The Effects of Standing Meditation on Balance and Mindfulness in Older Adults: a Tai Chi Component Study ______

THE EFFECTS OF STANDING MEDITATION ON BALANCE AND MINDFULNESS IN OLDER ADULTS: A TAI CHI COMPONENT STUDY ______

A Thesis

Presented to the

Faculty of

California State University, Fullerton ______

In Partial Fulfillment

of the Requirements for the Degree

Master of Science

Kinesiology ______

Brent David Brayshaw

Thesis Committee Approval:

David Chen, Department of Kinesiology, Chair Debra J. Rose, Department of Kinesiology Joao Barros, Department of Kinesiology

Fall, 2017

ABSTRACT

Standing meditation (SM) is the fundamental component of Tai Chi Chuan

(TCC)—a complex neuromotor exercise found to be associated with many health benefits including improved mindfulness and fall reduction in older adults (OA). PROBLEM:

Despite its importance in TCC, few studies have included SM as a part of their TCC intervention, and no prominent studies have tested the effects of SM alone. METHODS:

Sixteen participants were recruited into a 5-week progressive SM intervention. Thirteen completed the full program. However, quantitative data analysis was conducted on only ten participants (M = 69 years, SD = 6) after removing three that later did not meet inclusion/ exclusion criteria. The Fullerton Advanced Balance (FAB) Scale and Mindful

Attention Awareness Scale (MAAS) were used to assess balance and mindfulness.

Additionally, participants were assigned weekly homework logs and a post-intervention survey. Quantitative analysis compared the pre- and post-cores of assessments with paired-samples t tests. The study also conducted qualitative analysis of participant commentary. RESULTS: Post-scores (M = 37.8) on the FAB scale were significantly higher than pre-scores (M = 30.9). For mindfulness, however, post-scores (M = 66.1) on the MAAS were significantly less than pre-scores (M = 70.6). Qualitatively, participants received the intervention well, and reported feeling steadier in daily tasks, like walking, after the intervention. CONCLUSION: this first look at SM suggests it is a simple exercise that may have a positive effect on multiple dimensions of balance in OA.

TABLE OF CONTENTS

ABSTRACT ...... ii

LIST OF TABLES ...... vi

LIST OF FIGURES ...... vii

ACKNOWLEDGMENTS ...... viii

Chapter 1. INTRODUCTION ...... 1

Hypothesis ...... 6 Delimitations ...... 6 Limitations ...... 7

2. REVIEW OF LITERATURE ...... 9

Sedentary Behavior and Rising Older Adult Population ...... 9 Tai Chi as an Effective Exercise for Older Adults ...... 10 Psychological Effects ...... 10 Mindfulness ...... 11 Neuromotor Effects of Tai Chi ...... 12 Fall Reduction ...... 14 Defining Mechanisms of Tai Chi...... 15 Standing Meditation ...... 17 Evidence for Potential Benefit of Standing Meditation ...... 19 Prolonged Standing ...... 19 Biomechanical Components ...... 20 Spinal Stabilization ...... 21 Benefits of Standing ...... 22 Conclusions ...... 23

3. METHODS ...... 25

Participant Recruitment ...... 25 Inclusion Criteria ...... 25 Exclusion Criteria ...... 25 Procedures ...... 26

iii Prescreen ...... 26 Session One ...... 26 Group Sessions ...... 27 Session Six ...... 28 Measures ...... 29 Quantitative Measures ...... 29 Qualitative Measures ...... 29 Assessment Instrumentation ...... 30 Mindful Attention Awareness Scale (MAAS) ...... 30 Fullerton Advanced Balance Scale (FAB) ...... 30 Standing Meditation Homework Log ...... 31 Post-Intervention Survey ...... 31 Statistics ...... 31

4. RESULTS ...... 32

Recruitment and Attrition ...... 32 Demographic Data ...... 33 Intervention Dose ...... 35 Quantitative Analysis ...... 36 Mean Comparisons of Initial and Final Scores ...... 36 Correlation of Post-Assessment Scores and Total Dose ...... 36 Qualitative Analysis ...... 37 Themes ...... 38 Closed-Ended Questions ...... 40 Testimonials ...... 41

5. DISCUSSION ...... 45

Mindfulness Assessment Implications...... 46 Balance Assessment Implications ...... 48 Correlation Implications ...... 50 Qualitative Measures ...... 51 Themes ...... 51 Closed-Ended Questions ...... 53 Testimonials ...... 54 Limitations ...... 54 Small Sample Size ...... 54 No Control Group ...... 55 Intervention Length ...... 55 Primary Investigator Conducted Assessments ...... 55 Mindfulness Measure Implementation ...... 56 Participant Disparity ...... 56 Implications for Future Research and Conclusion ...... 57

iv APPENDICES ...... 59

A. CONSENT TO ACT AS A HUMAN RESEARCH SUBJECT ...... 59 B. PAR-Q+ ...... 64 C. HEALTH ACTIVITY QUESTIONNAIRE ...... 70 D. MINDFUL ATTENTION AWARENSS SCALE ...... 79 E. FULLERTON ADVANCED BALANCE SCALE ...... 81 F. STANDING MEDITATION HOMEWORK LOG ...... 84 G. POST-INTERVENTION SURVEY ...... 85 H. HANDOUT 1 ...... 87 I. HANDOUT 2 ...... 88 J. HANDOUT 3 ...... 89 K. HANDOUT 4 ...... 90

REFERENCES ...... 91

LIST OF TABLES

Table Page

1. Intervention Schedule ...... 28

2. Participant Demographics and Intervention Statistics ...... 34

3. Standing Meditation Intervention Dose Totals ...... 35

4. Paired Samples t test for total FAB score and MAAS score of participants ...... 36

5. Testimonials collected from post-intervention survey and homework ...... 44

6. Mean Comparisons of FAB Scale Items ...... 49

LIST OF FIGURES

Figure Page

1. Flowchart of participant recruitment and data collection ...... 33

2. Correlation of post-score of the FAB scale versus total intervention dose in minutes; r=.694, p=.026. Dashed vertical line was the recommended dose ...... 37

3. Themes reported from open-ended questions in homework, discussion, and post-intervention survey ...... 40

4. Symptoms reported from closed-ended questions on physical and psychological effects...... 41

5. Intervention questions for study improvement ...... 42

vii

ACKNOWLEDGMENTS

I want to thank my thesis committee for their support in this two-year endeavor.

Dr. Chen, thank you for your unwavering confidence, and push to write every day. Dr.

Rose, thank you for applying your academic rigor to my study with your thorough review and challenges. Dr. Barros, thank you for enthusiastically backing my research and helping me apply a motor behavior emphasis. I also would like to thank my girlfriend,

Evelyn, for being patient and helping me bounce ideas and practice my presentation.

Finally, thanks to my parents for both their financial and emotional support in my graduate pursuits.

viii 1

CHAPTER 1

INTRODUCTION

Over the past several decades, a dramatic increase in sedentary behavior has been observed in Americans, resulting in the rise of obesity and major diseases such as cardiovascular disease, cancer, and diabetes (Owen, Healy, Matthews, & Dunstan, 2010).

Most sedentary behavior involves sitting, which has been linked to increased mortality

(van der Ploeg, Chey, Korda, Banks, & Bauman, 2012). Additionally, America, like most industrialized nations, is experiencing significant growth of the older adult population as the "baby boomers" age (Ortman, Velkoff, & Hogan, 2014). Age-associated changes are exacerbated by sedentary behavior, causing susceptibility to fall, and, thus, leading to a

“downward spiral” of mobility, depression, and increasing sedentary behavior (Rose &

Hernandez, 2010). Sedentary behavior leads to reduced mobility due to poor muscle strength, resulting in reduced balance. Poor balance increases the risk of falling, which often leads to further debilitation. Depression and fear of falling increase with disability, resulting in more chronic sedentary behavior and a continued downward spiral. Well- rounded exercise programs that incorporate cardiorespiratory, musculoskeletal, and neuromotor exercises have been found to be very beneficial in improving multiple areas of health in adults (Garber et al., 2011), and they are essential in countering sedentary behavior. Neuromotor exercises, like Tai Chi, have been associated with improving

2 balance and coordination (Garber et al., 2011), and are, therefore, ideal for the older adult population (Tsang, Wong, Fu, & Hui-Chan, 2004).

Tai Chi—full name being Tai Chi Chuan or Taijiquan—is a Chinese martial art that has gained popularity as a low-intensity mind-body exercise (Yang et al., 2015). This movement form has been shown to have many health benefits, including improvements in areas of cardiopulmonary effects, physical function, falls and related risk factors, quality of life, self-efficacy, patient-reported outcomes, psychological symptoms, and immune function (Jahnke, Larkey, Rogers, Etnier, & Lin, 2010). It has also been cited in dozens of research articles as an effective balance intervention that significantly decreases fall risk (Li, Harmer, Fisher, & McAuley, 2004; Liu & Frank, 2010; Sattin,

Easley, Wolf, Chen, & Kutner, 2005; Tousignant et al., 2012; Tsang et al., 2004; Yang et al., 2007). Additionally, it has been shown to increase lower body strength (Li, Xu, &

Hong, 2009; Yang et al., 2015), and has long been associated with decreasing stress, and improving mindfulness (Caldwell, Emery, Harrison, & Greeson, 2011; Chang, Nien,

Chen, & Yan, 2014). Furthermore, Tai Chi is increasingly recommended as an appropriate exercise for older adults, especially those at low risk for falls (Rose, 2008).

Though Tai Chi apparently has been found to have numerous benefits, the mechanisms by which this may be achieved are not fully understood (Hong & Li, 2007).

There has been some attempt to define Tai Chi as a “complex multicomponent” exercise

(Wayne & Kaptchuk, 2008), and over the years several "simplified tai chi" programs have arisen that focus primarily on the movement forms (Chen, Chen, & Huang, 2006;

Fisher, Li, & Shirai, 2004; Jahnke et al., 2010; Li et al., 2008;). However, the full traditional practice of Tai Chi is rarely tested in research, and thus presents the problem

3 of research-based “Tai Chi” not accurately representing the original art (Jahnke et al.,

2010; Yang et al., 2007). The traditional “pillars of practice” in Tai Chi are: Zhan

Zhuang—literally “pole-standing”—also referred to as “standing meditation,” Taolu— literally “moving pole”—primarily known as the “movement forms” most associated with Tai Chi, and Tui Shou—literally "push hands"—a two-person exercise practiced to apply the movements and develop strength (Yang & Grubisich, 2005). Tai Chi form movement involves slow, coordinated motion, weight-shifting, and intentional gaze, highlighting common mechanisms associated with balance (Rose & Hernandez, 2010).

However, traditional masters emphasize the static posture of zhan zhuang as the foundation of internal martial art practice, and believe it to be the key to the benefits in health and martial art prowess (Yang et al., 2007; Yang & Grubisich, 2005; Yu, 2006).

While a majority of the research on Tai Chi has focused on form training, this study will evaluate the effects of the first component of practice: zhan zhuang—or as we shall refer to it in this study, “standing meditation”—and its effects on balance and mindfulness.

Standing meditation is traditionally performed for up to two hours at a time, and some advanced students practice even longer (Yu, 2006). However, the amount of time spent in standing meditation varies by age and ability, so older adults could benefit from much shorter periods of time (Yang & Grubisich, 2005; Yu, 2006). One of the few studies that incorporated standing meditation was conducted by Yang et al. (2007) who incorporated a 10 to 20-minute standing meditation component to their Tai Chi intervention, as participants were new to Tai Chi.

When practiced, one of several unique postures may be assumed in standing meditation. The ten principles of Tai Chi Chuan created by Yang Chengfu in the early

20th century (Yang, Tom, & Repetto, 2013) highlights the essential body and focus requirements. Generally, the feet are kept shoulder-width apart with the hips externally rotated, giving a slight impression of straddling a horse. The knees are bent slightly to prevent hyper-extension, and weight is centered beneath the spine. The crown of the head is suspended, reducing the curvature of the cervical and thoracic spine with the head pulled back and chin dropped slightly. Next, the pelvis is posteriorly tilted as if sitting on a stool, causing a reduction in lumbar lordosis. The shoulders are relaxed, and attention is brought to the breath in the lower abdomen. All cues for the standing meditation posture are practiced in a relaxed and unstrained manner (Yang et al., 2013; Yang & Grubisich,

2005; Yu, 2006). The most basic form of standing meditation incorporates this posture with hands resting on the abdomen below the navel (Yu, 2006). Practitioners focus on slow, deep breaths, directing breath to the lower abdomen. Traditional masters generally advocate practicing standing for as long as one can tolerate (Yang & Grubisich, 2005;

Yu, 2006).

As standing meditation is considered the traditional foundation and

“fundamental” exercise of Tai Chi practice (Chang et al., 2014; Yang et al., 2007), it could be assumed that it is in some way linked to the many benefits reported by Tai Chi practitioners. Some potential effects are an increase in leg and core strength, improved posture as a result of statically stretching muscles along the spine, and improved steady- state balance (Yang & Grubisich, 2005).

Standing meditation exercise has similar postural and respiratory requirements to the extensively tested exercise theory of dynamic neuromuscular stabilization (DNS)

(Frank, Kobesova, & Kolar, 2013). Specifically, it meets its three basic principles: “one,

5 restore proper respiratory pattern and intra-abdominal pressure (IAP) regulation; two, establish a good quality of support for any dynamic movement of the extremities; and three, ensure that all joints are well centered throughout the [exercise]” (Frank et al.,

2013). DNS is specifically focused on improving the integrated spinal stabilizing system

(ISSS), and findings suggest that a stable spine—as created with intra-abdominal pressure in DNS exercise—improves performance and reduces risk of injury during functional tasks (Frank, Kobesova, & Kolar, 2013).

With the rise in sedentary behavior and sitting hours causing negative health effects and poor posture, increased standing time has been a suggested counter-measure, thus leading to the rise of standing desks (Minges et al., 2016). Though there is no research on standing meditation specifically, there is a growing body of research on prolonged standing, and the biomechanics of neutral standing postures that support the standing meditation requirements. Several studies have evaluated the development of low back pain while standing. Postural habits, weight placement, and lumbopelvic muscle activation all have been found to contribute to the occurrence of back pain in prolonged standing (Gallagher, Nelson-Wong, & Callaghan, 2011; Ringheim et al., 2015). In patients with spinal cord injuries, prolonged standing in a standing frame has been shown to have a multitude of benefits including improved quality of life, circulation, digestion, sleep quality, and reduced pain (Eng et al., 2001). These prolonged standing studies offer relatable evidence for the potential benefit of standing meditation.

