Abstract

Tai Chi Chuan (TCC) is among the most used Integrative and Complementary Health Practices (PICS) and, according to the scientific literature, presents clinical evidence for the treatment of various health problems. However, little is known about the development of this practice in the context of the Brazilian National Health System (SUS). In this sense, the objective of the article was to understand the therapeutic practice of TCC in a reference service in PICS in SUS, from a qualitative case study with participant observation and semi-structured interviews with users and therapists. Dissimilarities were observed between the therapeutic practice of TCC and biomedical body practices, as well as the presence of guidelines for SUS care, such as welcoming, qualified listening, therapeutic connection, and comprehensive care. The prevalence of mental distress was also identified as a reason for seeking the practice, as well as the need for greater financial support for the service, and the resistance to the use of Traditional Chinese Medicine by some female users’ support network.

Keywords:
Traditional Chinese Medicine; Tai Chi; Complementary Therapies; Brazilian National Health System

Introduction

Integrative and Complementary Health Practices (PICS) is a Brazilian term close to what the World Health Organization calls Traditional, Complementary and Integrative Medicines (TCIM) (OMS, 2013)OMS - ORGANIZACIÓN MUNDIAL DE LA SALUD. Estrategia de la OMS sobre medicina tradicional 2014-2023. Ginebra: Organización Mundial de la Salud, 2013.. The use and offer of these practices in health systems has been growing since the late 20th century. According to Souza and Luz (2009SOUZA, E. F.; LUZ, M. T. Bases socioculturais das práticas terapêuticas alternativas. História, Ciências, Saúde-Manguinhos, Rio de Janeiro, v. 16, n. 2, p. 393-405, 2009. DOI: 10.1590/S0104-59702009000200007
https://doi.org/10.1590/S0104-5970200900... ), in the Brazilian context, this phenomenon could be observed through the import of Eastern therapies, such as Traditional Chinese Medicine (TCM), in the late 1970s and early 1980s.

TCIM body practices have been established in the Brazilian National Health System (SUS) since 2006, by the National Policy on Integrative and Complementary Practices (PNPIC), which also contains guidelines on acupuncture. The PNPIC contributed to the visibility of the provision of PICS services in the country, demonstrated by the increase in registrations and therapeutic pluralism in the public health system. In 2017 and 2018, the policy expanded its repertoire of therapeutic resources and systems by offering 29 practices (Silva et al., 2020SILVA, G. K. F.; SOUSA, I. M. C., CABRAL, M. E. G. S.; BEZERRA, A. F. B.; GUIMARÃES, M. B. L. Política Nacional de Práticas Integrativas e Complementares: trajetória e desafios em 30 anos do SUS. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 30, n. 1, 2020. DOI: 10.1590/S0103-73312020300110
https://doi.org/10.1590/S0103-7331202030... ).

According to the Ministry of Health data (Cresce…, 2019)CRESCE 46% procura por Práticas Integrativas Complementares no SUS. Ministério da Saúde, Brasília, DF, 15 mar. 2019. Notícias. Disponível em: <Disponível em: https://conselho.saude.gov.br/ultimas-noticias-cns/206-cresce-46-procura-por-praticas-integrativas-complementares-no-sus >. Acesso em: 13 de jan de 2022.
https://conselho.saude.gov.br/ultimas-no... , PICS are present in 9,350 establishments, distributed across 3,173 municipalities, 88% of which are offered in Primary Care. In 2017, 1.4 million individual visits were recorded. Adding together collective activities, the estimate is that around 5 million people per year use these therapies in the SUS. Among the most used PICS, acupuncture comes first, with 707 thousand visits and 277 thousand individual consultations, followed by body practices of Traditional Chinese Medicine, such as Tai Chi Chuan (TCC), with 151 thousand sessions.

