommer report that Konno drew on Shizuto Masunaga's ideas (Zen Shiatsu) about stretching meridians and balancing yin and yang. Within that tradition, relaxation is said to increase the flow of qi ("chi"), forearm turning (supination and pronation) is said to balance yin and yang, and particular scapular, trunk and pelvic movements are said to stretch named meridians. These are concepts of East Asian medicine and of the method's founders, not established physiology; Lambeck and Bommer themselves set them aside and describe Ai Chi in Western terms as an active relaxation technique emphasising postural control and breathing. The sources consulted do not use the word "Daoist"; any Daoist framing is the broader tai chi and qigong tradition's, not a documented Ai Chi teaching [uncertain: not verified]. [source: Lambeck & Bommer; AEA Ai Chi General Info]

How change is thought to happen. In the developers' account, change comes from (a) breath-led, unhurried movement that shifts attention inward and lets excess tension go; (b) water's support, which allows pain-limited people to move through a wider range with less joint load; and (c) a graded postural challenge, from a wide, static stance with symmetrical arms to narrow or one-legged stances, rotation, stepping and turning without fixing the eyes, which trains balance. Benefits reported in trials are improvements in balance, pain, fatigue and sleep in specific groups, but the evidence base is small (see Section 2, evidence status). [source: Lambeck & Bommer; AEA; Castro-Sánchez et al. 2012; Calandre et al. 2009; So et al. 2023]

Scope for the psychotherapist. Ai Chi is a movement and exercise method delivered in a pool by certified Ai Chi instructors, aquatic fitness professionals and aquatic physiotherapists. A psychotherapist delivers it only if personally certified as an Ai Chi instructor, working in a pool with the safety arrangements described below, and acting within their own profession's competence rules. Otherwise the psychotherapist's role is to suggest, refer, prepare the client and integrate the experience into therapy (Section 4, final entries). It is not a treatment for multiple sclerosis, Parkinson's disease, arthritis, fibromyalgia or any other physical disease; it is an adjunct exercise and relaxation method whose reported effects are on symptoms and function. [synthesis, drawing on AEA certification scope and the codes cited in Section 3]

2. Framework

Who delivers it and how they are credentialed

Ai Chi International Certified Ai Chi Instructor (through AEA courses): AEA states that the certification qualifies the holder to teach group classes, use Ai Chi in one-to-one therapy, rehabilitation or personal training, and run in-service training for colleagues. Requirements: complete the Ai Chi Basic Training/Cert Prep course (in person or live online, including posture practice on deck and in the water, teaching tips, partner leadership activities and modifications for different pools) and the online Ai Chi Principles & Foundations course (benefits and principles, breathing science including the vagus nerve, tips for different populations); pass an examination; hold current basic CPR/AED certification throughout the certification term. Certification is renewable. [source: AEA Ai Chi General Info]
Clinical Ai Chi: Konno granted the name "Clinical Ai Chi" to the International Aquatic Therapy Foundation (IATF) in Switzerland, to separate therapeutic use, which should rest on evidence, from wellness use. It is used by aquatic therapists, typically physiotherapists. [source: Lambeck & Bommer; Wikipedia, Ai Chi] Current IATF course structure [uncertain: not verified].
Aquatic physiotherapists: in the UK, the Aquatic Therapy Association of Chartered Physiotherapists (ATACP), a professional network of the Chartered Society of Physiotherapy, publishes guidance (2021) on competence for physiotherapists and non-physiotherapy staff, organising a safe aquatic service, and which patients should not enter the pool. [source: ATACP Guidance on Aquatic Physiotherapy 2021 page] The US APTA Academy of Aquatic Physical Therapy is a comparable body [uncertain: not verified].
In research trials, Ai Chi was led by a physiotherapist with small groups. [source: Castro-Sánchez et al. 2012]

Format

Standing upright in water at about shoulder-to-neck depth, soft (slightly flexed) knees, feet at least shoulder-width apart at the start, usually barefoot; no equipment needed. Delivered as group classes, one-to-one therapy, or individual practice. Warm, thermo-neutral water and air are described as supporting relaxation; a cooler-pool modification exists. Some practitioners have adapted Ai Chi to land. [source: AEA/Human Kinetics excerpt; AEA General Info; Lambeck & Bommer; Wikipedia] No temperatures, session lengths or frequencies are given here as instructions; these are set by the instructor or aquatic therapist after screening.
Each posture flows into the next: each begins where the previous one ended, with even force and speed and no hold at the end of a movement. [source: AEA General Info; Human Kinetics excerpt]
Trial programmes opened and closed with a period of in-water relaxation, with tai-chi-style background music. [source: Castro-Sánchez et al. 2012]