The purpose of this study was to investigate the effects of a standing meditation intervention on balance and mindfulness in older adults. Additionally, as this was the first study to look at standing meditation separately from the Tai Chi movement forms, this

6 study was designed to establish a starting point for future research on standing meditation

(Chang et al., 2014; Yang et al. 2007). This study compared differences between the pre- and post-assessments on balance and mindfulness over the course of five weeks.

Additionally, this study evaluated correlation of intervention dose and post-scores.

Finally, qualitative analysis of open-ended themes, closed-ended study questions, and testimonials was conducted to support the findings, and provide feedback for future studies.

Hypothesis

The study investigated the following hypotheses:

1. The posttest measures for balance—as tested by the Fullerton advanced balance

(FAB) scale—would be significantly greater than the pretest measures for the

Standing Meditation group.

2. The posttest measures for mindfulness—as tested by the mindful attention

awareness scale (MAAS)—would be significantly greater than the pretest

measures for the Standing Meditation group.

3. A significant positive correlation would be found between intervention dose and

the post-score for the FAB scale.

4. A significant positive correlation would be found between intervention dose and

the post-score for the MAAS.

Delimitations

The study was conducted with the following delimitations:

1. Participants were limited to a population of convenience, drawn from active

members of the Osher Lifelong Learning Institute (OLLI) at California State

University, Fullerton (CSUF).

2. Participants were limited to those who met inclusion criteria, which required that

(a) participants be over the age of 60 years; (b) were cleared for physical activity

based on the physical activity readiness questionnaire (PAR-Q+) and/ or doctor

clearance, (c) able to stand for a minimum of 30 minutes without rest.

3. Participants were limited to those who were absent of any exclusion criteria,

which required that participants may not (a) have had a fall that resulted in a

serious injury in the past year, (b) had any major surgery that affects the ability to

stand or perform balance assessment, (c) have severe musculoskeletal or

neuromuscular disease, (d) have chronic/ acute illness that may affect ability to

stand or perform balance assessment, (e) be currently engaged in a balance or

meditation-based program, (f) enroll in a new physical activity or class in duration

of the study, and (g) have extensive practice in Tai Chi, standing meditation, or

other meditation-related activities (those with some experience are noted but not

excluded).

4. Participants were limited to those who complete an informed consent form

approved by the Institutional Review Board of California State University,

Fullerton, a PAR-Q+, and optional Health Activity Questionnaire (HAQ).

Limitations

The study was conducted with the following limitations:

Researcher:

1. The primary researcher of this study led all intervention sessions and conducted

measure assessments (FAB scale and MAAS).

2. The primary investigator is a Tai Chi Chuan instructor, creating a minor conflict

of interest.

Participants:

1. All participants were enrolled under the assumption that they are representative of

the population of convenience.

2. All participants were enrolled under the condition that they meet all inclusion

criteria, and absent of all exclusion criteria.

3. It was assumed that participants would attend and perform progressive

intervention dose in all sessions (6) over the course of five consecutive weeks.

4. Participants were assumed to perform all measures including the pre- and post-

intervention assessments (Mindful Attention Awareness Scale and FAB Scale).

5. Participants were assumed to implement intervention outside of class, and record

total weekly dose and comments in homework log.

CHAPTER 2

REVIEW OF LITERATURE

Sedentary Behavior and Rising Older Adult Population

Since the 1950s, sedentary behavior has been on the rise due to the advent of television, automobile use, and technological advancement (Matthews et al., 2012).

Formally defined as “any waking behavior characterized by an energy expenditure ≤1.5

METs while in a sitting or reclining posture,” sedentary behavior has been the center of a significant amount of research over the years (Tremblay et al., 2012). In conjunction with the rise of sedentary behavior, the population of older adults, age 65 and older, has been rising and is expected to rise dramatically for the next 40 years. In fact, the U.S, Census

Bureau predicts that by 2050 over twenty percent of Americans will be 65 years or older

(Ortman et al., 2014).

A systematic review by Harvey, Chastin, and Skelton (2013) concluded that sedentary behavior is very prevalent in older adults, with over sixty percent sitting for more than four hours each day. Recent findings have shown sedentary behavior— particularly sitting—has many negative effects on health, and research has overwhelmingly shown it to be associated with greater mortality risk (Chau et al., 2013).

In fact, Chau and colleagues (2013) found that each hour sitting increased mortality risk by 2%, and after 7 hours it increased incrementally by 5% each hour. Owen et al. (2010) found that sedentary behavior in America has increased significantly, and that it

10 increased risk of mortality even for those involved in some physical activity. These studies demonstrate an urgent need to counter sitting time with physical activity and standing time.

Tai Chi as an Effective Exercise for Older Adults

Tai Chi—also referred to as Taiji, Tai Chi Chuan, and Taijiquan—is an internal martial art dating back from at least the 17th century, and is literally translated from

Chinese as “Supreme Ultimate Boxing” (Wayne & Kuo, 2008). It has been considered a holistic exercise with benefits to the physical and psychological health of older adults

(Posadzki & Jacques, 2009). In addition to musculoskeletal and cardiorespiratory exercise, the American College of Sports Medicine (ACSM) recently recommended the inclusion of “neuromotor” exercise—focused on balance, agility, and coordination—for adults, and Tai Chi currently has the largest research base in such a category (Garber et al., 2011). Posadzki and Jacques (2009) define Tai Chi as a “mind-body technique that is used to increase an individual’s health and well-being.” They describe its movements as slow and gentle, and recommend it as an effective exercise for older adults. In fact, Tai

Chi is increasingly recommended as an effective exercise for older adults due to its benefits not only in psychological factors like well-being, but also neuromotor factors, like balance.

Psychological Effects

Tai Chi appears to have many benefits in psychological wellness. Li, McAuley,

Harmer, Duncan, and Chaumeton (2001) conducted a study to evaluate Tai Chi’s effect on self-efficacy and exercise behavior specifically. The study took place over six months with a waitlist control, and class attendance and self-efficacy were measured between the

11 groups. Overall, they found a significant increase in self-efficacy for the Tai Chi group as opposed to the control. Additionally, they found that there was a positive relationship between class attendance and self-efficacy. These findings demonstrate regular Tai Chi practice may improve older adult motivation and confidence in performing physical activity.

A cohort study conducted by Caldwell, Emery, Harrison, and Gresson (2011) evaluated mindfulness, mood, perceived stress, self-regulatory self-efficacy, and sleep quality in students aged 18 to 48 following a 15-week Tai Chi course. It was found that all factors significantly increased in the Tai Chi group, and mindfulness was correlated to well-being and sleep quality. Baxter and Francis (2013) conducted a similar study with participants aged 18 to 68years. Their study compared a Tai Chi group to a sedentary

(book club) and active (gym exercise) group in biopsychosocial quality of life factors.

Again, the Tai Chi group scored significantly better than the other groups on psychological and physical quality of life (QoL), and the physical QoL improved with years of practice. Both studies evaluated similar psychological components of well-being and found Tai Chi to be superior. These studies demonstrate a possible wellness effects that may be observable in any Tai Chi intervention.

Mindfulness

Mindfulness is an increasingly popular psychological measure to test as it is associated with various positive effects such as well-being. A review of literature examining neuroimaging scans of the brain for those with mindfulness practice found changes in multiple areas of the brain. This included the medial cortex, default mode network, insula, amygdala, lateral frontal regions of the prefrontal cortex, and basal

12 ganglia (Marchand, 2014). Mindfulness is most associated with meditation, but it is also commonly associated with Tai Chi. Mindfulness is a diverse commonly tested component in Tai Chi research, and is, thus, an important psychological factor of Tai Chi. Ma and associates (2016) tested the effects of Tai Chi on sleep quality while also including a mindfulness component using the mindful attention awareness scale (MAAS) with participants ages 28-65 (M = 54 years). They found a significant improvement between the pre- and post-scores on the MAAS and well as sleep quality variables in their ten- week pilot study. Miller and Taylor-Piliae (2017) conducted an observational study in which they compared safe driving performance measures—including the MAAS—with normative values for older adults between the ages of 65 and 85 (M = 73 years) with Tai

Chi experience. Results for the MAAS scores were found to be significantly higher than the normative value. In addition to these studies, many of the Tai Chi articles specifically refer to Tai Chi as having a strong mindfulness component (Chang et al., 2014; Hanley,

Garland, & Black, 2014; Jahnke et al., 2010; Posadzki & Jacques, 2009; Wayne &

Kaptchuk, 2008; Yeh et al., 2004).

Neuromotor effects

As indicated in ACSM’s recent position stand (Garber et al., 2011), Tai Chi is well recognized as an effective neuromotor exercise, which include balance, agility, and coordination-based exercises. Tsang and Hui-Chan (2003) performed a knee joint repositioning test and a balance test on forty-two older adult participants over the age of

60 (M = 70 years). Half were long-term Tai Chi practitioners (over 3 years), and the other half had no Tai Chi experience. They found that the Tai Chi group had significantly less error in the knee repositioning test, and though there was no difference in static balance,

13 the Tai Chi group was found to have faster reaction time in weight shifts and greater limits of stability. Fong and Ng (2006) conducted a similar cross-sectional controlled trial comparing the sensorimotor performance of long-term and short-term Tai Chi practitioners, and a non-practitioner control group, all between the ages of 40 and 78

(M = 54 years). They found that long-term practitioners of a year or more had significantly faster reflex reaction time in the hamstrings and gastrocnemius, and could maintain balance for a longer time when standing on a tilt board, than short-term and non-practitioners. In addition, both Tai Chi groups had significantly less knee joint repositioning error than the non-practicing group. Based on these studies a clear distinction can be observed between older adults that practice Tai Chi long term and those that do not. The faster reaction times, balance, and proprioceptive awareness demonstrate Tai Chi’s effectiveness as a neuromotor exercise.

Hakim, Kotroba, Cours, Teel, and Leininger (2010) conducted a study comparing

Tai Chi and Yoga with older adults over the age of 65 (M = 74 years). Their study incorporated several balance scales including the Single Limb Stance (SLS), the

Multidirectional Reach Test (MDRT), the Fullerton Advanced Balance Scale (FAB), the

Activities-Specific Balance Confidence Scale (ABC), and the Timed Floor Transfer

(TFT). They found that both the Yoga and Tai Chi group scored significantly better than the no exercise group on the FAB scale. The Tai Chi group scored significantly better than the Yoga group on the MDRT, while the Yoga group was significantly better than the no exercise group. The other tests (TFT, SLS, ABC) yielded no significant effects, though a higher percentage of the Tai Chi group (76%) were willing or able to complete the TFT compared to Yoga (54%) and no-exercise group (30%). The comprehensive

14 balance measures of this study further highlight Tai Chi’s effectiveness as a neuromotor fitness intervention.

Fall Reduction

Neuromotor exercise is especially beneficial for older adults as improvements in balance and reaction time reduce occurrence, and fear of falling (Garber et al., 2011).

Many studies have demonstrated powerful fall-reducing qualities of Tai Chi. Li and colleagues (2004) conducted a randomized-controlled trial that evaluated changes in functional balance and the number of post-intervention falls in older adults ages 70-92

(M = 77 years) following a six-month Tai Chi intervention, and a six-month follow-up period. The Tai Chi group demonstrated a significant improvement in functional balance

(measured with the Berg balance scale, dynamic gait index, and functional reach), and a subsequent decrease in the number of falls. Sattin and associates (2005) tested what they referred to as “fear of falling” in older adults between the ages of 70 and 92 (M = 80 years) using the Activities-Specific Balance Confidence Scale (ABC) and Falls Efficacy

Scale. Participant were either part of a Tai Chi group or wellness education group, and tested every four months for a year. While the Falls Efficacy Scale yielded no significant results, the ABC scores for the Tai Chi group for were significantly greater than the wellness education group. Tousignant et al. (2012) conducted a study comparing a Tai

Chi intervention with a physiotherapy intervention for generalized fall reduction in older adults over the age of 65 (M = 79). Both groups demonstrated similar improvements in balance, gait, and reduced fear of falling, but the Tai Chi group also showed a significant improvement in general self-efficacy.

Defining Mechanisms of Tai Chi

Though a host of benefits, especially as a neuromotor wellness exercise, have been presented with the practice of Tai Chi, the mechanisms by which they occur is not well understood. Being deeply rooted in Chinese medicine and philosophy, Tai Chi is also not fully understood without mentioning the concept of “qi.” Chu (2004) describes qi as the “universal life force in all living things” that is directed through mindful attention.

He suggests that the practice of Tai Chi is to cultivate and enhance one’s qi which leads to a host of health benefits. With such an emphasis on calm mindfulness, Posadzki and

Jacques (2009) suggest in their article that Tai Chi and meditation are intimately connected, and assert that Tai Chi could be referred to as “meditation in movement

(MIM).” This idea puts Tai Chi in a category that identifies many of its effects— relaxation, wellness, and stress reduction—but it does not capture some of the neuromotor effects.

Wayne and Kuo (2008) wrote a two-part article addressing the challenges inherent in Tai Chi research, asserting it should be evaluated as a “multicomponent complex intervention.” They suggest the components may be labeled as musculoskeletal factors, breathing, mindfulness, intention, physical touch, psychosocial interactions, philosophy, and rituals (Wayne & Kuo, 2008). Each of these offer unique effects on their own, and so they argue that it is difficult to ascertain what effects are happening from Tai

Chi as a whole. Whereas Posadzki and Jacques (2009) attempt to reduce Tai Chi to being primarily meditation, Wayne and Kuo (2008) highlight that Tai Chi is best approached as

“whole systems research.” They suggest that adopting a pluralistic approach of

“controlled randomized trials of fixed protocols, community-based pragmatic trials,

16 cross-sectional studies of long-term practitioners, and studies that integrate qualitative methods” are all necessary to effectively research the effects of Tai Chi.

In evaluating Tai Chi itself, masters of traditional Yang Family Tai Chi teach multiple components of practice. These components are standing meditation (also called

“Zhan Zhuang”), forms, and push hands—a two-person exercise also known as “Tui

Shou (Yang & Grubisich, 2005). Most scientific research with Tai Chi tends to focus on the forms practice (Yang et al., 2007, Chang et al., 2014), as that is where Tai Chi gets its reputation as a slow and gentle exercise. Often, however, the practice is not specified other than “a Tai Chi “master,” “qualified instructor” (Li et al., 2009), or “experienced teacher” (Dechamps, Onifade, Decamps, & Boudel-Marchasson, 2009) led the class.