The scientific literature has shown the positive effects of Tai Chi Chuan for various health problems. Highlights include systematic reviews and meta-analyses on TCC for negative feelings, depression and anxiety (Zhang et al., 2019ZHANG, S. et al. The effect of Tai Chi Chuan on negative emotions in non-clinical populations: a meta-analysis and systematic review. International Journal of Environmental Research and Public Health, Basel, v. 16, n. 17, p. 3033, 2019. DOI: 10.3390/ijerph16173033
https://doi.org/10.3390/ijerph16173033... ), the risk of falls in older adults (Huang et al., 2017HUANG, Z. et al. Systematic review and meta-analysis: Tai Chi for preventing falls in older adults. BMJ Open, London, v. 7, n. 2, p. 1361, 2017.), fibromyalgia (Cheng et al., 2019CHENG, C. et al. Effectiveness of Tai Chi on fibromyalgia patients: A meta-analysis of randomized controlled trials. Complementary therapies in medicine, Amsterdam, v. 46, p. 1-8, 2019. DOI: 10.1016/j.ctim.2019.07.007
https://doi.org/10.1016/j.ctim.2019.07.0... ), systemic arterial hypertension (Wu et al., 2021WU, Y. et al. Tai Ji Quan as antihypertensive lifestyle therapy: a systematic review and meta-analysis. Journal of Sport and Health Science, Amsterdam, v. 10, n. 2, p. 211-221, 2021. DOI: 10.1016/j.jshs.2020.03.007
https://doi.org/10.1016/j.jshs.2020.03.0... ) and chronic obstructive pulmonary disease (Liu et al., 2021LIU, X. et al. The effect of Tai Chi on the pulmonary rehabilitation of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Annals of Palliative Medicine, Hong Kong, v. 10, n. 4, 2021. DOI: 10.21037/apm-20-940
https://doi.org/10.21037/apm-20-940... ).

However, most of the studies on TCC are focused on its clinical effects and do not address other qualitative aspects that may be relevant to this practice, especially its context of implementation in the SUS. Thus, this article sought to understand the therapeutic practice of Tai Chi Chuan in a reference service in Integrative and Complementary Health Practices in the SUS.

Method

This is a descriptive, exploratory and qualitative study, carried out as a case study. The research was based on a qualitative methodology, as it is the one that best suits the topic and is thus applied to understanding perceptions. These are influenced and influence the process of deconstruction and reconstruction of representations which, in the case of therapeutic experiences in health, is a constant movement (Minayo; Costa, 2019MINAYO, M. C. S.; COSTA, A. P. Técnicas que fazem uso da palavra, do olhar e da empatia: pesquisa qualitativa em ação. Aveiro: Ludomedia, 2019.).

The chosen scenario was a public reference service in Integrative and Complementary Practices in the city of Recife-PE. The municipality is a pioneer in the implementation of PICS, being the first in northeastern Brazil to establish a unit specializing in these therapies in its health network (Santos et al., 2011SANTOS, F. A. S.; SOUSA, I. M. C.; GURGEL, I. G. D.; BEZERRA, A. F. B.; BARROS, N. F. Política de práticas integrativas em Recife: análise da participação dos atores. Revista de Saúde Pública, São Paulo, v. 45, n. 6, p. 1154-1159, 2011. DOI: 10.1590/S0034-89102011000600018
https://doi.org/10.1590/S0034-8910201100... ).

Data collection consisted of semi-structured interviews with TCC users and therapists, as well as participant observation from July 2016 to February 2017. The interviews were conducted individually, immediately after the experiences, with users over 18 years old who wished to participate in the study and who had been performing body practice there for at least 4 months. Its script consisted of questions about: knowledge about the practice, reason for seeking it, access, class execution process and effects/changes attributed to TCC. The sampling criterion used was the theoretical saturation of responses (Ribeiro; Souza; Lobão, 2018RIBEIRO, J.; SOUZA, F. N.; LOBÃO, C. Saturação da análise na investigação qualitativa: quando parar de recolher dados?. Revista Pesquisa Qualitativa, [s.l.], v. 6, n. 10, p. 3-8, 2018.), which corresponds to the suspension of participant inclusion when the data begins to present, in the researcher’s assessment, a certain redundancy or repetition, with no pre-defined duration or number of interviews.

The interviews were recorded, transcribed and later triangulated with a literature review on the topic and field diary records. The latter was an important research tool for textual narrative of the researcher’s impressions during participant observation (Kroef; Gavillon; Ramm, 2020KROEF, S. R. F.; GAVILLON, P. Q.; RAMM, L. V. Diário de Campo e a Relação do(a) Pesquisador(a) com o Campo-Tema na Pesquisa-Intervenção. Estudos e Pesquisas em Psicologia, Rio de Janeiro, v. 20, n. 2, p. 464-480, 2020. DOI: 10.12957/epp.2020.52579
https://doi.org/10.12957/epp.2020.52579... ). The information was analyzed according to Thematic Content Analysis through the following steps: full transcription; pre-analysis with floating reading; exploration of the material or coding (Chart 1); treatment of results, inference and interpretation (Minayo; Costa, 2019MINAYO, M. C. S.; COSTA, A. P. Técnicas que fazem uso da palavra, do olhar e da empatia: pesquisa qualitativa em ação. Aveiro: Ludomedia, 2019.).