The movement progression (by published name)

AEA (Sova) gives the order of focus as: breathing → upper extremity → trunk stability → lower extremity → cultivating the chi → total coordinated body. [source: Human Kinetics excerpt from the AEA Aquatic Fitness Professional Manual] Lambeck and Bommer list the postures, in order, with what changes biomechanically [source: Lambeck & Bommer]:

Contemplating, Floating, Uplifting, Enclosing, Folding: symmetrical trunk, wide stance, no shift of the centre of gravity, symmetrical arm movements (the qigong-derived opening).
Soothing: wide stance, no weight shift, arms now asymmetrical.
Gathering: tandem (one foot in front of the other) stance, near-symmetrical trunk, asymmetrical arms.
Freeing: trunk rotation in tandem stance; the eyes follow the moving hand.
Shifting: thorax–pelvis rotation in a wide stance, with side-to-side weight shift.
Accepting: tandem stance, forward-and-back weight shift.
Accepting with Grace and Rounding: single-leg stance, lifting one leg within a breath.
Half Circling, Encircling, Surrounding, Nurturing: symmetrical arms, continuous weight movement, eyes following the hands.
Balancing: single-leg stance held across several breaths, with no fixed visual point.
Flowing and Reflecting: walking sideways with cross-steps and pivots.
Suspending: a turn of the whole body with a floating phase, no visual fixation.

How these names map onto AEA's six focus groups (in particular which postures form "Cultivating the Chi") is not stated in the sources consulted [uncertain: not verified]. The grouped list above contains one more name than the published total, so one grouping may be a single posture [uncertain: sources conflict]. The multiple sclerosis trial used a shorter clinical set including some different names (for example "Transferring", "Relaxing" and "Sustaining"), showing that clinical versions vary. [source: Castro-Sánchez et al. 2012] The exact arm, hand and foot choreography of each posture is taught in the certification course and in Sova's chapter in Brody and Geigle (2009); it is not reproduced here [uncertain: not verified].

Principles of progression and criteria for moving on

Lambeck and Bommer describe difficulty increasing along six lines: trunk from symmetrical to rotating; centre of gravity from static to moving; arm movements from small to large and from symmetrical to asymmetrical; base of support from wide to narrow (wide → tandem → one leg → stepping); and balance control from visual (eyes fixed) to vestibular (no fixed point, turning). [source: Lambeck & Bommer] Published criteria for moving a client from one stage to the next are [uncertain: not verified]. Practical criteria [synthesis]: the client can keep the breath smooth and unforced, keep movement continuous without grabbing for support, and report no dizziness, pain increase or anxiety at the current level before the base is narrowed or the eyes are released.

Evidence status (attributed)

Older adults / falls: Lambeck and Bommer report an assessor-blinded randomised trial in frail older adults (Teixeira et al.) in which Ai Chi improved static and dynamic balance and fear of falling did not rise, while it rose in controls; they note Ai Chi contains some features linked to fall reduction but that their fall-prevention adaptations are untested. [source: Lambeck & Bommer; original trial: uncertain: not verified]
Multiple sclerosis: a randomised trial in 73 people with MS found Ai Chi reduced pain and improved spasm, disability, fatigue and depression compared with land-based relaxation, with effects lasting after the programme ended; the paper has inconsistencies and possible unblinding, and the effect of the music cannot be separated. [source: Castro-Sánchez et al. 2012]
Fibromyalgia: a randomised comparison in 81 patients found no overall between-group difference from pool stretching, but Ai Chi improved fibromyalgia impact and sleep quality within-group, while stretching improved some psychological measures. [source: Calandre et al. 2009]
Parkinson's disease: a pilot study without a control group (10 participants) reported balance improvements but no gait-parameter change. [source: So et al. 2023] Earlier small Parkinson's and stroke studies are summarised by Lambeck and Bommer, with methodological limits. [source: Lambeck & Bommer]
Overall: small trials, mostly single-centre; the existence and findings of a systematic review specific to Ai Chi are [uncertain: not verified]. AEA lists wider uses (pain management, arthritis, COPD, diabetes, prenatal clients, neurological and orthopaedic conditions) drawn from evidence-based and anecdotal sources; these are the association's claims, not established effects. [source: AEA General Info; Human Kinetics excerpt]