Each component of Tai Chi plays an important part in the overall development of skill.

For example, the standing meditation component is practiced to develop mindfulness and learn the proper posture, while the push hands component allows participants to apply Tai

Chi principles with an external stimulus (Yang et al., 2013; Yang & Grubisich, 2005).

The benefits of these components are not well understood, however, due to the emphasis on form practice in scientific research. As Gatts (2008) stated in her article, the “rising popularity and spreading of Tai Chi Chuan, traditional time-tested forms and training principles are being lost amid a growing number of personalized interpretations.”

There are a growing number of simplified Tai Chi programs such as the

Simplified Tai Chi Exercise Program (STEP) (Chen, Chen, & Huang, 2006), Ezy Tai Chi

(Fisher et al., 2004), and notably the nationally disseminated “Tai Chi: Moving for Better

Balance” program developed by Li and colleagues (2008). One cannot help but wonder if something is lost from the traditional practice and principles with a focus on simplified

17 movement forms. As Yang et al. (2007) stated, “Chinese internal arts [are] clear on the primacy of standing and sitting meditation in nurturing complete and efficient development of Taiji’s many benefits.” Therefore, Yang et al. (2007) suggests future studies should to investigate the effects of the full practice of Tai Chi as well as its individual components like standing meditation.

Standing Meditation

Standing meditation is a component of Tai Chi regarded as the foundation of all internal martial arts (Yu, 2006) and the “fundamental exercise” of Tai Chi (Chang et al.,

2014; Yang et al., 2007). It is widely practiced in China as it is believed to improve the flow of “qi,” and, hence, have many health benefits. Unfortunately, there is very little research that includes standing meditation, and no research—to the primary investigator’s knowledge—that has tested it specifically. Yang and colleagues (2007) produced two studies that specifically incorporated a progressive standing meditation component to their Tai Chi intervention (focused on the movement forms with a standing meditation warmup). One study found significant improvement in older adult (M = 77 years) immune response to influenza. While the second study found significant improvement in vestibular ratios in the sensory organization test (SOT) in older adults (M = 80 years).

The same author, Yang, wrote Taijiquan: The Art of Nurturing, the Science of Power

(2005), in which he explores the importance of standing meditation in the full practice of

Tai Chi.

As the name implies, standing meditation is practiced in much the same way as other forms of meditation, with a focus on mindfulness, and attention to the body and breath (Yang & Grubisich, 2005). Meditation has been found to have significant impact

18 on improving back pain acceptance in older adults, and improvement in physical function and focus (Morone, Greco, & Weiner, 2008). As many people suffer from standing low back pain meditating while standing may allow participants to reduce back pain through relaxed posture, breathing and mindful attention.

Regular standing posture and standing meditation posture do differ in a few areas.

Both postures should be upright and natural. However, standing meditation—as a component of Tai Chi—is focused on relaxation (Yang & Grubisich, 2005). The standing meditation posture has weight evenly distributed in the feet (Yang et al., 2013), whereas regular standing tends to have the weight toward the front of the feet (Swann, 2009).

Additionally, the standing meditation posture necessitates the knees are slightly bent, hips are in a slight external rotation, and the pelvis in a minor posterior tilt (Gallagher, 2003).

The lordotic and kyphotic curves of the spine should be less pronounced as the crown of the head suspends. Finally, shoulders and waist relax in this naturally erect posture (Yang et al., 2013). Tai Chi has been shown to improve spinal posture as seen in the study by

Gao and Tsang (2007) likely due to this relaxed straight posture. Standing meditation may be practiced as short as two minutes (Yang et al., 2013), but generally an hour or longer is recommended (Yu, 2006).

Using the traditional understanding and research discussion of Gallagher (2003),

Yang (2005), and Yu (2006), a comprehensive definition for standing meditation has been created by the primary investigator: also referred to as zhan zhuang—literally “post standing”—standing meditation is a form of static qigong in which one holds a prolonged quiet standing stance as a form of mindfulness meditation, with an emphasis on internal body awareness. Practitioners actively work to relax the body, minimizing muscle

19 contraction, while maintaining a natural elongation of the spine (reducing lordosis and kyphosis). Additionally, low diaphragmatic breathing is incorporated, generating intra- abdominal pressure (IAP). This exercise is done with the goal of improving the “frame” of the body, which is expected to translate into improved movement (the “moving frame”), internal strength, and generalized health. What follows is research on prolonged duration, biomechanics, and spinal stability compared with the requirements of standing meditation.

Evidence for Potential Benefit of Standing Meditation

Prolonged Standing

There have been a number of studies evaluating the effects of prolonged standing from fifteen minutes to two hours at a time. Much of the research evaluates the cause of back pain, and labels those that get pain over the course of standing as pain developers

(PDs), and those that do not as non-pain developers(NPDs) (Gallagher & Callaghan,

2015). Generally, back pain relates to less standing sway (Gallagher et al., 2011), reduced anticipatory postural adjustments (APAs) in the transverse abdominus and oblique muscles (Marshall et al., 2014), and the inability for trunk muscles to relax (Ringheim et al., 2015). Gallagher and Callaghan (2015) also found that NPDs tended to move their center of pressure (CoP) toward their heels and have larger body weight shifts between feet. These finding suggest that pain development relates to weak deep core stability muscles, a lack of relaxation, and possible postural cues like shifting CoP to heels.

Interestingly, all of these aspects are addressed specifically in standing meditation. A common requirement is to relax the waist and upper body (Yang et al., 2013) which relates to Ringheim and colleagues (2015). Additionally, shifting the CoP toward the heel

20 for a more even weight distribution is a common cue in standing meditation (Yang &

Grubisich, 2005) supported by Gallagher and Callaghan (2015).

Biomechanical Components

Standing meditation kinematics are very similar to those of erect standing.

O'Sulivan et al. (2001) found that markers placed on the acromium process, greater trochanter, and lateral ankle malleolus formed roughly a 180-degree angle; standing meditation also follows a similar position of 170-180 degrees at the same points. The biomechanical difference is seen predominantly at the head and pelvis positioning.

Whereas erect standing necessitates a neutral head and pelvis, standing meditation has a slight anterior tilt of the head, and posterior tilt of the pelvis. Additionally, both head and pelvis translate posteriorly. This causes a slightly more elongated posture with reduced kyphotic and lordotic curvature than normal erect posture. However, though these adjustments to the spine may seem counter to the natural curves of the spine, it is important to note these cues emphasize relaxing the spine into the elongated position rather than forcefully attempting to straighten the spine.

Though no research has yet evaluated these specific kinematics of standing meditation, some research findings provide support the potential benefits of such a posture. Research by Kiefer, Parnianpour, and Shirazi-Adl (1997) demonstrated that the spine under no stress in a relaxed position produces a reduced lumbar lordosis. Hence, the requirement to straighten the spine through relaxation is a logical cue given in standing meditation. Another common cue is allowing the tail bone to drop (Yang et al., 2013) which causes a slight posterior tilt of the pelvis. This tilt not only reduces lumbar lordosis, but has also been shown to minimize spinal canal stenosis (Endo, Suzuki,

Nishimura, Tanaka, Shishido, & Yamamoto, 2012) increases diaphragmatic activity

(Frownfelter & Dean, 2014). Due to the strong link between excessive kyphosis and falls in older adults (Kado, Huang, Nguyen, Barrett-Connor, & Greendale, 2007), cues to suspend the crown of the head (Yang et al., 2013), which brings the head back and slightly tilt the head anteriorly may prove beneficial to reduce kyphosis. Early studies by

Bridger, Wilkinson, and van Houweninge (1989) suggest excessive lordosis reduces hip mobility, thus it may be inferred that by reducing the level of lordosis, hip mobility is improved. In contrast, studies have found that lordosis in the spine has a natural stabilizing component during bipedal walking (Wagner, Liebetrau, Schinowski, Wulf, & de Lussanet, 2012). Regardless, in a static position, standing meditation offers at least similar benefits to erect standing, and may prove to have other benefits in muscle activation and spinal stability.

Spinal Stabilization

O'Sullivan et al. (2002) found that erect standing and sitting had greater muscle activation of the deep lumbopelvic muscles than sway standing or slumped sitting. Since standing meditation also requires positional cues counter to sway or slumped standing, it may be inferred that similar muscles are engaged. In this study, the superficial multifidi and internal oblique muscles, and well as the thoracic erector spinae, had significantly more EMG readings than the sway standing condition, while the superficial rectus abdominus and external obliques had less EMG response. Many studies suggest that the deep lumbopelvic muscles are essential for spinal stabilization, and hence important to prevent injury and reduce back pain (Cholewicki & McGill, 1996). Major stabilizing muscles of the lumbar spine were found to be the psoas, multifidus, and quadratus

22 lumborum muscle groups (Christophy, Senan, Lotz, & O’Rieilly, 2012). Recent research also suggests that the diaphragm plays a role in maintaining intra-abdominal pressure, and helps reduce back pain (Cholewicki, Juluru, & McGrill, 1999; Kolar et al., 2012).

The integrated spinal stabilization system (ISSS) developed by Kolar, suggests that the pelvic floor, abdominal wall, diaphragm, and deep neck flexors work as a kinetic chain to maintain and produce spinal stabilization (Frank et al., 2013). These findings, though relatively recent, relate positively to standing meditation requirements. The deep neck flexors are active with the suspended crown, there is a focus on deep diaphragmatic breathing, the erect posture activates the deep muscles of the abdominal wall, and the posterior positioning of the pelvis potentially stimulates the pelvic floor muscles.

Therefore, standing meditation may hypothetically be an ideal isometric exercise to train the ISSS.

Benefits of Standing

Eng and colleagues (2001) found significantly positive effects in the areas of well-being, circulation, plasticity, digestion, self-care, breathing, and pain for a group of patients with spinal injuries who engaged in standing practice. The findings of this study were based on self-report surveys of effects of prolonged standing, but it still offers insight on associated positive effects of standing. Its largest reported benefit was in well- being, which demonstrates standing may be an effective counter to depression associated prolonged sitting.

Several studies have shown a relationship between balance and standing.

O’Connor and Kuo (2009) found that quiet standing resulted in increased anteroposterior

(AP) sensitivity to visual stimuli 2.3 times greater than mediolateral (ML) sensitivity.

While walking, visual interference only affected ML sensitivity, as AP balance was maintained due to walking necessitating “uncontrolled, passively stabilized series of falls.” In addition, though several studies have not found a relationship between dynamic and static balance (Hrysomallis, McLaughlin, & Goodman, 2006; Karimi & Solomonidis,

2011), Nagai and colleagues (2013) found that quiet standing balance was positively correlated with dynamic balance. An earlier study by Hsiao-Wecksler et al. (2003) was able to predict dynamic postural response in older adults using only quiet stance data.

Their study was based on the fluctuation-dissipation theorem (FDT), and highlights a similar mechanism between dynamic and static postural control. These studies suggest that a quiet standing activity like standing meditation could potentially improve postural control mechanism of balance, and therefore potentially affect dynamic balance activities.

Other studies have suggested that standing may also improve bone density. Sakai et al. (2009) found that one-legged standing for a minute at a time had significant effects on increasing bone-density, and it was especially effective for participants over age 70.

This study highlights that standing may be effectively used as an intervention for older adults to improve bone density.

Conclusion

Tai Chi movements, although slow, are often complex, and take several sessions to become familiar. Therefore, standing meditation may offer a simple means of improving steady-state balance and mindfulness in older adults without the challenge of memorizing complex movements, while also following the traditional practice of the art of Tai Chi. Though older adults, in general, are significantly less balanced while standing when compared with young adults (Teasdale & Simoneau, 2001), standing meditation

24 offers a host of potential benefits and presents less or the same risk as a normal Tai Chi program. Additionally, research on this single component of Tai Chi may allow for a better understanding of its underlying mechanisms, and present a new direction in Tai

Chi research. Research on standing meditation may lead to an improved understanding of Tai Chi as a whole, and provide some insight on its effects on mindfulness and balance.

CHAPTER 3

METHODS

Participant Recruitment

After receiving approval to test participants from the Institution Review Board

(IRB) of California State University, Fullerton, the primary investigator collaborated with the Osher Lifelong Learning Institute (OLLI)—a membership organization that offers various classes and events for retired and semi-retired adults older adults—to recruit participants ages 60 and above to be part of the intervention. Flyers were posted both at the OLLI site on campus, and in an online newsletter sent to OLLI members. Participants were to meet all inclusion and exclusion criteria requirements prior to enrollment in the study.

Inclusion Criteria

Participants were limited to those who met inclusion criteria, which required that (a) participants be over the age of 60 years; (b) were cleared for physical activity based on the physical activity readiness questionnaire (PAR-Q+) and/ or doctor clearance, (c) able to stand for a minimum of 30 minutes without rest.

Exclusion Criteria

Participants were limited to those who were absent of any exclusion criteria, which required that participants should not (a) have had a fall that resulted in a serious injury in the past year, (b) had any major surgery that affects the ability to stand or

26 perform balance assessment, (c) have severe musculoskeletal or neuromuscular disease,

(d) have chronic/ acute illness that may affect their ability to stand or perform balance assessment, (e) be currently engaged in a balance or meditation-based program, (f) begin a new physical activity or class for the duration of the study, and (g) have extensive practice in Tai Chi, standing meditation, or other meditation-related activities (those with some experience were noted but not excluded).

Procedures

Prescreen

Interested participants enrolled in the study by contacting the primary investigator via phone or email. If the potential participant met the inclusion criteria, and appeared to pass the exclusion criteria, they were invited to come to the first individual session.

Session One

In depth prescreen. Before official enrollment into the study, prospective participants met at individual time-slots to fill out the Consent Form (see Appendix A),

Physical Activity Readiness Questionnaire (PAR-Q+) (see Appendix B), and Health

Activity Questionnaire (HAQ) (see Appendix C). If they had health and physical activity clearance, all inclusion criteria were met, and no exclusion criteria applied, they would officially start the intervention.

Intervention start. Following a successful enrollment, participants were given the pre-assessments for mindfulness (MAAS) (see Appendix D) and balance (FAB scale)

(see Appendix E). Next, they were given a brief introduction to the standing meditation posture cues, and received “Handout 1: Standing Meditation Posture Cues” (See

Appendix H) and their first Standing Meditation homework log (See Appendix F). They

27 then put the cues into practice, and did the standing meditation for five minutes.