This work was submitted to the Research Ethics Committee, having been approved in accordance with the terms of Resolution no. 466, of December 12, 2012, from the National Health Council. All interviewees consented to participate by signing the Free and Informed Consent Form. To guarantee participant anonymity, the therapists and users were named with the letters T and U, respectively, along with the order in which the interviews were carried out (e.g., T1, T2, U1, U2, U3).

Results and discussion

The research results were divided into four topics for better understanding and debate. The statements of therapists, users and reports of participant observation are explored in the following sections: Study scenario and participant profile, which is the description of the space and contextualization of the SIS, as well as the profile of Tai Chi practitioners and professionals and their motivations for seeking the practice. In the topic The experience of Tai Chi Chuan in the Integrated Health Service, the aspects considered important for understanding the therapeutic process are described, based on the narrative of those involved. They are: access, reception, class planning, differences between biomedical and TCM body practices and the termination/disconnection of the practitioner. Next, we have a section about the Effects and changes ascribed to the practice of Tai Chi Chuan, reported by therapists and users. The last part that makes up the results and discussions of this article is titled: Recognition and resistance regarding the use of Integrative and Complementary Practices. In it, we bring reports about the need for greater management support for PICS, especially regarding their financing, and examples of resistance to the use of Eastern therapies by conservative religious groups.

Study setting and participant profile

The city of Recife is a differentiated field for research in Integrative and Complementary Practices, as it is one of the pioneering Brazilian municipalities in its implementation, being the first in the Northeast to offer a public service specialized in PICS. Before the establishment of the PNPIC, UCIS Guilherme Abath opened, in 2004, its first Comprehensive Care Unit. In 2013, it expanded its offer through the Integrated Health Service (SIS), the setting for this study (Santos et al., 2011SANTOS, F. A. S.; SOUSA, I. M. C.; GURGEL, I. G. D.; BEZERRA, A. F. B.; BARROS, N. F. Política de práticas integrativas em Recife: análise da participação dos atores. Revista de Saúde Pública, São Paulo, v. 45, n. 6, p. 1154-1159, 2011. DOI: 10.1590/S0034-89102011000600018
https://doi.org/10.1590/S0034-8910201100... ).

The SIS constitutes a space for health care and professional training, the result of a partnership between the Municipal Health Department of Recife and the Universidade Federal de Pernambuco. It is located in a lower middle-class neighborhood, close to universities and border areas of the Recife metropolitan region. It acts as a reference for the municipal network, especially for Family Health teams. It offers several collective practices (Integrative Community Therapy, Tai Chi Chuan, Lian Gong, Self-Massage, Aromatherapy, Flexibility, Bioenergetics, Yoga, Biodanza , Circular Dance, Relational Psychomotricity for young people, Family Constellation and Art Therapy for women), individual therapies (Nutrition in healthy eating, Auriculotherapy, Osteopathy and Craniosacral Therapy) and other therapeutic programs (Spine Health Program, Voice Health Program and Art Therapy Program for obesity-related problems).

These integrative practices were developed in the unit by twenty-three therapists, including two from Tai Chi Chuan. Both chose to participate in the research. As for their professional profiles, they had a higher education degree and specific training in Chinese body practice. They also had an employment relationship with the municipality, but were hired for their academic backgrounds unrelated to PICS, even though they exclusively carried out activities related to them. According to them, the motivations that led them to work with TCC were diverse, from the influence of Eastern culture films and cartoons in childhood, the practice of martial arts in adolescence, to the experience in extension projects and university internships in adulthood.