3. Guiding principles

Breath leads movement. Deep, abdomen-focused breathing paces each movement; in the clinical description the palms turn up (supination) on the in-breath and down (pronation) on the out-breath. Practical meaning: cue breath first and let the arms follow; never ask the client to hold the breath. [source: Lambeck & Bommer; AEA]
Listening inward. Attention is directed to internal sensations. Practical meaning: cue noticing rather than performing; keep talk sparse. [source: Lambeck & Bommer; Human Kinetics excerpt]
Roundness. A pliant body and mind adapt more easily; slow, round movements "mimic nature" and allow reflection. Practical meaning: favour curved paths and soft joints over straight, locked ones. [source: AEA General Info]
Flow. Continuous movement with equal force throughout each posture, encouraging pain-free range. Practical meaning: no pauses at end-range, no pushing into pain. [source: AEA General Info; Human Kinetics excerpt]
Alignment. Attention to sound movement mechanics that carry over to land. Practical meaning: watch knees, pelvis and shoulders; correct gently. [source: AEA General Info]
Slowness and no force. Movements are slow and performed without force and without using the hands for support. Practical meaning: slow the client down rather than adding effort. [source: Lambeck & Bommer]
Relaxation as a skill. Letting go of excess tension is linked to deeper, smoother breathing. Practical meaning: name relaxation as something the client practises, not something done to them. [source: Lambeck & Bommer]
Graded challenge. Progress from wide to narrow base, symmetrical to asymmetrical, eyes fixed to eyes free. Practical meaning: narrow the base or release the gaze only when the previous level is calm and steady. [source: Lambeck & Bommer]
Even distribution of force. Force is spread across the body rather than concentrated in one part. Practical meaning: if one area is working hard (often shoulders), scale the movement down. [source: AEA General Info]
Therapeutic vs wellness use. Clinical Ai Chi should rest on evidence and be adapted to the client's condition. Practical meaning: in a clinical context, choose variants and goals deliberately and record outcomes. [source: Lambeck & Bommer]
Safety before practice. Screening, an observer on the poolside and emergency competence are part of the method's delivery (CPR/AED is a certification requirement). Practical meaning: no session without screening and a safe pool set-up. [source: AEA General Info; SCHN Aquatic Physiotherapy procedure]
Attributed concepts stay attributed. Qi, yin–yang and meridian ideas belong to the tradition Ai Chi draws on. Practical meaning: offer them as the method's imagery, not as facts, and drop them for clients who find them unwelcome. [synthesis, following Lambeck & Bommer's own Western framing]
Work within competence. UK and US codes require practitioners to offer only what they are trained for (UKCP item 23; BACP 2018 para 13; APA 2.01(a)). Practical meaning: a psychotherapist teaches Ai Chi only with instructor certification; otherwise refers. [source: UKCP Code 2019; BACP Ethical Framework 2018; APA Ethics Code]

4. Intervention inventory

The entries below are written for a certified Ai Chi instructor or aquatic therapist (including a psychotherapist who holds that certification), followed by entries for the psychotherapist who refers. Posture choreography is described only as far as the sources describe it; detailed hand and foot patterns come from certified training. All example language is illustrative.

4.1 Pre-participation screening and medical clearance

Purpose / when: before the first session, at the start of each new course, and whenever the client's health changes. [source: SCHN Aquatic Physiotherapy procedure]
Steps:
1. Take a health history covering the conditions professional aquatic guidance lists as possibly unsuitable (each judged case by case, not automatic exclusions): unstable medical condition; heat-sensitive conditions; skin grafts or donor sites with poor skin integrity; skin rashes, lesions or open wounds; chemical (chlorine) sensitivity; radiotherapy sites; acute deep vein thrombosis; acute kidney dysfunction; acute inflammatory conditions; fear of water (hydrophobia); incontinence or urgency and vomiting in people on chemotherapy. [source: SCHN Aquatic Physiotherapy procedure]
2. Also ask about heart and lung disease, blood pressure and fainting, epilepsy or seizures, pregnancy, diabetes and hypoglycaemia, medicines that cause drowsiness, dizziness or low blood pressure, alcohol (no participation after drinking), balance problems and recent falls, vestibular disorders, joint hypermobility or instability, recent surgery (especially shoulder), continence, and swimming ability. [synthesis, from the general aquatic-safety risks set out by professional and medical sources; an Ai Chi-specific contraindication list is uncertain: not verified]
3. Where any of these apply, obtain clearance from the client's doctor or treating specialist; for people on chemotherapy, clearance in consultation with the oncologist and pharmacist. The aquatic professional makes the final decision to accept. [source: SCHN procedure]
4. Record what help the client needs to get in and out of the pool, change, and move around the pool deck. [source: SCHN procedure]
5. For people with MS, ask about heat sensitivity and fatigue patterns; for people with Parkinson's disease, about freezing, falls and timing of medication; for fibromyalgia, about post-exertional flare. [synthesis]
Example language (illustrative): "Before we get in the water I need to go through some health questions. None of them automatically rules you out; they help us decide how to make the pool safe for you."
Watch for: clients minimising symptoms because they want to join; undisclosed fear of water; recent changes in medicines. Working signs: clear documentation, clearance on file before the first session, client knows they can stop at any time.