Following this session, their assignment goal was to practice standing meditation at least five days for at least 5 minutes each before the next session.

Group Sessions

The next four sessions were led in a group setting. Each group had between two and five participants, and was led by the primary investigator. Each session lasted about thirty minutes, and progressed systematically in terms of standing practice and homework requirements. Each session’s standing meditation time increased by five minutes from the previous session. Hence, session two was ten minutes, three was fifteen minutes, four was twenty minutes, and five was twenty-five minutes. This progression follows the traditional recommendation of starting with five minutes, and progressing gradually (Yu,

2006).

Session format. Each weekly session started with a review and discussion of the previous week’s homework, a short lecture on a meditation concept accompanied with a handout (see Appendices H-K), and standing practice. Three to 5 minutes was allocated in homework review, 5 to 10 minutes for lecture, and the remaining time for the standing meditation intervention. As the standing practice is progressive, earlier sessions spent more time on discussion and lecture to establish a stronger understanding of the practice and discuss concerns or advice for success. Later sessions had shorter homework review and lecture to maximize standing time (the last session was 25 minutes, leaving only five minutes for homework review and no lecture).

During the standing practice, participants were advised to quietly meditate, and peaceful music was played to help the participants relax. Symptoms of dizziness,

28 instability, and fatigue were monitored during the intervention. Later sessions encouraged closing eyes while meditating if participants felt comfortable doing so. Before leaving each session, participants were given a standing homework goal for the week to record in a standing log sheet. It was advised to do the same amount of time standing in the session on five different days throughout the week. The homework goal was considered a minimum, and participants were encouraged to practice more if able.

Session Six

The last session (session six) participants were assigned to meet at the same individual time-slots in which they met for the pre-screen/ first session to control for time of day differences. They turned in the last homework log, filled out the Mindful Attention

Awareness Survey and a post-intervention survey created by the principle investigator, and were then assessed on balance with the FAB scale.

Table 1. Intervention Schedule

Session Topic Standing Homework Initial measures 5 minutes 5 min * 5 days 1 Introduction/ Handout 1: Posture Cues SM HW review 10 minutes 10 min * 5 days 2 Handout 2: Concept 1 Pine Tree SM HW review 15 minutes 15 min * 5 days 3 Handout 3: Concept 2 Yin and Yang SM HW review 20 minutes 20 min * 5 days 4 Handout 4: Concept 3 Empty Mind SM HW review 25 minutes 25 min * 5 days 5 Putting everything to practice. Final Measures No standing None 6 No topic Only measures

Measures

Quantitative Measures

Balance and mindfulness measures were obtained during the first and last week of the intervention. The Mindful Attention Awareness Scale (MAAS) (Brown & Ryan,

2003) was used to evaluate mindfulness. Mindfulness is linked to the psychological quality of well-being, and is associated with relaxation and enjoyment of the moment

(Brown & Ryan, 2003).

The Fullerton Advanced Balance (FAB) Scale was used to evaluate balance

(Rose, Lucchese, & Wiersma, 2006). The FAB scale is conceptually based upon the systems theory of postural control, making it appropriate in evaluating the balance of a postural task like standing meditation.

Qualitative Measures

Homework logs, discussion notes, and a post-intervention survey were used to assess qualitative feedback on the effect of the standing meditation intervention.

Homework logs had a comment section to report any feelings, effort, and changes.

Discussion notes were taken on participant feedback in each session. In addition, a post- intervention survey was created by the principle investigator to further assess physical and psychological symptoms, and study improvement with close-ended bubble-in questions. The survey also included open-ended questions on any positives and negatives experienced with the intervention and study.

All open-ended written data from these documents were evaluated based procedures for qualitative content analysis described by Graneheim and Lundman (2004).

Common themes of all content were compiled and developed into a visual graph. The

30 closed-ended questions on the survey were also gathered and formed into separate bar graph comparisons. Additionally, select testimonies were included that were relevant to the study and tested measures.

Assessment Instrumentation

Mindful Attention Awareness Scale (MAAS)

The MAAS (Brown & Ryan, 2003) (see Appendix D) was designed to assess mindfulness, especially as it relates to the present moment. While not specifically tested with older adults, it has been found to have excellent psychometric properties in testing community adults and cancer populations. The MAAS has high internal consistency levels, high test-retest reliability, discriminant and convergent validity, and criterion validity. The MAAS consists of 15 questions rated on a 1 to 6 ordinal scale.

Fullerton Advanced Balance Scale (FAB)

The FAB scale (Rose, Lucchese, & Wiersma, 2006) (see Appendix E) was designed to assess risk of falls in independent older adults. It involves ten physical test items that include varying dimensions of balance, rated on a 0 to 4 ordinal scale. Its items cover all three sensory systems of balance (somatosensory, visual, and vestibular), as well as a reactive balance component not seen in other scales like the Berg balance scale.

Additionally, it is less likely to have ceiling effect when testing high-functioning older adults due to the moderate and high-level physicality of the test items. The FAB scale has good construct validity, test-retest, inter-rater, and intra-rater reliability. It also requires little equipment, takes minimal time to test (~8-12 minutes), and the principle investigator had over a year of implementing this balance scale prior to the study.

Required materials are two Airex pads, two nonslip sheets, six-inch bench, stopwatch, metronome, and pencil.

Standing Meditation Homework Log

Created by the primary investigator, the homework log (see Appendix F) has a chart with seven days of the week, and space to fill in the approximate amount of time the participant practiced standing meditation. The bottom has a comments section to report feelings, effort, and changes. This sheet was given to participants each week to complete prior to the next session.

Post-Intervention Survey

Created by the primary investigator, the post-intervention survey (see Appendix

G) consists of nine questions—6 closed-ended, 3 open-ended—to assess perceived effects of the intervention. The first two closed ended questions highlight common physical and psychological associated with standing meditation based on traditional understanding as discussed by Yang (2005) and Yu (2006). The next two questions are open-ended and ask for the perceived positives and negatives of practicing standing meditation. The next four ask specific closed-ended questions in relation to study improvement. Finally question nine is an open-ended question asking for any further comments or suggestions. This survey was only conducted at the end of the study.

Statistics

Quantitative data was analyzed on SPSS Statistics for Windows, version 24 (IBM

Corp., Armonk, N.Y., USA). Paired-samples t tests were conducted to compare the pre- and post-assessment scores for both the FAB scale and MAAS. Pearson correlations were conducted to assess the relationship of post-scores with total dose of standing meditation.

CHAPTER 4

RESULTS

Recruitment and Attrition

After screening 29 potential participants over the phone or email, 16 met inclusion criteria and enrolled in the study, completing the initial assessment/ session one.

Three participants dropped out between weeks one and two due to circumstances unrelated to the study (one health related, and two family related). The 13 remaining participants completed the program, completing the pre- and post-assessments. In analyzing data, two of the participants had to be removed as they were discovered to have higher-than-reported arthritis of the knee, thus not meeting the exclusion criteria. Another participant was excluded from all analyses as he/ she missed half of the intervention sessions, and did not turn in any of the homework. This lack of adherence to the program resulted in this participant being an outlier compared to the other participants.

As a result, only 10 participants were included in the demographic and quantitative findings. The qualitative analysis, however, included at all participants

(N = 13) that completed both the pre- and post-assessments. Due to high attrition and time constraints, this study did not include a control group. Hence, the hypotheses relating to control group comparisons were eliminated, and the focus of the analyses was limited to the within-subjects variable of time (pre- and post-scores comparison). Figure

1 represents the recruitment and attrition phases of this study.

Phone/ Pre- Post- Data email Assessment: Assessment: Analysis: Prescreen: N = 16 N = 13 N = 10 N = 29 • Excluded/ • Dropout • Revised cancelled N = 3 exclusion N = 13 N = 3

Figure 1. Flowchart of participant recruitment and data collection.

Demographic Data

Demographic data of qualifying participants is listed in Table 2. The average age of the remaining 10 participants was 69.3 years, with the youngest age 60, and the oldest age 81. The group included mostly female (80%) and Caucasian (80%) participants.

Forty percent reported having experience with Tai Chi, but very little or no experience with standing meditation. Three participants declined to complete the full health activity questionnaire (HAQ) due to feeling it was too invasive, and only filled out the basic demographics on the first page, and physical activity readiness questionnaire (PAR-Q+) to verify inclusion criteria.

Participants that did complete the HAQ exercised an average of 4 days a week

(SD = 2.0). All participants reported leaving the house most days, and were high functioning (M = 23, SD = 2) based on the Composite Physical Function Scale (Rickli &

Jones, 1998) included in the HAQ (labeled as “functional survey”). Additionally, quality of life was rated an average of 6 out of 7 (SD = 0.6). Two participants reported having one non-injurious fall in the past year. However, fear of falling was rated as low based on

34 a mean score of 2 out of 7 (SD = 1.4). Overall, participants reported a high quality of life, high functioning, and independent lifestyle, despite a wide age range.

Table 2. Participant Demographics and Intervention Statistics

Number of participants 10 Age Mean age (SD) 69.3 (5.8) yr. Median age 69.5 yr. Minimum age 60 yr. Maximum age 81 yr. Mean Weight (SD) 135.6 (24.5) lb. Mean Height (SD) 64.0 (3.3) in. Gender N of females (%) 8 (80%) N of males (%) 2 (20%) Race Caucasian (%) 8 (80%) Asian (%) 2 (20%) Tai Chi Experience (%) 4 (40%) Health Activity Questionnaire (HAQ) Opted not to complete HAQ (%) 3 (30%) Exercise days per week (SD)* 4.1 (2.0) Fell once in past year (%) 2 (20%) Fear of Falling (SD)** 2.0 (1.4) Quality of Life (SD)*** 6.0 (0.6) Functional Survey**** 23 (2.0) Intervention Dose Mean (SD) 470.4 (130.2) min. Minimum 274 min. Maximum 690 min. Recommended 450 min. Note. *Regular exercise that causes noticeable change in respiration, heartrate, and/or perspiration. **Rated on 1-7 scale: 1–Not, 7–Extremely. ***Rated on 1-7 scale: 1– Very low, 7–Very High. ****Sum (max: 24) from 12 questions rated: 2–Can do, 1– With difficulty, 0–Cannot do.

Intervention Dose

Table 2 also included the intervention dose statistics of participants. On average participants exceeded the recommended total dose of 450 minutes (M = 470.4 min.) for the intervention. However, there was a large standard deviation of 130.2 minutes, with the minimum dose completed being 274 minutes, and the maximum being 690 minutes.

Table 3 highlights the total dose over the five-week intervention. Total dose included both weekly session participation and reported homework. Five participants exceeded the recommended dose, as indicated by the 1 notation. Two participants missed one or two sessions, as indicated by the 2 notation. One participant missed one homework assignment, as indicated by the 3 notation.

Table 3. Standing Meditation Intervention Dose Totals

S1 S2 S3 S4 S5 Total P S1 HW S2 HW S3 HW S4 HW S5 HW Min. Note 1 5 27 10 50 15 60 20 100 25 115 427 2 5 35 10 60 15 105 20 140 25 175 590 1 3 5 35 10 103 15 132 20 61 25 201 607 1 4 5 58 10 61 15 90 20 100 25 125 509 1 5 5 39 10 77 15 75 20 80 25 125 471 1 6 5 96 10 99 15 108 20 150 25 162 690 1 7 5 42 10 60 15 54 20 68 . . 274 2, 3 8 5 25 10 45 15 59 20 100 25 119 423 9 5 75 10 17 15 85 20 67 25 62 381 10 5 22 . 30 15 90 . 80 25 65 332 2 R 5 25 10 50 15 75 20 100 25 125 450 Note. P = participant. S = session. HW = homework. R = recommended dose. 1 = exceeded recommendations. 2 = missed one or more sessions. 3 = did not turn in one or more homework.

Quantitative Analysis

Mean Comparisons of Initial and Final Scores

Paired-sample t tests were conducted to evaluate differences between pre-test and post-test performance on the Fullerton Advanced Balance (FAB) scale and Mindful

Attention Awareness Scale (MAAS). Table 3 highlights the statistics from the paired- sample t tests for both the FAB scale and MAAS. Both measures indicated significant change between the pre- and post-assessment.

For the FAB scale (see Table 4), post-scores (M = 37.80, SD = 1.93) were significantly higher than pre-scores (M = 30.90, SD = 5.53), t(9) = -4.98, p = .001, d = -1.6. For the MAAS (see Table 4), post-scores (M = 66.10, SD = 10.77) were significantly less than pre-scores (M = 70.60, SD = 14.19), t(9) = 2.32, p = .045, d = -.73.

Table 4. Paired Samples t-Test for Total FAB Score and MAAS Score of Participants

Pre-Score Post-Score 95% CI for M M SD M SD n difference d t-test df FAB -10.04, 30.90 5.53 37.80 1.93 10 -1.6 -4.98** 9 Scale -3.76 MAAS 70.60 14.19 66.10 10.77 10 .11, 8.89 .73 2.32* 9 Note. *p<.05. **p<.001. FAB Scale is sum of ten items graded on a 0-4 ordinal sale. MAAS is sum of fifteen items graded on 0-6 ordinal scale.

Correlation of Post-Assessment Scores and Total Dose

Pearson correlations were conducted to evaluate the relationship between total intervention dose (in minutes) and the post-scores of the FAB scale and MAAS. A significant correlation between the total dose and post-scores of the FAB scale (see

Figure 2) suggest a strong positive relationship between the two variables (R = .694,

37 p = .026). The post-scores of the MAAS, however, were not significantly related

(R = -.180, p = .619).

36 Post-FABScore 35

33 250 300 350 400 450 500 550 600 650 700 750 Total Dose (minutes)

Figure 2. Post-score of the FAB scale versus total intervention dose in minutes; R = .694, p = .026. Dashed vertical line was the recommended dose.

Qualitative Analysis

A qualitative analysis was conducted on the 13 participants that completed the intervention to evaluate participant reaction to the standing meditation. The post- intervention survey, homework log comments, and written notes from discussions were assessed based on content analysis methods described by Graneheim and Lundman

(2004). Data was organized into open-ended themes, closed-ended symptoms, closed- ended study improvement questions, and open-ended testimonials.

All participants completed the post-intervention survey. All closed-ended questions and testimonial data was obtained from the survey. Eleven participants turned in most or all homework logs, while two did not turn in any. Only three commented on all days, two commented two-three days, three commented on 1 day, and three did not provide any comment. Written discussion notes only highlighted common topics, and were not recorded word for word.