At the time of the research, Tai Chi Chuan at SIS was offered to a group of 28 users, of which seven were willing to participate in the research. Of these, most were female (85.7%), married (42.8%), aged over forty-nine (85.7%), with complete higher education (71.4%), a health worker (42.8%), and had been attending the unit for more than two years (57.1%). Among the complaints reported were systemic arterial hypertension, diabetes mellitus, musculoskeletal pain and inflammation and post-stroke sequelae. This profile was similar to that found in studies by Cintra and Pereira (2012CINTRA, M. E. R.; PEREIRA, P. P. G. Percepções de corpo identificadas entre pacientes e profissionais de medicina tradicional chinesa do Centro de Saúde Escola do Butantã. Saúde e Sociedade, São Paulo, v. 21, p. 193-205, 2012. DOI: 10.1590/S0104-12902012000100019
https://doi.org/10.1590/S0104-1290201200... ) and Tavares et al. (2017TAVARES, Y. A. et al. Qualidade de vida de indivíduos praticantes de qigong na Comunidade. Extensão em Ação, Fortaleza, v. 1, n. 13, p. 83-93, 2017. DOI: 10.32356/exta.v1.n13.19710
https://doi.org/10.32356/exta.v1.n13.197... ), especially in the variables age group, gender and health complaints of TCM users.

The reasons why research users sought the service were to alleviate musculoskeletal pain, lose weight, improve memory and treat depression. This last reason was reported by all of the interviewees. In this sense, PICS are shown to be a powerful comprehensive care strategy, especially due to their elective affinities with the field of mental health (Tesser; Sousa, 2012TESSER, C. D.; SOUSA, I. M. C. Atenção primária, atenção psicossocial, práticas integrativas e complementares e suas afinidades eletivas. Saúde e Sociedade, São Paulo, v. 21, p. 336-350, 2012. DOI: 10.1590/S0104-12902012000200008
https://doi.org/10.1590/S0104-1290201200... ). Furthermore, in the research municipality, local experiences have been observed in which UCIS have also served as a reference for people with psychological distress (Santos et al., 2011SANTOS, F. A. S.; SOUSA, I. M. C.; GURGEL, I. G. D.; BEZERRA, A. F. B.; BARROS, N. F. Política de práticas integrativas em Recife: análise da participação dos atores. Revista de Saúde Pública, São Paulo, v. 45, n. 6, p. 1154-1159, 2011. DOI: 10.1590/S0034-89102011000600018
https://doi.org/10.1590/S0034-8910201100... ).

The experience of Tai Chi Chuan in the Integrated Health Service

The history of the introduction of Integrative and Complementary Practices in Brazil is linked to the entry of Eastern therapies, especially Traditional Chinese Medicine, into the country. The import of these exogenous systems of beliefs and philosophical orientations served as the foundation for the construction of an ideological body of practical guidelines, which was a strategic part of the counterculture movement of the 1960s. Later, in the 1980s, the gradual insertion of Chinese medicine into Western countries continued, through the process of commodification of health products and services and their institutionalization (Souza; Luz, 2009SOUZA, E. F.; LUZ, M. T. Bases socioculturais das práticas terapêuticas alternativas. História, Ciências, Saúde-Manguinhos, Rio de Janeiro, v. 16, n. 2, p. 393-405, 2009. DOI: 10.1590/S0104-59702009000200007
https://doi.org/10.1590/S0104-5970200900... ).

According to Souza and Luz (2009SOUZA, E. F.; LUZ, M. T. Bases socioculturais das práticas terapêuticas alternativas. História, Ciências, Saúde-Manguinhos, Rio de Janeiro, v. 16, n. 2, p. 393-405, 2009. DOI: 10.1590/S0104-59702009000200007
https://doi.org/10.1590/S0104-5970200900... ), the growth in social demand for these therapies can be justified by the unfavorable aspects of biomedicine: the significant dehumanization of its professional practices, abusive use of hard technologies and their iatrogenic effects, as well as the difficulty of access. In addition, PICS reposition the user as the center of care, encourage the construction of autonomy, consider the therapist-user relationship as a fundamental element of therapy, and use light technologies with equal or greater effectiveness in common situations of illness (Sousa; Tesser, 2017SOUSA, I. M. C.; TESSER, C. D. Medicina Tradicional e Complementar no Brasil: inserção no Sistema Único de Saúde e integração com a atenção primária. Cadernos de Saúde Pública, São Paulo, v. 33, n. 1, 2017. DOI: 10.1590/0102-311X00150215
https://doi.org/10.1590/0102-311X0015021... ).