4.2 Pool safety set-up (every session)

Purpose / when: every session, group or one-to-one.
Steps:
1. A poolside observer who knows the emergency procedures (alarm, telephone, rescue) is present; nobody enters the pool area without the responsible professional. [source: SCHN procedure]
2. The instructor holds current CPR/AED certification (an Ai Chi certification requirement) and pool rescue training per the facility's rules. [source: AEA General Info; SCHN procedure]
3. Water chemistry is within public-health limits; clients shower and use the toilet before entering; continence products suited to water are used where needed. [source: SCHN procedure]
4. Non-slip footwear or care on wet floors to and from the pool; handrails or steps for entry; a stool or bar available for seated or wall variants. [synthesis; variants per Lambeck & Bommer]
5. Report incidents and near misses through the facility's system. [source: SCHN procedure]
Example language (illustrative): "If at any point you feel dizzy, cold, short of breath or just want to stop, walk to the rail or raise a hand. Stopping is always fine."
Watch for: slips on deck, light-headedness on leaving warm water, shivering, and clients drifting into deeper water. Working: no incidents, clients know the stop signal.

4.3 Water entry, stance and settling

Purpose / when: start of every session; establishes the base position the sequence develops from.
Steps:
1. Guide the client into water at about shoulder-to-neck depth (shallower for clients who are anxious or unsteady). [source: AEA/Human Kinetics excerpt; Lambeck & Bommer]
2. Stance: feet at least shoulder-width apart, knees soft, body upright and vertical, usually barefoot. [source: Human Kinetics excerpt; AEA General Info]
3. Arms rest on or just below the water surface. [source: Human Kinetics excerpt]
4. Invite a period of settling or in-water relaxation, optionally with quiet music, before the postures begin. [source: Castro-Sánchez et al. 2012]
Example language (illustrative): "Let your knees soften and your feet spread a little wider than your hips. Let the water hold some of your weight. Notice where you are tight, without trying to change it yet."
Watch for: locked knees, raised shoulders, breath-holding, fear when water reaches the chin. Working: the client looks settled, shoulders drop, breath slows of its own accord.

4.4 Breath-led movement (the core skill)

Purpose / when: throughout; Ai Chi's first focus is breathing. [source: Human Kinetics excerpt]
Steps:
1. Teach deep, abdomen-focused (diaphragmatic) breathing in the base stance. [source: Lambeck & Bommer; Wikipedia]
2. Couple movement to breath: in the clinical description, palms turn upward (supination) as the client breathes in and downward (pronation) as they breathe out. [source: Lambeck & Bommer]
3. Let the client's own comfortable breath set the pace; movement follows breath, never the reverse. Do not prescribe breath counts or holds. [synthesis, consistent with principles above]
4. Keep movement continuous with no pause at the end of each phase. [source: AEA General Info]
Example language (illustrative): "Breathe in and let your palms turn up to the sky; breathe out and let them turn down to the water. Your breath decides how fast we go."
Watch for: over-breathing (tingling, light-headedness), effortful or noisy breathing, holding the breath while concentrating. If seen, stop the movement and return to ordinary breathing. Working: breath and movement become one rhythm without effort.