Themes

Themes (see Figure 3) were extracted from all content: survey, homework, and discussion notes. The resultant data for themes was created by adding the total number of times participants mentioned them. For example, the same participant may have mentioned feeling relaxed on two separate days, as well as on the post-intervention survey, so this would add a total of three to the “relaxation” theme. Three categories were created to better organize the common themes that arose in discussion and in the open- ended questions of the homework and survey. These categories were methods (nine total), positives (six total), and negatives (three total).

Methods. For methods, “soft music” (N = 16) and “meditation concepts” (N = 16) were most reported as helping with standing meditation practice. The “meditation concepts” theme consisted of any report of using the meditation concepts covered in the sessions, as well as prayer or other meditation techniques like visualization. The next most reported theme was using a “timer” (N = 12) to complete the recommended dose, followed by “breathing technique” (N = 8) and watching “calm media” (N = 8). “Calm media” included of watching a television station or streaming a YouTube channel that had natural scenery or meditation related content. Participants were discouraged from

39 listening to, or watching, the news, or other forms of media that may have a strong emotional effect. “Time of day” (N = 7), “location” (N = 6), “warmup” (N = 5), and clothing (N = 5) completed the list of method themes reported. The “warmup” theme included stretching and walking prior to doing the standing meditation, while the

“clothing” theme covered wearing comfortable loose clothes and comfortable shoes.

Positives. For positives, a feeling of “relaxation” was the most reported (N = 24), followed by “accomplishment” (N = 19), “physical improvement” (N = 16), “awareness”

(N = 12), “healthiness” (N = 10), and “balance” (N = 8). The theme of “relaxation” also included feeling calm and a sense of well-being. The “achievement” theme included feeling of enjoyment, improvement, or accomplishment after doing the practice.

“Physical improvement” included perceived improvements in posture, lower body strength, and activities of daily living. The “awareness” theme also included reports of improved focus and concentration. The theme of “healthiness” also included pain relief and improved digestion. Finally, the “balance” theme highlighted perceived improvement in balance, feeling centered, and being more stable.

Negatives. For negatives, feeling of “boredom” (N = 22), “physical discomfort”

(N = 20), and having “restless thoughts” (N = 16). “Boredom” also included reports of sleepiness and feeling the intervention was too long. “Physical discomfort” included low level pain in the feet and back, muscle fatigue, perspiration, and dizziness. Lastly,

“restless thoughts” also included anxiousness.

0 Timer Balance Warmup Clothing Location Boredom Relaxation Awareness Soft MusicSoft Healthiness Calm Media Calm Time of Time Day Achievement Restless Thoughts Restless Meditation Concept Meditation Physical Discomfort Physical Breathing Technique Breathing Physcial Improvement Physcial Methods Positives Negatives

Figure 3. Themes reported from open-ended questions in homework, discussion, and post-intervention survey.

Closed-Ended Questions

Symptoms. The symptoms are found in Figure 4. The most reported psychological symptom was peacefulness (84.6%). This was followed by boredom

(53.8%), happiness/ well-being (46.2%), and focus (38.5%). The most often reported physical symptom was pain, being reported by 61.5% of participants. Participants were asked to report where the pain was felt, and at what level out of ten. Feet (N = 4), back

(N = 4), knees (N = 2), shoulders (N = 1), and neck (N = 1) were all mentioned, with the most reported pain being 2 out of 10. Other physical symptoms of warmness/ hotness

(30.8%), dizziness (23.1%), and tingling (15.4%) were less reported.

Focus 38.5%

Happiness/ Wellbeing 46.2%

Boredom 53.8%

Peacefulness 84.6%

Tingling 15.4%

Dizziness 23.1%

hsclPsychological Physical Warm/ Hot 30.8%

Pain 61.5%

Figure 4. Symptoms reported from closed-ended questions on physical and psychological effects.

Study improvement questions. The study improvement questions are found in

Figure 5. Almost half of the participants found the progression of the study (increasing standing meditation by five minutes per week) to be “very appropriate” (N = 6), five said it was “appropriate,” and two said it was “difficult.” Only three found the study “very enjoyable,” while a majority said it was “enjoyable” (N = 9), and one reported that it was

“unenjoyable.” Over half of the participants found the intervention handouts “very helpful” (N = 7), while the remaining six participants said they were “helpful.” Finally, six reported they are “very likely” to continue practicing standing meditation, while the remaining seven reported they will “likely” continue.

10 9 8 7 6 5 4 3 2 1 0 Likely Helpful Difficult Unlikely Enjoyable Unhelpful Appropriate Very Likely Very Unenjoyable Very Helpful Very Very Difficult Very Very Unlikely Very Very Enjoyable Very Unhelpful Very Very Appropriate Very Very Unenjoyable Very Appropriate Enjoy the study? Handouts Helpful? Likeliness to Progression? Continue practice?

Figure 5. Intervention questions for study improvement.

Testimonials

Table 5 highlights individual testimonials of the participants. The three participants that were excluded from quantitative analysis are identified. One participant highlighted a major challenge they and many of the others experienced stating, “I'm a pretty active person, so standing and being cognizant of the five cues is a bit hard for me." Most of the participants reported feeling “relaxation,” “calmness,” and

“peacefulness,” and others mentioned it was “very helpful for focus” and “increased concentration.” About half of the participants reported physical improvements with statements like “I feel more balanced when walking,” “I felt it strengthened my legs, ankles, and lower back,” and “I feel more aware of my posture.” Three participants reported unique experiences while practicing. One said, “after 25 minutes I began to get

43 hot and kind of sweaty.” Another reported experiencing “visual changes—like color hallucinations—when meditating with eyes open.” The third mentioned they “had a perception of dissolving boundaries in deep meditation.” Lastly, one participant mentioned that, "the assignment forced [them] to carve out the time to do it, but [they fear that [they] may not have the discipline to do it on [their] own," highlighting similar sentiments verbally expressed by several of the participants.

Table 5. Testimonials Collected from Post-Intervention Survey and Homework

Participant Testimonials "I'm a pretty active person, so standing and being cognizant of the five cues is a bit hard for me." "I began to get hot and kind of sweaty. Then I got kind of light-headed and was losing my balance. I stopped, got my 1 wits about me, and within seconds I felt fine/normal" "I feel more aware of attempting to do one thing at a time, rather than several things at once." 2 "Increased concentration; relaxed." 3 "I feel healthier; more regular." "I experienced some visual changes when meditating with my eyes 4 open." "I feel more balanced when walking." "Very helpful for me to focus and relax my mind." "Enjoyed group 5* setting over alone." 6 "Felt it strengthened my legs, ankles, and lower back." "Had perception of dissolving boundaries in deep meditation." I feel 7 centered after a good meditation, more than I do during normal everyday awareness." "I enjoyed participating." I felt a sense of relaxation and calmness [with 8 the standing meditation]." "I felt a sense of calm/relaxation afterwards, and also a sense of 9 accomplishment." "The assignment forced me to carve out the time to do it, but I fear that I may not have the discipline to do it on my own." "I feel more aware of my posture." "I can walk further and steadier than 10* before." "body felt good in [standing meditation] posture." "I now walk better, more stable, better posture." 11* "I felt relaxation and peacefulness." "[It gave me] more awareness of body position." “Better at holding head 12 up." In relation to the tandem walk: “I noticed I had better balance with my head up looking forward like we did in the standing meditation.” 13 "Felt good after I did it." " Note. *Participant not included in quantitative analysis due to not fully meeting inclusion/ exclusion criteria.

CHAPTER 5

DISCUSSION

This study tested the hypotheses: (1) The posttest measures for balance—as tested by the Fullerton advanced balance (FAB) scale—will be significantly greater than the pretest measures for the Standing Meditation group; (2) The posttest measures for mindfulness—as tested by the mindful attention awareness scale (MAAS)—will be significantly greater than the pretest measures for the Standing Meditation group; (3) A significant positive correlation will be found between intervention dose and the post score for the FAB scale; and (4) A significant positive correlation would be found between intervention dose and the post-score for the MAAS. The results indicate that hypotheses were partially supported. A significant improvement was found in balance scores, and the standing meditation dose positively correlated with the post-assessment score on the FAB scale, supporting hypotheses 1 and 3. However, the hypotheses in relation to the mindfulness measure (hypotheses 2 and 4) were not met. Instead of an improvement, we detected a significant decrease in mindfulness between the pre- and post-assessments.

Additionally, no significant correlation was found between dose and post-assessment score on the MAAS.

To the primary investigator’s current knowledge, this is the first study to investigate the benefits of standing meditation alone. Hence, a broad approach of evaluating mindfulness, balance, and qualitative factors was developed to lay a

46 foundation for designing future standing meditation studies. This study has a number of limitations that make it difficult to make any clear determinations of the true effect of standing meditation on balance and mindfulness in older adults. However, the significant changes in the measures of this study, and the positive reception from participants as assessed qualitatively, provide a unique overview of standing meditation and its potential implications in future research.

Mindfulness Assessment Implications

Mindfulness was tested using the Mindful Attention Awareness Scale (MAAS).

While the intent of the study was to evaluate a change in mindfulness between the pre- and post-assessments, as tested in the Tai Chi study by Ma et al. (2016), the implementation was not strategically applied. The pre- and post-assessments were both conducted independent of the standing meditation intervention. Hence, the pre- and post- scores had little difference. As the MAAS was designed to test a participant’s present mindfulness (Brown & Ryan, 2003), a more effective strategy would be to conduct the

MAAS immediately after standing meditation sessions.

Interestingly, despite this implementation error, a significant difference was found between the pre- and post-assessments. Opposite of what was hypothesized however, the post-scores (M = 66.1) were significantly less than the pre-scores (M = 70.6). This finding suggests a few possibilities: (1), small sample size data is easily distorted and likely does not accurately represent the real change; (2), participants may not have read the directions thoroughly in the beginning, but were more thorough the second time due to the learning effect; (3), the intervention environment or testing procedure may have some deleterious effect on present mindfulness; or (4), given the fact that two participants

47 reported perfect scores in the pretest, while no perfect posttest scores were reported, participants may have ironically provided more mindful answers in the posttest. A mindful answer would be more carefully considered, and not reside in the extremes of the ordinal scale; thus, perfect scores in the pre-assessment may indicate a lack of mindfulness.

Furthermore, in retrospect, a mindfulness scale may not be the most fitting measure for standing meditation. Mindfulness is a diverse concept of awareness, attention, and observation. However, it does not distinguish between internal (body) and external (environmental) awareness (Mehling et al., 2009). Standing meditation—and Tai

Chi for that matter—is focused primarily on internal awareness and development. Thus, a

“body awareness” scale would be more appropriate. Body awareness is frequently conflated with mindfulness in research, but Mehling and colleagues (2009) provided a clear definition and assessment of current models designed to detect it. They defined it as

“the perception of bodily states, processes, and actions that is presumed to originate from sensory proprioceptive and interoceptive afferents, and that an individual has the capacity to be aware of.” (Mehling et al., 2009, p. 4) While Mehling et al. (2009) were clear to state there still is not an instrument that fully encompasses the depths of body awareness, they found the two instruments with the strongest psychometric properties for measuring body awareness are the body awareness questionnaire (BAQ) and private body consciousness sub-scale (PBCS). Future studies on standing meditation would benefit from testing body awareness effects with one or both of these scales. Body awareness may provide a potential mechanism for the improvement of balance found in this study and other studies on Tai Chi Chuan. The close association of Body awareness with

48 proprioception—a major component in developing postural stability—makes it closely linked to one’s balance (Mehling, Hamel, Acree, Byl, & Hecht 2005).

Balance Assessment Implications

Balance was assessed using the Fullerton Advanced Balance Scale, as it is an effective measure for assessing multiple dimensions of balance in high-functioning older adults (Rose et al., 2006). This study found the post-assessment scores (M = 37.8) were significantly higher than the pre-assessment scores (M = 30.9), confirming the original hypothesis. In comparing the pre- and post-assessment mean scores of the individual test items (see Table 6), the items expected to improve most (items 1, 2, 6, 7)—as they tested steady state balance—did not show the largest change. Instead, item 3 (360 turn) and item

9 (walk with head turns) had the greatest mean differences of 1.0 and 1.1 respectively.

Items 6 (stand on one leg) and 7 (stand on foam with eyes closed)—two of the items expected to improve—also had large mean differences of .81 and .73 respectively, but they were still less than or equal to the change in most of the more dynamic items (items

3, 8, 9, 10).

Table 6. Mean Comparisons of FAB Scale Items

Pre-Score Post-Score M FAB Item M SD M SD Diff. 1 Stand with feet together and eyes closed* 3.82 .40 4.00 .00 .18 2 Reach forward to retrieve object* 3.82 .40 4.00 .00 .18 3 Turn 360 degrees in right and left directions 2.73 .65 3.73 .47 1.0 4 Step up and over 6-inch bench 3.73 .47 3.91 .30 .18 5 Tandem walk 3.09 .70 3.64 .67 .55 6 Stand on one leg* 2.73 1.35 3.54 .82 .81 7 Stand on foam with eyes closed* 3.18 .98 3.91 .30 .73 8 Two-footed jump 2.73 1.10 3.54 .69 .81 9 Walk with head turns 2.54 .82 3.64 .50 1.1 10 Reactive postural control 2.91 1.04 3.73 .47 .82 Note. *Expected to have greatest difference.

While this study was not designed to investigate changes in the different dimensions of balance reflected by individual test items on the FAB scale, the large differences observed in mean scores for some of the dynamic balance test items is an interesting finding. The limited change in items 1 (stand with feet together and eyes closed) and 2 (reach to retrieve object) are not too surprising, as they were comparatively easier to complete, and most participants in the pre-and post- assessments received perfect scores. The very large change detected in items 3 and 9 could be explained by the following: (1), small sample size data is easily distorted and likely does not accurately represent the real change; (2) a large learning effect may have influenced the scores, especially with a short duration of five weeks between assessments; (3), standing meditation has some mechanism by which these items improved; or (4) tester bias may have indirectly affected scores. It is beyond the scope of what was specifically tested in

50 this study, but an interesting observation is items 3 and 9 both have a vestibular sensory systems component. In fact, all items testing the vestibular system (3, 7, 9) on the FAB scale (Rose et al., 2006) had large differences between the pre- and post-assessments, so it leads to wonder if standing meditation may especially benefit this sensory system.