Currently, there is a slow expansion of the incorporation of these practices into health systems, encouraged by the recommendations of the World Health Organization (WHO) (Sousa, 2021SOUSA, D. G. A importância das Práticas Integrativas e Complementares no âmbito do Sistema Único de Saúde. Journal of Multiprofessional Health Research, Salvador, v. 2, n. 3, p. 3166-68, 2021.). In the Brazilian context, the National Policy on Integrative and Complementary Practices (PNPIC) was established, which contributed to strengthening PICS in the country. Its guidelines were based on the model of humanized care and centered on the individual’s wholeness, and its actions were aimed at the prevention, promotion, maintenance and recovery of health. Additionally, the policy allowed the population access to services previously restricted to private practices (Dacal; Silva, 2018DACAL, M. P. O.; SILVA, I. S. Impactos das práticas integrativas e complementares na saúde de pacientes crônicos. Saúde em debate, Rio de Janeiro, v. 42, n. 118, p. 724-735, 2018. DOI: 10.1590/0103-1104201811815
https://doi.org/10.1590/0103-11042018118... ): “I always wanted to learn Tai Chi Chuan, but I never found a school. I lived very far away and it was very expensive. So, I couldn’t afford it. Then, when I discovered it was here, I had no second thoughts” (U4).

Access to the Integrated Health Service was organized on the basis of referrals from the Family Health Strategy (ESF) teams. On arriving at the unit, therapists welcomed users who explained their needs and demands through qualified listening. On this occasion, they also informed what practices were available and, together, chose an individual and a collective practice to be tried out initially. Welcoming was perceived as central to the UCIS institutional project, in line with the National Humanization Policy (PNH), the National Primary Care Policy (PNAB) and the establishment of comprehensive care.

The emphasis on warm listening and the creation of a therapeutic connection, global promotion of human care, especially self-care, and the expanded view of the health-disease process were other representations found in the Tai Chi Chuan therapeutic process in SIS. These strategies form part of the basis of the expanded clinical perspective recommended by the PNHJ, in addition to representing characteristics of Integrative and Complementary Health Practices (Telesi Júnior, 2016TELESI JÚNIOR, E. Práticas integrativas e complementares em saúde, uma nova eficácia para o SUS. Estudos avançados, São Paulo, v. 30, p. 99-112, 2016. DOI: 10.1590/S0103-40142016.00100007
https://doi.org/10.1590/S0103-40142016.0... ). The therapist-user bond was observed in the relationship demonstrated by the constant conversations between users and therapists, which occurred constantly before or after the experiences, individually with each practitioner. This “colloquial” aspect reveals that the relational dimension of reception and the therapeutic project permeates the service’s entire care action. According to the professionals interviewed, these moments of conversation and reception were important for the therapeutic process, as they guided the progress of classes and the adjustment of exercises and helped to understand the evolution of each user.

TCC classes took place weekly and lasted about an hour and a half. They always started in this sequence: applying some relaxation technique, stretching or warming up and training with TCC exercises. TCC is a martial art of Chinese origin, which is based on performing gestures that symbolize the transformation of elements of nature and, at the same time, simulate combat. There are different hypotheses for its origin, but researchers accept that it came from the martial style known as chen, created by Chen Wangting (1600-1680 AD). It is important to highlight that TCC is an extremely sophisticated body art, as it involves a sequence of 18 movements that move the body in space in different planes of movement, in addition to using different parts of the body (Santos, 2022SANTOS, O. G. Práticas corporais e saúde: algumas contribuições da medicina tradicional chinesa para o contexto brasileiro. Caderno de Educação Física e Esporte, Marechal Cândido Rondon, v. 20, 2022. DOI: 10.36453/cefe.2022.28260
https://doi.org/10.36453/cefe.2022.28260... ).

It is typical that, during practice, the exercises take place in a condition of full attention, because by focusing on a constant rhythm, the practitioner focuses attention on themselves, which contributes to TCC becoming a type of meditation in movement. Body awareness and concentration were recognized by research participants as being essential for practicing Tai Chi Chuan, differentiating it from conventional body practices. According to two of the users interviewed:

According to de Oliveira Santos (2022OLIVEIRA SANTOS, G. Práticas corporais e saúde: algumas contribuições da medicina tradicional chinesa para o contexto brasileiro. Caderno de Educação Física e Esporte, Marechal Cândido Rondon, v. 20, 2022. DOI: 10.36453/cefe.2022.28260
https://doi.org/10.36453/cefe.2022.28260... ), the body practices of Traditional Chinese Medicine seek to recognize one’s own movement tendencies, in the opposite direction of automation. In other words, embodied knowledge as a form of self-care. In this way, the process of carrying out TCC leads to the discernment of one’s own limits and possibilities, enhancing the balance between preserving and expending vitality, as well as a genuine relationship between doing and feeling.