4.5 Opening, symmetrical upper-limb postures: Contemplating, Floating, Uplifting, Enclosing, Folding

Purpose / when: first block of the sequence; trains breath-movement coupling and relaxation with minimal balance demand (wide base, no weight shift, symmetrical arms). Suitable for nearly all clients and for anxious beginners. [source: Lambeck & Bommer]
Steps:
1. From the base stance, lead each named posture in order, both arms moving the same way, trunk symmetrical, weight centred. [source: Lambeck & Bommer]
2. Each posture begins where the last ended. [source: AEA General Info]
3. Keep the eyes on a fixed point if balance is a concern. [source: Lambeck & Bommer]
4. Choreography of each posture: as taught in certification [uncertain: not verified].
Example language (illustrative): "Both arms move together, slowly, like seaweed in a gentle current. If anything hurts, make the movement smaller."
Watch for: shoulder pain at the top of arm movements, neck tension, rushing. Working: smooth, even speed and visible softening of the upper body.

4.6 Soothing (asymmetrical arms, stable base)

Purpose / when: introduces arms moving differently from each other while the base stays wide and still. [source: Lambeck & Bommer]
Steps: keep the wide stance and centred weight; arms move asymmetrically; keep breath leading. [source: Lambeck & Bommer]
Example language (illustrative): "Now the arms do different things, but your feet stay rooted and your weight stays in the middle."
Watch for: loss of breath coupling as coordination demand rises; trunk starting to twist. Working: the client keeps calm breathing while coordinating both sides.

4.7 Trunk postures: Gathering, Freeing, Shifting

Purpose / when: trunk stability and rotation; first narrowing of the base. [source: Lambeck & Bommer; Human Kinetics excerpt]
Steps:
1. Gathering: tandem stance (one foot in front of the other), trunk nearly symmetrical, arms asymmetrical.
2. Freeing: trunk rotation in tandem stance, with the eyes following the moving hand (this begins to reduce reliance on a fixed visual point).
3. Shifting: rotation between ribcage and pelvis in a wide stance, with side-to-side weight shift. [source: Lambeck & Bommer]
Example language (illustrative): "Let your eyes follow your hand. If the room starts to feel like it is moving, fix your eyes on the wall again."
Watch for: dizziness when the eyes track the hand (vestibular sensitivity), low back pain on rotation, loss of balance in tandem stance. Offer the wall variant (4.12) if unsteady. Working: rotation without wobble or breath-holding.

4.8 Lower-limb and weight-transfer postures: Accepting, Accepting with Grace, Rounding

Purpose / when: forward-and-back weight shift and then single-leg stance; balance training. [source: Lambeck & Bommer]
Steps:
1. Accepting: tandem stance with forward-and-back weight shift.
2. Accepting with Grace and Rounding: single-leg stance, one leg lifted within a breath. [source: Lambeck & Bommer]
3. Return to a wider base immediately if the client cannot stay steady without grabbing. [synthesis]
Example language (illustrative): "Let the weight travel forward as you breathe out, back as you breathe in. Only lift a foot if you feel steady; it is fine to keep both feet down."
Watch for: hip or knee pain, fear of falling, using the hands on the water or rail for support (the method asks for no hand support; offer the wall variant instead). Working: controlled weight shift, rising confidence.

4.9 Continuous-flow postures: Half Circling, Encircling, Surrounding, Nurturing

Purpose / when: symmetrical arms with continuous movement of the centre of gravity, eyes following the hands; whole-body flow at moderate balance demand. [source: Lambeck & Bommer] Whether these postures make up the "Cultivating the Chi" group, which Sova proposed so participants can relax before the total-coordinated-body postures, is not stated in the sources consulted [uncertain: not verified]. [source for the group's purpose: AEA General Info]
Steps: keep arms symmetrical, weight moving continuously, eyes following the hands; breath leading. [source: Lambeck & Bommer]
Example language (illustrative): "Let your whole body sway with the movement of your arms, as if the water were moving you."
Watch for: motion sickness or dizziness from eye tracking; drifting attention. Working: the client describes the movement as easy or restful.

4.10 Balancing

Purpose / when: single-leg stance sustained over several breaths with no fixed visual point; a high balance challenge. [source: Lambeck & Bommer]
Steps: offer only when the earlier single-leg postures are steady; keep the client within reach of a rail or the instructor; allow the eyes to fix on a point if needed. [source for posture: Lambeck & Bommer; safety steps synthesis]
Example language (illustrative): "This one is optional. If your foot comes down, that is part of the practice, not a failure."
Watch for: falls in water (submersion risk), fear, breath-holding. Working: steady stance with soft breathing.