However, the FAB scale in designed to determine the individual effects of test items, so any individual interpretation is only for qualitative purposes, and does not represent a valid quantitative finding. The balance results show that standing meditation may have a beneficial effect on sensory reception and integration.

Correlation Implications

Correlation analysis was conducted to see if any relationship existed between the total amount of time (dose) participants practiced the standing meditation intervention— both in and outside of class—and the post-assessment scores from the FAB and MAAS.

While results indicated that the total dose had no significant relationship with the final

MAAS score, a strong relationship was found between the final FAB score and total dose

(R = .694, p = .026). This finding suggests that those that devoted the most time to the standing meditation homework had higher FAB scores. These findings also suggest that while there may be a relationship between balance and the standing meditation intervention, mindfulness does not seem to be related (at least over the duration of this study).

Traditional masters of Tai Chi often promote standing meditation as a daily practice, and advocate practicing it for as long as two hours at a time (Yang & Grubisich,

2005; Yu, 2006). The belief is that standing meditation is the source of improvement both for health and martial prowess (Yang & Grubisich, 2005). Therefore, many traditional

51 masters will emphasize standing meditation practice over the movement forms. This notion may seem strange from a western perspective, but this study highlights there may be something to it. Participants that practiced close to the recommended 450-minute total dose or more had the best FAB scores. Therefore, there may be some balance mechanism that standing meditation benefits. Of course, the small sample size limits the implications of this finding, but it establishes further evidence as to the possible balance benefit of standing meditation, and the potential for longer practice yielding stronger results.

Qualitative Measures

A qualitative component was added to this study to better understand the quantitative findings and provide insight on implementing a standing meditation intervention for future studies. All participants that completed the entire intervention

(N = 13) were included in the qualitative analysis. As mentioned earlier, three of those participants were removed from quantitative data analysis due to exclusion criteria, but since these three participants still participated with the rest of the group, their feedback was included in the content analysis.

Themes

The themes that emerged from the open-ended questions on the homework log, in class discussions, and post-intervention survey provide insight into methods used, and the perceived positives and negatives in relation to standing meditation.

Methods. The methods category was the largest (N = 9) demonstrating participants were proactive in finding the best means of completing the standing meditation intervention on their own. The reported methods could be interpreted from a constraints-led approach of motor learning (Davids, Button, & Bennett, 2008).

Participants modified environmental, task, and individual constraints in order to best succeed in performing the standing meditation task. Participants primarily modified their environment in order to achieve the task. This involved listening to music, using a timer, watching some form of media, choosing a specific time of day, selecting a specific location, or wearing comfortable clothing/ shoes. The task of performing the standing meditation was modified depending on which meditation concept was incorporated or using a specific breathing strategy. Finally, some participants altered individual constraints by warming up or stretching prior to the intervention task. In implementing a standing meditation intervention for future research, all of these methods offer insight on what may allow for success in practicing standing meditation. Ideally, with practice, standing meditation becomes more internal and less focused on the external environment.

However, for beginners, a comfortable environment with adherence to the posture is most important for success.

Positives and negatives. The positives category was the second largest (N = 6), while the negatives only had three major themes. Both, however, reported at a higher rate than themes in the methods category. This is likely due to participants focusing on practice methods early in the study, while experiencing various positives and negatives throughout the entire study. Additionally, not all participants agreed on what methods they preferred in order to be successful, while most reported experiencing similar positives and negatives. For example, almost all participants reported feeling a sense of

“relaxation,” as well as “boredom,” in the course of the intervention.

Closed Ended Questions

Symptoms. Questions on specific physical and psychological symptoms were chosen to compare with the traditional Tai Chi understanding of symptoms experienced by beginners of standing meditation. Yu (2006, p. 23) created a chart that highlighted the typical symptoms—specifically pain, tingling, warming, and well-being—experienced in the first six weeks of standing meditation. The symptoms of peacefulness, boredom, focus, and dizziness were added based on the primary investigator’s previous experience.

While the present study was not quite six weeks, participants did experience at least some of the symptoms, with almost all reporting a sense of peacefulness (84.6%), and most reporting experiencing some pain (61.5%). These results do not tell when symptoms may have occurred, but they highlight those that left lasting impression at the end of the study.

Future research may want to more thoroughly test these symptoms, determining the time of occurrence, and whether they increase or decrease over time.

Study improvement. Most participants scored positively on all four study- improvement questions. While most agreed the study progression was appropriate, two did find it difficult. This was especially noticeable during the 20 and 25-minute standing meditation periods. Most participants agreed that up to 15 minutes was very manageable, and even enjoyable, but fatigue and boredom became more pronounced in the later standing times.

Due to the challenge of the intervention, one found it unenjoyable, only three participants found it “very enjoyable,” and remaining participants less enthusiastically reported it as just “enjoyable.” All participants found the handouts “very helpful” or

“helpful,” suggesting the learning model for this intervention was well received. Even

54 more promising, all participants said they were either “very likely” or “likely” to continue practicing standing meditation on their own. These findings suggest participants had a positive reception to the intervention, highlighting potential ease in implementation for future studies.

Testimonials

The collected testimonials were almost entirely positive, encompassing psychological and physical improvements, as well as distinct experiences brought about by standing meditation. They provide insight on the group of older adults learning this new unique exercise that was contrary to the active lifestyle most led. Most of the testimonials were collected with the post-intervention survey, and, thus, participants tended to highlight the positives they experienced. In fact, none of the participants reported any specific negatives on the survey, indicating that despite a challenging start, most found benefit to doing the standing meditation.

Limitations

This study has several limitations that make it difficult to make any clear determinations of the intervention’s effect. The limitations are: small sample size, no control group, intervention length, primary investigator conducted assessments, mindfulness measure implementation, and participant disparity.

Small Sample Size

The sample size unfortunately did not meet original goals, and resulted in the investigator eliminating the control group. Though significant effects were found, the small sample makes it impossible to determine if these effects observed may be

55 generalized to the general population. The small sample size unfortunately greatly reduces the power of the results and increases the chance for type II error.

No Control Group

Due to small sample size, a control group could not be created for the present study. Without a control, it is impossible to say whether the changes were caused by the intervention, or due to some other activity in the generally active lifestyle of most participants. Future studies will need to use a randomized controlled trial to effectively evaluate the true effects of standing meditation.

Intervention Length

The present study took place over the course of five weeks which may not have been enough time for effects to be observed. Additionally, this may have increased the potential learning effect to affect the post-scores for the assessments, as the testing protocol may still be familiar after only five weeks. While this study increased the dose in attempt to instigate effects over the short duration, this created a more challenging experience for participants. Most Tai Chi and Qigong studies find significant effects with minimum duration of 12 weeks (Jahnke et al., 2010; Liu & Frank, 2010), so it would be beneficial for future studies to aim for a duration of at least three months.

Primary Investigator Conducted Assessments

The primary investigator led all sessions, and conducted all assessments. Though the investigator was well versed in testing protocols, unconscious bias may have influenced scores on the FAB scale. To limit bias effects, scores were not totaled or compared until both the pre- and post-assessments had been completed for all

56 participants. Future studies should incorporate an experienced tester who is blind to group assignment to eliminate this potential bias.

Mindfulness Measure Implementation

As mentioned in the “Mindfulness” portion of this discussion, the present study’s implementation of the MAAS was not the most appropriate as it was not directly linked to the standing meditation intervention itself. Future studies would benefit from conducting the MAAS immediately after each standing meditation practice. Furthermore, a body awareness-specific measure, like the body awareness questionnaire (BAQ), would be valuable in assessing standing meditation’s effects. Tai Chi is often considered to have a strong body awareness component, so this measure should be tested with standing meditation (Gyllensten, Hui-Chan, & Tsang, 2010; Mehling et al. 2009; Mehling et al.,

2011).

Participant Disparity

The study’s sample was mostly composed of Caucasian, female, independent, high-functioning older adults. However, aspects like age, chronic conditions, activity level, and tai chi experience likely caused some disparity in the homogeneity of participants. There was a large range in age with the youngest being 60 and the oldest being 81 years of age. Two participants reported the chronic condition of severe osteoarthritis late in the study, requiring their data to be excluded from final analysis.

While on average participants were active (with a mean of 4 exercise days per week), one participant was very active (exercising all 7 days a week), and one was not active at all

(no exercise days per week). Four of the participants also reported having some Tai Chi experience which may have affected assessment scores. Future studies would benefit

57 from controlling for these factors, in addition to recruiting a more diverse sample to better represent the general population.

Implications for Future Research and Conclusion

This study represents a preliminary investigation into the effects of standing meditation on balance and mindfulness in older adults. A broad approach was used to evaluate potential directions for future research studies. In evaluating the significant improvements found between the pre- and post-assessments of the FAB scale, strong positive correlation of FAB scores and dose, and the positive reception given by the participants based on qualitative themes, closed-ended questions, and testimonials, this study suggests standing meditation may be a simple yet effective intervention for balance improvement. However, randomized controlled trials with larger sample sizes and emphasis on specific dimensions of balance, mindfulness, and/ or body awareness are the next step to validating the effects of standing meditation on a variety of physical and psychological outcomes.

Standing meditation is a simple intervention that combines physical postural awareness with traditional meditation concepts. As it requires little memorization of complex choreography or physical effort in the way that the Tai Chi forms require, it may be an ideal intervention substitute for older adults and other special populations. It also may be recommended as a more physical alternative to the popular sitting meditation.

Future research investigating Tai Chi would benefit from incorporating standing meditation into their intervention programs, as it plays a foundational role in Tai Chi practice and the development of its internal focus.

This study’s purpose was to investigate the effects of standing meditation on balance and mindfulness, while also filling the gap of research on this fundamental exercise of Tai Chi. While the results of this study are promising, research on standing meditation is very much in its infancy. This study begins to develop a foundation from which new research can better determine the effects of standing meditation. Standing meditation may be an effective means to better understand Tai Chi Chuan, and help bridge the gap between Eastern and Western thought.

APPENDIX A

CONSENT TO ACT AS A HUMAN RESEARCH SUBJECT

California State University, Fullerton (CSUF) CONSENT TO ACT AS A HUMAN RESEARCH SUBJECT

The Effect of Standing Meditation on Balance, Functional Fitness, and Mindfulness

You are being asked to participate because you are a healthy adult between 65 and 74 years of age. Participation in this research study is completely voluntary. Please read this information below and ask questions about anything that you do not understand before deciding if you want to participate. A researcher listed below will be available to answer your questions.

INVESTIGATORS AND SPONSOR Lead Researcher • Brent Brayshaw B.S. - Department of KHS

Additional Researchers • David Chen PhD. - Department of KHS • Debra Rose PhD. - Department of KHS • Joao Barros PhD. - Department of KHS

Study Sponsor(s): • This study is a student thesis without outside funding.

PURPOSE OF STUDY The purpose of this research study two-part: One, to investigate the long-term effects of standing meditation on balance, functional fitness, and mindfulness in healthy older adults, and two, to evaluate standing meditation’s efficacy as a simple exercise substitute to the Tai Chi forms.

WHY THIS IS A RESEARCH STUDY This is a research study because the effects of balance, function, and mindfulness will be tested on participants who do standing meditation, as compared with a control that does not.

The study will follow the scientific method, including collecting and analyzing data for the sake of adding further information to scientific literature. You will be asked to stand

60 for a prolonged period of time up to 24 consecutive minutes. Additional education will be provided to those in the standing meditation group in order to achieve proper posture and mindset. The intervention will be performed eight times over the course of eight weeks, and measures will be assessed at the beginning and end of the study.

SUBJECTS Inclusion Requirements: You are being asked to participate because you:  Are a healthy adult between the ages of 65 and 74,  Are in good health based on self-report  Have doctor clearance for exercise  Are able to stand for a minimum of 30 minutes without rest

Exclusion Requirements: You are being asked to participate in this study because you:  Do not have an illness, injury, condition or physical defect that would inhibit ability to stand for prolonged period of time.  Have not had any serious falls, serious injury, or msjor surgery in the past year (365 days).  Have had no prior experience with Tai Chi or standing meditation,  Are not be currently enrolled in any balance programs  Are not currently practicing any form of meditation  Will not start any new exercise or movement programs during the intervention.

Number of participants: The investigator plans to enroll 50 participants from four sites including this one.

PROCEDURES  Random assignment to intervention group (standing meditation) and waitlist control group. The intervention group will progressively increase time of activity each week. The first week will start at three (3) minutes, and each week after will increase by three (3) minutes up to a maximum of twenty-four (24) minutes at week eight. o Standing Meditation Sessions Each session is roughly thirty (30) minutes, consisting of practice review, a short lecture lesson, and standing meditation practice for a designated period of time. Additionally participants will be required to log additional standing hours outside of class, and report their progress at the following class’ practice review.

 Measurement o Feedback Measures (Before and after every session): . Rating of perceived exertion will be taken on a scale of 1-10 . Similarly, a measure of pain will be taken on a scale of 0-10.

o Pre- and Post- Intervention Measures (at the first (1) and last (9) session) . The Fullerton Advance Balance (FAB) Scale will be administered by trained graduate students. . Mindfulness Attention Awareness Survey (MAAS) will be filled out by each participant.

o Qualitative Practice Measures (Five times/ week, outside of class): . Participants are to record standing meditation minutes in a log with weekly homework goals to aim at. . Participants will note any feelings, pains, and efforts toward the practice.

Total Time Involved:  You will be involved in this study for nine (9) nonconsecutive weeks for approximately thirty minutes per session, totaling 270 minutes or 4 hours 30 minutes.  Additionally you will be expected to do the assigned standing homework five times a week, week one totaling 15 minutes, progressing to week eight totalling 120 minutes. The total homework time is 540 minutes, or 9 hours.

RISKS

Risk of Standing Meditation Exercise  May experience imbalance, muscle fatigue, dizziness, light-headedness, discomfort, and back pain. In rare instances, exercise tests may cause chest pain, tightness, or a change in vital signs.  May have psychological/ emotional discomfort from philosophy, lack of movement, or boredom.

Risk of Physical Assessments  FAB Scale – may experience imbalance, increased risk of falling, muscle fatigue, dizziness, light-headedness, shortness of breath and/or physical/ emotional discomfort. In rare instances, exercise tests may cause chest pain, tightness, or a change in vital signs.