From another perspective, in a contemporary Western society like ours, the phenomenon of sportization is influential in the organization of body practices. In sport, the body needs to be operationalized, since otherwise there is no result or improvement in body performance. From this perspective, it tends to disharmonize the relationship between preservation and consumption of vitality, as it proposes the requirement to place the body under maximum control. High-performance sport and its technical and scientific framework encourage the logic of pain and sacrifice, which can increase damage to health, since it is based on the assumption that to obtain satisfactory results it is necessary to go through a saga of distress: “Pain is no longer seen as an ally in defense of life, a living expression of corporeality, but as an obstacle to be overcome, dominated, ignored, becoming, perhaps, even a source of pleasure” (Vaz, 1999VAZ, A. F. Treinar o corpo, dominar a natureza: Notas para uma análise do esporte com base no treinamento corporal. Cadernos Cedes, Campinas, v. 19, p. 89-108, 1999., p. 104). It is the “no pain, no gain” logic, which prepares the practitioner to endure and even desire sacrifice, so that, when there is no pain, there is no result.

As it is an activity that involves motor skills, balance and muscular strength, as well as memory to assimilate all the practice, starting TCC may not be an easy experience. According to practitioners and research professionals, some users were frustrated because they were unable to perform the exercises correctly or because they did not understand the holistic nature of Tai Chi Chuan. As a consequence, they became dependent on the service and the therapist, weakening the development of their autonomy and weakening the practice’s integrative potential. To try to correct this scenario, classes were planned according to the practitioners’ needs and complaints, allocating a number of weeks to learning part of the exercise sequence. Furthermore, one of the professionals stated that he promotes studies with classic works of Traditional Chinese Medicine. According to him, stimulating the theoretical understanding of TCC would help the user with practice and, consequently, enhance its therapeutic effects:

Unlike biomedicine (Souza; Luz, 2009SOUZA, E. F.; LUZ, M. T. Bases socioculturais das práticas terapêuticas alternativas. História, Ciências, Saúde-Manguinhos, Rio de Janeiro, v. 16, n. 2, p. 393-405, 2009. DOI: 10.1590/S0104-59702009000200007
https://doi.org/10.1590/S0104-5970200900... ), which aims to resolve the user’s specific symptoms and complaints, TCC, like other integrative practices, seeks to promote health through the user’s autonomy and independence. Its care actions are not limited to standardized technical application, but to encouraging the user’s self-care and perception and knowledge of their own weaknesses and potential (Contatore et al., 2015CONTATORE, O. A. et al. Uso, cuidado e política das práticas integrativas e complementares na Atenção Primária à Saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 20, p. 3263-3273, 2015. DOI: 10.1590/1413-812320152010.00312015
https://doi.org/10.1590/1413-81232015201... ). Likewise, the therapists interviewed agree that the purpose of the therapeutic practice of TCC is the empowerment from the technique and self-care of users:

Individual empowerment is a central element of health promotion, which can be understood from a conceptual perspective of life power. In other words, it means understanding how and why to make choices and decisions that seek to enhance change processes. This choice is not dissociated from the notions of autonomy and responsibility. Therefore, it is not possible to refer to autonomy as a process of solely individual choices, with absolute independence. Autonomy thus depends on a set of individual and community factors. In this direction, other aspects have also been appreciated, including: encouraging changes in the culture of care and learning new ways of thinking about the body, health and illness (Oliveira; Pezzato; Mendes, 2022OLIVEIRA, G. A. M.; PEZZATO, L. M.; MENDES, R. Articulação entre Práticas Integrativas e Promoção da Saúde: ações coletivas com acupuntura na Estratégia Saúde da Família. Revista de APS, Juiz de Fora, v. 25, 2022. DOI: 10.34019/1809-8363.2022.v25.35053
https://doi.org/10.34019/1809-8363.2022.... ) .