4.11 Total coordinated body: Flowing, Reflecting, Suspending

Purpose / when: final block; sideways walking with cross-steps and pivots (Flowing, Reflecting) and a whole-body turn with a floating phase and no visual fixation (Suspending). Highest vestibular and coordination demand. [source: Lambeck & Bommer; Human Kinetics excerpt]
Steps:
1. Teach stepping patterns slowly in shallower water first if the client is unsteady. [synthesis]
2. For Suspending, ensure the client is confident in water and the instructor is close; omit for clients with vestibular disorders, seizure risk or fear of losing footing unless the aquatic therapist judges otherwise. [synthesis]
Example language (illustrative): "Step sideways and let your back foot cross in front. Go as slowly as you need."
Watch for: loss of footing, disorientation after turning, panic when feet leave the floor. Working: fluid stepping and turning with calm breath.

4.12 Clinical Ai Chi variants: Wall Ai Chi, Seated Ai Chi, Ai Chi Ne

Purpose / when: adapting the sequence to clients who cannot or should not do the standing form. [source: Lambeck & Bommer]
Steps:
1. Wall Ai Chi: postures performed holding a bar at the pool wall; for apprehensive or unsteady clients.
2. Seated Ai Chi: postures on a stool in shallower water; for people who cannot stand (for example leg paralysis) or with low back pain.
3. Ai Chi Ne: Ai Chi in pairs, as a bridge toward Watsu. Because it involves partner contact, obtain explicit consent before and during, agree how either person can stop, keep contact non-sexual and away from intimate areas, and let the client choose or refuse a partner. [source for variants: Lambeck & Bommer; AEA/Human Kinetics excerpt; consent standards: USABP Code of Ethics VIII]
4. Cooler-water modification and fusion classes (adding higher-intensity work) are listed as AEA variations; their protocols are not described here [uncertain: not verified]. [source: Human Kinetics excerpt]
Example language (illustrative): "In the partner version, your partner's hands may rest on your arms. You can say 'stop' or step away at any moment, and we can switch back to doing it alone."
Watch for: in partner work, freezing, going quiet or appeasing behaviour, which can signal discomfort with touch; in seated work, stool stability. Working: the client stays in charge of contact and reports feeling safe.

4.13 Fall-prevention emphasis (proposed adaptation)

Purpose / when: older or frail adults and people with neuromusculoskeletal conditions at risk of falls. Lambeck and Bommer suggest these adaptations but state they have not been tested. [source: Lambeck & Bommer]
Steps: more asymmetrical tandem and single-leg work; cross-steps without pivots; side-stepping without crossing the feet; reaching in several directions with brief holds; more trunk rotation with the eyes following the hands; emphasis on hip strategies. [source: Lambeck & Bommer]
Example language (illustrative): "We are practising what your body does when you reach for something and wobble, but with the water to catch you."
Watch for: over-confidence transferring to land too early; fatigue. Working: improved steadiness and reduced fear of falling as the client reports it.

4.14 Closing relaxation and return to land

Purpose / when: end of each session. [source: Castro-Sánchez et al. 2012 (relaxation period at start and end)]
Steps: a period of still or gently moving relaxation in the water; brief check-in; slow exit using rails; warn about light-headedness and slippery floors; encourage the client to warm and rest before driving. [first step: source as above; remaining steps synthesis]
Example language (illustrative): "Let the movement get smaller until you are just standing and breathing. When you are ready, walk slowly to the steps and hold the rail as you come out."
Watch for: dizziness on standing out of the water, sleepiness, emotional release. Working: the client leaves calm and steady.

4.15 Psychotherapist: deciding when to suggest Ai Chi

Purpose / when: clients who want a gentle, low-impact body practice for relaxation, pain-related distress, fear of falling or reconnecting with movement, especially where land exercise is painful (for example fibromyalgia, MS, arthritis, older adults with balance worries), and who are medically able to use a pool. [indications from AEA General Info and Lambeck & Bommer; framing synthesis]
Steps:
1. Clarify the goal (relaxation, coping with pain, confidence in the body, social contact) and present Ai Chi as a supplement to medical and psychological care, not a treatment for the underlying disease.
2. Check broadly for the screening issues in 4.1 and fear of water; advise the client to discuss pool exercise with their doctor or physiotherapist.
3. Prefer a certified Ai Chi instructor or an aquatic physiotherapist; for clients with significant neurological, cardiac or orthopaedic conditions, an aquatic physiotherapist offering Clinical Ai Chi. [synthesis, based on credentialing in Section 2]
Example language (illustrative): "Some people with pain like yours find slow movement in warm water easier than exercise on land. It won't treat the condition itself, but it may help with tension and sleep. Would you like to check with your doctor whether a pool class would be safe for you?"
Watch for: hopes that it will cure a disease; avoidance of medical treatment; strong fear of water presented as reluctance. Working: an informed choice by the client.