BENEFITS To Others or Society Others may benefit from the information gathered from this study by evaluating the effects of standing meditation on older adults. It is hypothesized that it will yield positive effects in the areas of balance and mindfulness. This is the first study of its kind evaluating standing meditation solely, and so data from this research will ultimately add to the body of scientific knowledge.

ALTERNATIVES TO PARTICIPATION The alternative is to not participate in this study.

COMPENSATION/COST/REIMBURSEMENT You will not be required to pay for research related procedures/treatments.

COMPENSATION FOR INJURY I understand that if I am injured as a result of my participation in this study, I will be provided reasonable and necessary medical care to treat the illness or injury at no cost to me or to my insurer/third party payer. CSU Fullerton does not provide any other form of compensation for injury. I understand that I must report any suspected study-related illness or injury to the study investigator immediately.

WITHDRAWAL OR TERMINATION FROM STUDY You are free to withdraw from the study at any time. If you decide to withdraw from the study, you should inform the researchers immediately. You may also be removed from the study without your consent because of the following: A) based on the researcher's judgment to improve your health and welfare, B) because you have not followed the study procedures, or C) because the study sponsor decides to stop the study. If you withdraw or are terminated from the study, you may be asked to... (e.g., return all unused medications, return to the clinic for a final evaluation). Final procedures are necessary to make sure there have been no changes in your health.

CONFIDENTIALITY Data Storage Computer-based data will be stored in an encrypted format on a password protected computer, and paper based data sheets will be stored in a locked cabinet in a secured building (KHS 249). Data will not be destroyed, and it will be retained for use in educational seminars or conferences.

Data Access The research team and authorized CSUF personnel may have access to your personal records to protect your safety and welfare. Data will be kept confidential to the extent allowed by law.

Level of Privacy • To protect your privacy and the confidentiality of the data, all personal identifiers will be removed from the data records such that each individual participant's identity will be coded so that actual identity is not compromised.

Data Privacy • The research data will be maintained indefinitely for use in educational seminars and conferences. • The research data will be maintained indefinitely.

NEW FINDINGS If during the course of this study, significant new information becomes available that may relate to your willingness to continue to participate, this information will be provided to you by the investigator.

IF I HAVE QUESTIONS For questions about your rights as a research participant, you may contact California State University, Fullerton Regulatory Compliance Coordinator at (714) 278-2327, or the Institutional Review Board (IRB) Chair at (714) 278-2141

Contacts:  Brent Brayshaw, Department of KHS Daytime Phone: 909-217-2805 Email: [email protected]  David Chen PhD., Department of KHS Daytime Phone: 657-278-2514 Email: [email protected]

OTHER CONSIDERATIONS Conflict of Interest Investigators must satisfy campus requirements for identifying and managing potential conflicts of interest before a research study can be approved. The purpose of these requirements is to ensure that the design, conduct and reporting of the research will not be affected by any conflicting interests. If at any time you have specific questions about the financial arrangements or other potential conflicts for this study, please feel free to contact any of the individuals listed above.

VOLUNTARY PARTICIPATION I have read the attached "Experimental Subject's Bill of Rights" and have been given a copy of it and this consent form to keep. I understand that participation in this study is voluntary. I may refuse to answer any question or discontinue my involvement at any time without penalty or loss of benefits to which I might otherwise be entitled. My decision will not affect my future relationship with or the quality of care I receive at CSU Fullerton. My signature below indicates that I have read the information in this consent form and have had a chance to ask any questions I have about the study. I consent to participate.

______Signature of Participant Date

______Signature of Witness Date

______Signature of Investigator Date

APPENDIX B

PAR-Q+

P. 1/4 PAR-Q+ The Physical Activity Readiness Questionnaire for Everyone (2012 Version, Canadian Society for Exercise Physiology)

Regular physical activity is fun and healthy, and more people should become more physically active every day of the week. Being more physically active is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active. SECTION 1 - GENERAL HEALTH

Please read the 7 questions below carefully and answer each one honestly: check YES YES NO or NO. 1. Has your doctor ever said that you have a heart condition OR high blood   pressure? Do you feel pain in your chest at rest, during your daily activities of living, 2.   OR when you do physical activity? Do you lose balance because of dizziness OR have you lost consciousness 3.   in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). Have you ever been diagnosed with 4.   another chronic medical condition (other than heart disease or high blood pressure)? 5. Are you currently taking prescribed medications for a chronic medical condition?   Do you have a bone or joint problem that could be made worse by 6. becoming more physically active? Please answer NO if you had a joint   problem in the past, but it does not limit your current ability to be physically active. For example, knee, ankle, shoulder or other. 7. Has your doctor ever said that you should only do medically supervised physical   activity?

If you answered NO to all of the questions above, you are cleared for physical  activity. Go to Section 3 to sign the form. You do not need to complete Section 2. › Start becoming much more physically active – start slowly and build up gradually. › Follow the Canadian Physical Activity Guidelines for your age (www.csep.ca/guidelines).

› You may take part in a health and fitness appraisal. › If you have any further questions, contact a qualified exercise professional such as a CSEP Certified Exercise Physiologist® (CSEP-CEP) or CSEP Certified Personal Trainer® (CSEP-CPT). › If you are over the age of 45 yrs. and NOT accustomed to regular vigorous physical activity, please consult a qualified exercise professional (CSEP-CEP) before engaging in maximal effort exercise.

If you answered YES to one or more of the questions above, please GO TO  SECTION 2.

Delay becoming more active if: › You are not feeling well because of a temporary illness such as a cold or fever – wait until you feel better › You are pregnant – talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the PARmed-X for Pregnancy before becoming more physically active OR › Your health changes – please answer the questions on Section 2 of this document and/or talk to your doctor or qualified exercise professional (CSEP-CEP or CSEP-CPT) before continuing with any physical activity programme. P. 2/4 SECTION 2 - CHRONIC MEDICAL CONDITIONS

Please read the questions below carefully and answer each one YES NO honestly: check YES or NO.   1 Do you have Arthritis, Osteoporosis, or Back Problems? If yes, If no, go . answer to questions question 1a-1c 2 Do you have difficulty controlling your condition 1a. with medications or other physician-prescribed   therapies? (Answer NO if you are not currently taking medications or other treatments) Do you have joint problems causing pain, a recent 1b. fracture or fracture caused by osteoporosis or   cancer, displaced vertebra (e.g., spondylolisthesis), and/ or spondylolysis/pars defect (a crack in the bony ring on

the back of the spinal column)?

Have you had steroid injections or taken steroid tablets 1c.   regularly for more than 3 months?   2 Do you have Cancer of any kind? If yes, If no, go . answer to questions question 2a-2b 3 Does your cancer diagnosis include any of the 2a.   following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and neck? 2b. Are you currently receiving cancer therapy (such as   chemotherapy or radiotherapy)?   Do you have Heart Disease or Cardiovascular Disease? 3 If yes, If no, go . This includes Coronary Artery Disease, High Blood Pressure, Heart Failure, Diagnosed Abnormality of answer to Heart Rhythm questions question 3a-3e 4 Do you have difficulty controlling your 3a. condition with medications or other physician-   prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) Do you have an irregular heart beat that 3b.   requires medical management? (e.g. atrial fibrillation, premature ventricular contraction) 3c. Do you have chronic heart failure?   Do you have a resting blood pressure equal to or greater 3d.   than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure) Do you have diagnosed coronary artery 3e.   (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?   4 Do you have any Metabolic Conditions? If yes, If no, go . This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes answer to questions question 4a-4c 5 4a. Is your blood sugar often above 13.0 mmol/L? (Answer YES if   you are not sure) Do you have any signs or symptoms of diabetes 4b. complications such as heart or vascular disease   and/or complications affecting your eyes, kidneys, and the sensation in your toes and feet? Do you have other metabolic conditions (such as 4c.   thyroid disorders, pregnancy- related diabetes,

chronic kidney disease, liver problems)?

  5 Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depression, If yes, If no, go . Anxiety Disorder, Eating Disorder, Psychotic Disorder, answer to Intellectual Disability, Down Syndrome) questions question 5a-5b 6 Do you have difficulty controlling your 5a. condition with medications or other physician-   prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) 5b. Do you also have back problems affecting nerves or muscles?  

P. 3/4 Please read the questions below carefully and answer each one YES NO honestly: check YES or NO.   6 Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, If yes, If no, go . Asthma, Pulmonary High Blood Pressure answer to questions question 6a-6d 7 Do you have difficulty controlling your condition 6a. with medications or other physician-prescribed   therapies? (Answer NO if you are not currently taking medications or other treatments) Has your doctor ever said your blood oxygen level is 6b.   low at rest or during exercise and/or that you require supplemental oxygen therapy? If asthmatic, do you currently have symptoms of chest 6c. tightness, wheezing, laboured breathing, consistent   cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week? Has your doctor ever said you have high blood pressure 6d.   in the blood vessels of your lungs?   7 Do you have a Spinal Cord Injury? This includes Tetraplegia and If yes, If no, go . Paraplegia answer to questions question 7a-7c 8 Do you have difficulty controlling your condition 7a. with medications or other physician-prescribed   therapies? (Answer NO if you are not currently taking medications or other treatments) Do you commonly exhibit low resting blood pressure 7b.   significant enough to cause dizziness, light- headedness, and/or fainting? Has your physician indicated that you exhibit sudden 7c.   bouts of high blood pressure (known as Autonomic

Dysreflexia)?

  8 Have you had a Stroke? If yes, If no, go . This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event answer to questions question 8a-c 9 Do you have difficulty controlling your condition 8a. with medications or other physician-prescribed   therapies? (Answer NO if you are not currently taking medications or other treatments) 8b. Do you have any impairment in walking or mobility?   Have you experienced a stroke or impairment in nerves or 8c.   muscles in the past 6 months?   9 Do you have any other medical condition not listed above or do you If yes, If no, . live with two chronic conditions? answer read the questions advice 9a-c on page 4 Have you experienced a blackout, fainted, or lost 9a. consciousness as a result of a head injury within the last 12   months OR have you had a diagnosed concussion within the last 12 months? Do you have a medical condition that is not listed 9b.   (such as epilepsy, neurological conditions, kidney problems)? 9c. Do you currently live with two chronic conditions?  

Please proceed to Page 4 for recommendations for your current medical condition and sign this document. P. 4/4 PAR-Q+

If you answered NO to all of the follow-up questions about your medical condition, you are  ready to become more physically active: › It is advised that you consult a qualified exercise professional (e.g., a CSEP-CEP or CSEP-CPT) to help you develop a safe and effective physical activity plan to meet your health needs. › You are encouraged to start slowly and build up gradually – 20-60 min. of low- to moderate- intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises. › As you progress, you should aim to accumulate 150 minutes or more of moderate-intensity physical activity per week. › If you are over the age of 45 yrs. and NOT accustomed to regular vigorous physical activity, please consult a qualified exercise professional (CSEP-CEP) before engaging in maximal effort exercise.

If you answered YES to one or more of the follow-up questions about your medical condition:  › You should seek further information from a licensed health care professional before becoming more physically active or engaging in a fitness appraisal and/or visit a or qualified exercise professional (CSEP-CEP) for further information.

Delay becoming more active if: › You are not feeling well because of a temporary illness such as a cold or fever – wait until you feel better › You are pregnant - talk to your health care practitioner, your physician, a qualified exercise profesional, and/or complete the PARmed-X for Pregnancy before becoming more physically active OR › Your health changes - please talk to your doctor or qualified exercise professional (CSEP-CEP) before continuing with any physical activity programme. SECTION 3 – DECLARATION › You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted. › The Canadian Society for Exercise Physiology, the PAR-Q+ Collaboration, and their agents assume no liability for persons who undertake physical activity. If in doubt after completing the questionnaire, consult your doctor prior to physical activity. › If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form. › Please read and sign the declaration below: I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that a Trustee (such as my employer, community/fitness centre, health care provider, or other designate) may retain a copy of this form for their records. In these instances, the Trustee will be required to adhere to local, national, and international guidelines regarding the storage of personal health information ensuring that they maintain the privacy of the information and do not misuse or wrongfully disclose such information.

NAME DATE ______

SIGNATURE WITNESS ______SIGNATURE OF PARENT/ GUARDIAN/ CARE PROVIDER______

APPENDIX C

HEALTH ACTIVITY QUESTIONNAIRE

Health Activity Questionnaire (2014 Version, CSUF Center for Successful Aging)

Name: ______

Address: ______

City: ______State: ______Zip: ______

Phone #: ______Gender: ______

Date of Birth: ______Height: ______Weight: ______

Name of Physician: ______Phone: ______

Emergency Contact: ______Phone: ______

1. Have you ever been diagnosed as If Yes having any of the following conditions? Year of Diagnosis

Heart attack ___Yes ___No ______

Transient ischemic attack ___Yes ___No ______

Angina (chest pain) ___Yes ___No ______

High blood pressure ___Yes ___No ______

Stroke ___Yes ___No ______

Peripheral vascular disease ___Yes ___No ______

Diabetes ___Yes ___No ______

Neuropathies ___Yes ___No ______

(problems with sensation)

Respiratory disease ___Yes ___No ______

Parkinson’s disease ___Yes ___No ______

Multiple sclerosis ___Yes ___No ______

Polio/ post-polio syndrome ___Yes ___No ______

Epilepsy/ seizures ___Yes ___No ______

Other neurological conditions ___Yes ___No ______

Osteoporosis ___Yes ___No ______

Rheumatoid arthritis ___Yes ___No ______

Other arthritic conditions ___Yes ___No ______

Visual/depth perception problems ___Yes ___No ______

Inner ear problems/ ___Yes ___No ______Recurrent ear infections

Cerebellar problems (ataxia) ___Yes ___No ______

Other movement disorders ___Yes ___No ______

Chemical dependency ___Yes ___No ______(alcohol and or drugs)

Depression ___Yes ___No ______

2. Have you ever been diagnosed as having any of the following conditions?

Cancer ___Yes ___No

If YES, please describe what kind and relevant details: ______

______

Joint replacement ___Yes ___No If YES, How many times? ______

Where? ___Right Hip ___Left Hip ___Right Knee ___Left Knee

If YES, please describe relevant details: ______

______

Cognitive Disorder ___Yes ___No

If YES, please describe condition(s) and relevant details: ______

______

Uncorrected visual problems ___Yes ___No

If YES, please describe what type and relevant details: ______

______

Any other type of health problem? ___Yes ___No

If YES, please describe condition(s) and relevant details: ______

______

3. Do you currently suffer any of the following symptoms in your legs or feet?

Numbness ___Yes ___No

Tingling ___Yes ___No

Arthritis ___Yes ___No

Swelling ___Yes ___No

4. Do you currently have any medical conditions for which you see a ___Yes ___No physician regularly?

If YES, please describe the condition(s) and relevant details: ______

______5. Do you require eyeglasses? ___Yes ___No

If YES, what type of glasses do you wear? ___Bi-focals ___Graded Lenses ___Magnification Only ___Tri-Focals

6. Do you require hearing aids? ___Yes ___No

If YES, which ear? ___Left ___Right ___Both

7. Do you use an assistive device for walking? ___Yes ___No ___Sometimes

If YES or SOMETIMES, what type of assistive device do you use?