Effects and changes ascribed to the practice of Tai Chi Chuan

Unlike the biomedical approach, which aims to specifically treat symptoms and their corresponding disorders, Tai Chi, like TCM, has a more comprehensive therapeutic approach. In this sense, TCC professionals stated that the user’s complaints, the therapist’s objective and the result of the practice do not always coincide. Thus, the effects achieved are quite diverse and even unexpected:

Among other changes reported by practitioners are the reduction in blood pressure and blood glucose. A similar result was found in a study that evaluated the effect of TCC on weight, glycemic control and blood pressure, as compared to aerobic exercise in people with depressive symptoms (Wang et al., 2022WANG, Y. et al. Comparison of the effects of Tai Chi and general aerobic exercise on weight, blood pressure and glycemic control among older persons with depressive symptoms: a randomized trial. BMC Geriatrics, London, v. 22, n. 1, p. 1-9, 2022.). Tai Chi Chuan was also able to produce clinically significant reductions in blood pressure in hypertensive users, indicating that it is a viable lifestyle therapy for this population (Wu, 2021WU, Y. et al. Tai Ji Quan as antihypertensive lifestyle therapy: a systematic review and meta-analysis. Journal of Sport and Health Science, Amsterdam, v. 10, n. 2, p. 211-221, 2021. DOI: 10.1016/j.jshs.2020.03.007
https://doi.org/10.1016/j.jshs.2020.03.0... ).

All study users who arrived at the service with some type of mental distress reported an improvement in their health:

I attempted suicide a few times, the last time I spent 6 months in a coma, I drove the car into a lamppost. I was treated by a psychiatrist for over 30 years, I was always on heavy medication, always doped up, I had no vanity, no spirit, no liveliness. SIS helped me a lot, a lot! You can be sure. Let’s say that out of 100%, in all honesty, 60% was SIS’s Tai Chi Chuan. (U7).

Clinical studies and systematic reviews on TCC in mental health have demonstrated its positive effects on depression and anxiety (Zhang et al., 2019ZHANG, S. et al. The effect of Tai Chi Chuan on negative emotions in non-clinical populations: a meta-analysis and systematic review. International Journal of Environmental Research and Public Health, Basel, v. 16, n. 17, p. 3033, 2019. DOI: 10.3390/ijerph16173033
https://doi.org/10.3390/ijerph16173033... ). Another benefit listed by users was the reduction or total suspension of the use of allopathic medicines, along with awareness of their effects on the body. One can observe, in integrative practices, a demedicalizing potential, as it is presented as an alternative to the abusive use of medicines and the excessive carrying out of exams, procedures and diagnoses that are often unnecessary (Tesser; Barros, 2008TESSER, C. D.; BARROS, N. F. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Revista de Saúde Pública, São Paulo, v. 42, p. 914-920, 2008. DOI: 10.1590/S0034-89102008000500018
https://doi.org/10.1590/S0034-8910200800... ).

Another review study provides evidence that TCC can reduce the rate of falls and the risk of falling, as it demonstrates a positive impact on balance, muscle strength, flexibility and postural control (Huang et al., 2017HUANG, Z. et al. Systematic review and meta-analysis: Tai Chi for preventing falls in older adults. BMJ Open, London, v. 7, n. 2, p. 1361, 2017.). These benefits were also identified among SIS users: “I notice a different balance in my own body. One’s posture in walking, in stumbling. How different falling is after Tai Chi Chuan!” (U5). These benefits occur mainly due to the increase and maintenance of the strength of the postural muscles of the lower limbs, as a result of the postures used during the practice.

Recognition and resistance regarding the use of Integrative and Complementary Practices

In general, users and therapists interviewed say they are satisfied with the way Tai Chi Chuan is offered in UCIS. However, they point out the importance of greater recognition of the practice, as well as the strengthening and expansion of PICS in general. Even though the health unit is a reference service implemented in the municipality for almost a decade and anchored by municipal and state policy, there is still a need for management support, especially in relation to its financing:

The introduction of Integrative and Complementary Practices into public health services can be understood as a strategy to expand the supply, access and quality of care, as they involve comprehensive health care for the population (Lima; Silva; Tesser, 2014LIMA, K. M. S. V.; SILVA, K. L.; TESSER, C. D. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface-Comunicação, Saúde, Educação, Botucatu, v. 18, n. 49, p. 261-272, 2014. DOI: 10.1590/1807-57622013.0133
https://doi.org/10.1590/1807-57622013.01... ). However, the hegemony of the biomedical model has fueled, centered emphasis on disease throughout history, promoting an institutional culture that devalues health promotion actions, which is revealed in the lack of real support from managers for some actions and services that try to escape the logic of productivism in health, as is the case with PICS.