4.16 Psychotherapist: referral and collaboration

Purpose / when: after the client agrees to try Ai Chi.
Steps:
1. Help the client find a provider who holds Ai Chi International certification (AEA) or is an aquatic physiotherapist; suggest they ask about credentials, CPR/AED, poolside supervision and screening. [source: AEA General Info; SCHN procedure]
2. With written consent, share only what the instructor needs for safety (for example fear of water, dissociation, panic, trauma relating to water or being held), not the clinical narrative. [synthesis]
3. Discuss with the client how the two services fit together, to reduce confusion (the EABP guidelines ask therapists to consider and discuss parallel services with the client). [source: EABP Ethics Guidelines 2020, 6.b]
4. Take no referral fees (EABP 5.d). [source: EABP Ethics Guidelines 2020]
Example language (illustrative): "Would it help if, with your permission, I let the instructor know that putting your face near water makes you anxious, so they can plan for that?"
Watch for: oversharing between providers; a client feeling "handed off". Working: the client goes, and both professionals know their roles.

4.17 Psychotherapist: preparing the client (fear of water, trauma, body image, dissociation)

Purpose / when: before the first class, for clients with trauma histories (including near-drowning, water-related abuse or restraint), panic, dissociation, or body-image distress. [synthesis]
Steps:
1. Explore what the client imagines: water up to the shoulders or neck, swimwear, changing rooms, others nearby, eyes closed or inward focus, and in Ai Chi Ne a partner's touch. [features of the method from AEA, Lambeck & Bommer; preparation synthesis]
2. Agree a personal stop plan (going to the rail, opening the eyes, fixing the gaze, making movements smaller, leaving the pool).
3. Rehearse grounding skills on land that work in water: feeling the feet on the pool floor, naming objects in view, eyes open.
4. Suggest starting with the wall or seated variant, shallower water, and declining partner work. [variants: Lambeck & Bommer]
5. For body image: discuss clothing options the facility allows and timing of arrival to avoid busy changing rooms. [synthesis]
Example language (illustrative): "You are allowed to keep your eyes open, stay near the edge, and skip anything that doesn't feel right. Let's practise what you will do if you start to feel far away."
Watch for: the client agreeing to please you; strong anticipatory anxiety, which may mean graded exposure work first. Working: the client can describe their stop plan and feels in control.

4.18 Psychotherapist: integrating the experience into therapy

Purpose / when: sessions after the client has started Ai Chi. [synthesis]
Steps:
1. Ask about concrete experiences: what the breath and slow movement felt like, moments of ease or unease, changes in pain, sleep or confidence.
2. Link body experiences to therapy goals (for example noticing tension early, tolerating stillness, trusting the body after illness).
3. Where helpful, borrow non-proprietary elements on land with the client's agreement (noticing breath, slowing down, soft knees), without presenting them as Ai Chi teaching.
4. Respect the client's view of the qi and meridian imagery; treat it as the method's language, neither endorsing nor dismissing it.
Example language (illustrative): "When you said the water made your body feel lighter, what happened to the worry you usually carry?"
Watch for: the practice becoming another arena of perfectionism; avoidance of difficult material through a focus on relaxation. Working: the client brings body awareness into everyday life.

4.19 Psychotherapist: recognising and passing on adverse effects

Purpose / when: throughout. [synthesis]
Steps:
1. Ask about physical effects: dizziness, falls or near-falls, pain or fatigue flares, skin or eye irritation, chest symptoms, worsening of heat-sensitive symptoms (for example in MS), infections. Direct the client to their doctor or the aquatic provider; urgent symptoms (chest pain, breathlessness, fainting, seizure) need emergency care.
2. Ask about psychological effects: panic in the water, dissociation, intrusive memories, shame about the body, distress around partner touch.
3. With consent, inform the instructor so they can adapt; any report of inappropriate or sexual touch is a safeguarding matter and may be reported to the provider's certifying or professional body. [touch standards: USABP Code of Ethics VIII; synthesis]
Example language (illustrative): "Sometimes slow, inward practices bring up feelings or memories. If that happens, it's useful information, not a sign you did it wrong. What did you notice?"
Watch for: clients pushing through symptoms; reluctance to criticise the instructor. Working: problems surfaced early and the plan adjusted.