There is also a gap in municipal policies regarding the role of Integrative and Complementary Practices in their health network, generating the absence of an institutional and financing agenda that guarantees greater sustainability (Sousa; Tesser, 2017SOUSA, I. M. C.; TESSER, C. D. Medicina Tradicional e Complementar no Brasil: inserção no Sistema Único de Saúde e integração com a atenção primária. Cadernos de Saúde Pública, São Paulo, v. 33, n. 1, 2017. DOI: 10.1590/0102-311X00150215
https://doi.org/10.1590/0102-311X0015021... ). This is because the insufficiency of production and research data on the development of these practices in the Brazilian public health network, specifically on ways to organize, adapt and include them in the SUS, can add to the obstacles to expanding the supply and use of these practices (Telesi Júnior, 2016TELESI JÚNIOR, E. Práticas integrativas e complementares em saúde, uma nova eficácia para o SUS. Estudos avançados, São Paulo, v. 30, p. 99-112, 2016. DOI: 10.1590/S0103-40142016.00100007
https://doi.org/10.1590/S0103-40142016.0... ).

Another difficulty brought by users and research professionals is resistance to the use of these practices, especially those of Eastern origin, such as TCC and Acupuncture:

This resistance may be related to the lack of knowledge of these therapies by the general public, professionals and managers, being a detrimental factor for implementing and expanding PICS in the SUS. According to Cruz and Sampaio (2016CRUZ, P. L. B., SAMPAIO, S. F. As práticas terapêuticas não convencionais nos serviços de saúde: revisão integrativa. Revista de APS, Juiz de Fora, v. 19, n. 3, p. 483-494, 2016.), the population’s lack of knowledge, as observed in the support network of some users, may be associated with prejudice and discrimination arising from professionals’ disbelief in relation to the benefits of practices, motivated by gaps in their training; the inability and insufficiency of the means of dissemination to reach users or, also, related to a historical process of prioritizing biomedicine, with regard to the development of public policies.

Final considerations

This article aimed to understand the therapeutic practice of TCC in a reference service in Integrative and Complementary Practices in Health, considering that much of the scientific debate is focused on its clinical effects and does not address other aspects relevant to its implementation. As a result, we anchored ourselves in the qualitative research approach, in order to understand the subjectivities linked to the experience of Chinese body practice, considered by the authors as the expression of a social phenomenon. The methodological design used was capable of achieving an interpretation of a specific section of reality, not constituting a basis for generalization. However, interpretations based on reports from users, TCC professionals and observations can elucidate answers and open new questions to the debate about the use of PICS in the SUS, especially those of Eastern origin.

The study setting was strategically chosen due to its history of pioneering the implementation of Integrative and Complementary Practices and the offering of traditional Chinese Medicine body practices. Furthermore, as it is also a field of academic training and research, it allowed the involvement of participants interested in collaborating with scientific production on these practices. Regarding their profile, the expression of issues linked to Mental Health was notable, both the most frequent complaint and the narratives of improvement after the Tai Chi Chuan experiences.

Even though PICS, especially those from TCM, show signs of an increase in supply in the public health network, the difficulty in accessing them was one of the points raised by users. However, with regard to the TCC experience in SIS, it is observed that the service is organized based on guidelines that prioritize welcoming, qualified listening, the therapeutic connection, and comprehensive care. This was reinforced by the professionals’ efforts to adapt Tai Chi Chuan classes individually and by users’ statements of satisfaction. The logic of health promotion was also present in the results, while the terms “self-care”, “empowerment” and “autonomy” were frequent in the participants’ reports when describing their perception of the therapeutic process experienced. In this way, we can see the proximity between PICS and humanized care, since the terms reported are basic concepts for its implementation. Because care that promotes recovery by the individual and their natural capacity for self-promotion of health is humanized and comprehensive care.

Tai Chi Chuan, like other traditional Chinese Medicine body practices, has different aspects than conventional ones, which explore the idea of automation and sportization. This difference was illustrated in the narrative of users, who perceived TCC as a more beneficial and safer therapeutic modality in relation to execution, and with positive effects for various health problems. For this reason, the practitioners and therapists interviewed claim to be satisfied with SIS Tai Chi Chuan and point out the importance of recognizing, strengthening and expanding PICS and the need for management support, in order to guarantee the permanence of the health unit and the continuity of the service offering. Added to this is the need for greater dissemination of information about PICS beyond the health sector, as there is still resistance to their use. Likewise, we can recognize Integrative and Complementary Health Practices as liberating care practices, organized in a user-centered logic that allows for the construction of links between workers and the community, as well as interventions, based on individual and collective needs.

References

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