5. Handling problems

Published Ai Chi sources give little on problem management beyond variants and precautions; most of this section is [synthesis] and labelled so.

Fear of water or panic as water reaches the chin. Move to shallower water or the wall variant; keep the eyes open on a fixed point; shorten the inward focus; allow leaving at any time. If fear is strong, work on it in psychotherapy first (graded exposure with consent and safety planning). [variants: Lambeck & Bommer; rest synthesis]
Unsteadiness or fear of falling. Return to the wide-stance opening postures, use Wall or Seated Ai Chi, keep the gaze fixed, stay near the rail. Progress narrowing of the base only when steady. [source: Lambeck & Bommer]
Dizziness or nausea with eye-tracking and turning postures (Freeing, the continuous-flow group, Balancing, Suspending). Fix the gaze, slow down, omit turning; refer for vestibular assessment if persistent. [posture features: Lambeck & Bommer; response synthesis]
Over-breathing or breath-holding. Stop the movement, return to normal breathing, reduce the breath emphasis; never cue holds. [synthesis]
Fatigue or pain flare after a session. Lambeck and Bommer report a case where the client tired quickly and intensity was kept low; scale movements smaller and reduce the sequence; for MS heat-related fatigue, discuss pool conditions with the aquatic therapist and doctor. [first clause: source Lambeck & Bommer; rest synthesis]
Shoulder pain. Make arm movements smaller and keep them at or below the surface; in early post-injury or post-surgical rehabilitation, avoid end-range external rotation (a caution Lambeck and Bommer give). [source: Lambeck & Bommer]
Dissociation, flashbacks or emotional flooding during inward focus. Open the eyes, feel the feet on the pool floor, name things in view, stop the posture, leave the water if needed; debrief in psychotherapy. [synthesis]
Distress with partner touch (Ai Chi Ne). Stop contact immediately, return to solo practice; the client never needs to justify refusal; review consent before any further partner work. [source: USABP Code of Ethics VIII (right to refuse or end touch at any time); application synthesis]
Body-image distress or shame in swimwear or changing rooms. Explore in therapy; consider quieter session times or one-to-one sessions; check what clothing the facility permits. [synthesis]
Non-attendance. Explore practical barriers (travel, cost, changing, fatigue after sessions) and emotional ones (fear, shame, disappointment with results); consider one-to-one rather than group. [synthesis]
Unrealistic expectations or discomfort with spiritual language. Restate that benefits shown in trials are modest and symptom-focused, not disease-modifying; clarify that qi and meridian ideas are the tradition's imagery and can be set aside. [evidence: Section 2; framing synthesis]
Rupture: client feels the referral means the therapist is "getting rid of" them. Name the referral as an addition, keep regular therapy sessions, invite the client to bring the experience back. [synthesis]
Instructor lacks credentials or the pool lacks supervision. Encourage the client to check certification and safety arrangements; suggest an aquatic physiotherapy service instead. [source: AEA General Info; SCHN procedure; synthesis]
A psychotherapist wanting to teach Ai Chi. Obtain Ai Chi instructor certification and CPR/AED, deliver only in a pool with an observer and emergency procedures, check that the professional code and indemnity cover combined work, and keep therapy and class roles clearly separated (dual-relationship rules in BACP 2018 para 33(b), UKCP item 8). [source: AEA General Info; BACP Ethical Framework 2018; UKCP Code 2019; synthesis]

Sources

Web sources:

Books and papers cited (details as given in the sources above):

Bommer A, Lambeck JF (2011). Ai Chi: applications in clinical practice. In Becker BE, Cole AJ (eds), Comprehensive Aquatic Therapy, 3rd ed. Washington State University Press. (Bibliographic details as given in the Wikipedia article.)
Sova R (2009). Ai Chi. In Brody LT, Geigle PR (eds), Aquatic Exercise for Rehabilitation and Training. Human Kinetics. [uncertain: not verified]
Aquatic Exercise Association. Aquatic Fitness Professional Manual, 8th ed. Human Kinetics (excerpt only).
Teixeira et al., trial of Ai Chi in frail older adults, as summarised by Lambeck & Bommer [uncertain: not verified].

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