___Single-Point Cane ___3-Point Cane ___Quad Cane ___Front Wheel Walker ___Four Wheel Walker w/ Seat ___Other, Specify: ______

8. List all medication that you currently take (including “over-the-counter” or “alternative medicines”).

Type of Medication For what Condition

______

______9. Have you required emergency medical care or hospitalization in the last year? ___Yes ___No

If YES, please list when this occurred and briefly explain why. ______

______

10. Have you ever had any condition or suffered any injury that has affected your balance or ability to walk without assistance? ___Yes ___No

If YES, please list when this occurred and briefly explain condition or injury. ______

______

11. Have you fallen within the past year? ___Yes ___No

If YES, indicate the following:

a. Number of times: ______

b. Date(s): ______

c. Location (i.e. indoors, getting out of bed): ______

d. Cause (i.e. uneven surface): ______

e. Did you require medical treatment? ______

12. Are you worried about falling?

___1 ------___2 ------___3 ------___4 ------___5 ------___6 ------___7 Not Little Moderate Very Extremely

13. How would you describe your health?

___Excellent ___Very Good ___Good ___Fair ___Poor

14. In the past 4 weeks, to what extent did health problems limit your everyday physical activities (such as walking and household chores)?

___Not at all ___Slightly ___Moderately ___Quite a bit ___Extremely

15. How much “bodily pain” have you generally had during the past 4 weeks (while doing normal activities of daily living)?

___None ___Very little ___Moderate ___Quite a bit ___Severe

16. In general, how much depression have you experienced within the past 4 weeks?

___None ___Very little ___Moderate ___Quite a bit ___Severe

17. In general, how would you rate the quality of your life?

___1 ------___2 ------___3 ------___4 ------___5 ------___6 ------___7 Very low Low Moderate High Very high

18. Functional Survey. Please indicate your ability to do each of the following.

Can With Cannot do difficulty do a. Take care of own personal needs (i.e. dressing yourself) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______

b. Bathe yourself using tub or shower If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______

c. Climb up and down a flight of stairs (like in a 2-story home) If you answered “With difficulty” or “Cannot do”, why ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______

d. Walk outside one or two blocks If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain

___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______e. Do light household activities (i.e. cooking, dusting) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______f. Do own shopping (i.e. groceries) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______g. Walk a half mile (6-7 blocks) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______h. Walk 1 mile (12-14 blocks) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______i. Lift and carry 10 pounds (i.e. bag full of groceries) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______j. Lift and carry 25 pounds (i.e. medium suitcase) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0

___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______

k. Do most heavy household chores (i.e. scrubbing floors) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______

l. Do strenuous activities (i.e. hiking, digging, moving furniture) If you answered “With difficulty” or “Cannot do”, why? ___2 ___1 ___0 ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______

19. In general, do you currently require household or nursing assistance to carry out daily activities? ___Yes ___No If YES, please indicate reason(s): ___Health problem ___Chronic pain ___Lack of strength or endurance ___Lack of flexibility or balance ___Other: ______

20. In a typical week, how often do you leave your house (i.e. run errands, go to work, meetings, classes, church, social functions)?

___less than 1 time/week ___3-4 times/week ___1-2 times/week ___Most every day

21. Do you currently participate in regular physical exercise (such as walking, sports, exercise classes, house work, or yard work) that is strenuous enough to cause a noticeable increase in breathing, heart rate, and/or perspiration?

___Yes ___No If YES, how many days per week? ___One ___Two ___Three ___Four ___Five ___Six ___Seven

22. When you go for walks (if you do), which of the following best describes your walking pace?

___Brisk (fast pace, can walk a mile in 15-20 minutes) ___Normal (can walk a mile in 20-30 minutes) ___Strolling (easy pace, takes 30 minutes or more to walk a mile) ___Do not go for walk on a regular basis

23. Did you require assistance in completing this form?

___None (or very little) ___Needed quite a bit of help

Reason: ______

APPENDIX D

MINDFUL ATTENTION AWARENESS SCALE

Day-to-Day Experiences

Instructions: Below is a collection of statements about your everyday experience. Using the 1-6 scale below, please indicate how frequently or infrequently you currently have each experience. Please answer according to what really reflects your experience rather than what you think your experience should be. Please treat each item separately from every other item. 1 2 3 4 5 6 Almost Very Somewhat Somewhat Very Almost Always Frequently Frequently Infrequently Infrequently Never

I could be experiencing some emotion and not be conscious of it until sometime later. 1 2 3 4 5 6

I break or spill things because of carelessness, not paying attention, or thinking of something else. 1 2 3 4 5 6

I find it difficult to stay focused on what's happening in the present. 1 2 3 4 5 6

I tend to walk quickly to get where I'm going without paying attention to what I experience along the way. 1 2 3 4 5 6

I tend not to notice feelings of physical tension or discomfort until they really grab my attention. 1 2 3 4 5 6

I forget a person's name almost as soon as I've been told it for the first time. 1 2 3 4 5 6

It seems I am "running on automatic," without much awareness of what I'm doing. 1 2 3 4 5 6

I rush through activities without being really attentive to them. 1 2 3 4 5 6

I get so focused on the goal I want to achieve that I lose touch with what I'm doing right now to get there. 1 2 3 4 5 6

I do jobs or tasks automatically, without being aware of what I'm doing. 1 2 3 4 5 6 I find myself listening to someone with one ear, doing something else at the same time. 1 2 3 4 5 6

I drive places on 'automatic pilot' and then wonder why I went there. 1 2 3 4 5 6

I find myself preoccupied with the future or the past. 1 2 3 4 5 6

I find myself doing things without paying attention. 1 2 3 4 5 6

I snack without being aware that I'm eating. 1 2 3 4 5 6

APPENDIX E

FULLERTON ADVANCED BALANCE SCALE

Scoring Form for Fullerton Advanced Balance (FAB) Scale

Name: ______Date of Test: ______

1. Stand with feet together and eyes closed ( ) 0 Unable to obtain the correct standing position independently ( ) 1 Able to obtain the correct standing position independently but unable to maintain the position or keep the eyes closed for more than 10 seconds ( ) 2 Able to maintain the correct standing position with eyes closed for more than 10 seconds but less than 30 seconds ( ) 3 Able to maintain the correct standing position with eyes closed for 30 seconds but requires close supervision ( ) 4 Able to maintain the correct standing position safely with eyes closed for 30 seconds 2. Reach forward to retrieve an object (pencil) held at shoulder height with outstretched arm ( ) 0 Unable to reach the pencil without taking more than two steps ( ) 1 Able to reach the pencil but needs to take two steps ( ) 2 Able to reach the pencil but needs to take one step ( ) 3 Can reach the pencil without moving the feet but requires supervision ( ) 4 Can reach the pencil safely and independently without moving the feet 3. Turn 360 degrees in right and left directions ( ) 0 Needs manual assistance while turning ( ) 1 Needs close supervision or verbal cueing while turning ( ) 2 Able to turn 360 degrees but takes more than four steps in both directions ( ) 3 Able to turn 360 degrees but unable to complete in four steps or fewer in one direction ( ) 4 Able to turn 360 degrees safely taking four steps or fewer in both directions 4. Step up onto and over a 6-inch bench ( ) 0 Unable to step up onto the bench without loss of balance or manual assistance ( ) 1 Able to step up onto the bench with leading leg, but trailing leg contacts the bench or leg swings around the bench during the swing-through phase in both directions ( ) 2 Able to step up onto the bench with leading leg, but trailing leg contacts the bench or swings around the bench during the swing-through phase in one direction ( ) 3 Able to correctly complete the step up and over in both directions but requires close

supervision in one or both directions ( ) 4 Able to correctly complete the step up and over in both directions safely and independently 5. Tandem walk ( ) 0 Unable to complete 10 steps independently ( ) 1 Able to complete the 10 steps with more than five interruptions ( ) 2 Able to complete the 10 steps with three to five interruptions ( ) 3 Able to complete the 10 steps with one to two interruptions ( ) 4 Able to complete the 10 steps independently and with no interruptions 6. Stand on one leg ( ) 0 Unable to try or needs assistance to prevent falling ( ) 1 Able to lift leg independently but unable to maintain position for more than 5 seconds ( ) 2 Able to lift leg independently and maintain position for more than 5 but less than 12 seconds ( ) 3 Able to lift leg independently and maintain position for 12 or more seconds but less than 20 seconds ( ) 4 Able to lift leg independently and maintain position for the full 20 seconds 7. Stand on foam with eyes closed ( ) 0 Unable to step onto foam or maintain standing position independently with eyes open ( ) 1 Able to step onto foam independently and maintain standing position but unable or unwilling to close eyes ( ) 2 Able to step onto foam independently and maintain standing position with eyes closed for 10 seconds or less ( ) 3 Able to step onto foam independently and maintain standing position with eyes closed for more than 10 seconds but less than 20 seconds ( ) 4 Able to step onto foam independently and maintain standing position with eyes closed for 20 seconds Do not introduce test item #8 if test item #4 was not performed safely and/or it is contraindicated to perform this test item (review test administration instructions for contraindications). Score a zero and move to next test item. 8. Two-footed jump ( ) 0 Unwilling or unable to attempt or attempts to initiate two-footed jump, but one or both feet do not leave the floor ( ) 1 Able to initiate two-footed jump, but one foot either leaves the floor or lands before the other ( ) 2 Able to perform two-footed jump, but unable to jump farther than the length of their own feet ( ) 3 Able to perform two-footed jump and achieve a distance greater than the length of their own feet ( ) 4 Able to perform two-footed jump and achieve a distance greater than twice the length of their own feet

9. Walk with head turns o ( ) 0 Unable to walk 10 steps independently while maintaining 30 head turns at an established pace o ( ) 1 Able to walk 10 steps independently but unable to complete required number of 30 head turns at an established pace o ( ) 2 Able to walk 10 steps but veers from a straight line while performing 30 head turns at an established pace o ( ) 3 Able to walk 10 steps in a straight line while performing 30 head turns at an o established pace but head turns less than 30 in one or both directions o ( ) 4 Able to walk 10 steps in a straight line while performing required number of 30 head turns at established pace 10. Reactive postural control ( ) 0 Unable to maintain upright balance; no observable attempt to step; requires manual assistance to restore balance ( ) 1 Unable to maintain upright balance; takes two or more steps and requires manual assistance to restore balance ( ) 2 Unable to maintain upright balance; takes more than two steps but is able to restore balance independently ( ) 3 Unable to maintain upright balance; takes two steps but is able to restore balance independently ( ) 4 Unable to maintain upright balance but able to restore balance independently with only one step TOTAL: 40 POINTS Evaluating Risk for Falls: Long Form Fullerton Advanced Balance (FAB) scale Cut-Off Score: ≤ 25/40 Points Short-Form Fullerton Advanced Balance (FAB) scale Cut-Off Score: ≤ 9/16 Points

APPENDIX F

STANDING MEDITATION HOMEWORK LOG

Standing Meditation Homework Log Week: ______

Name: ______

Shade in the boxes to estimate the total minutes spent standing per day. 60 57 54 51 48 45 42 39 36 33 30 27 24 21 18 15 12 9 6 3 Min. Wed. Thur. Fri. Sat. Sun. Mon. Tues.

Notes (Pain, Effort, etc.):

______

APPENDIX G

POST-INTERVENTION SURVEY

Standing Meditation Study Survey Name: ______Date:______1. Mark any physical symptoms you may have experienced during the standing meditation: o Tingling sensation o Warm/ hot sensation o Elevated heart-rate o Dizziness/ lightheadedness o Excessive fatigue o Pain in body; specify where and severity (i.e. feet, 2/10 pain): ______o Other: ______2. Mark any psychological effects you may have experienced during the standing meditation: o Peacefulness o Happiness/ Well-being o Focus o Boredom o Distress o Other: ______3. Please list any beneficial effects that you feel occurred due to practicing standing meditation.

______4. Please list any negative effects that you feel occurred due to practicing standing meditation. ______

5. Do you feel that the progression of standing time (+5 minutes/ week) was appropriate? o Very Appropriate o Appropriate o Difficult o Very Difficult 6. Did you enjoy this study? o Very Enjoyable o Enjoyable o Unenjoyable o Very unenjoyable 7. Were the Handouts helpful? o Very Helpful o Helpful o Unhelpful o Very Unhelpful 8. How likely are you to practice standing meditation on your own after this study? o Very likely o Likely o Unlikely o Very Unlikely 9. Other comments/ suggestions? ______

APPENDIX H

HANDOUT 1

Handout 1: Standing Meditation Posture Cues and Guidelines

Steps to Get Into Basic Standing Meditation Posture (Axial Extension) 1. Set the base (like you are sitting on a stool) a. Feet shoulder-width apart with toes forward. b. Feet evenly balanced (right and left, front and back). c. Arches naturally suspended, not collapsed. d. Keep the knees straight, but soft (not hyper- extended). e. Open hips so that the knees are over the feet. 2. Suspend the Crown a. Crown of head rises like a string is pulling it up, causing the head to pull back and upward, while the chin drops slightly b. Spine follows like a string of pearls c. Spine feels upright, but relaxed 3. Sink the Tailbone a. Imagine sitting on a tall stool. b. The tailbone drops, allowing the lower back to straighten. 4. Relax and Place the Arms a. Hands are place over the lower abdomen, just below the navel. b. Shoulders drop, and move toward sides following elbows. 5. Breath Toward the Center and Relax a. Focus on the breath b. Breathing in naturally fills belly, and breathing out relaxes the belly c. Let breath naturally deepen (don’t force it) d. Think of all the muscles and soft tissues sinking with gravity, while spine rises. e. Imagine the body is in a slight bow shape.

APPENDIX I

HANDOUT 2

Handout 2: Meditation Concepts #1 Standing like a Pine Tree  After you have adjusted to the “five basic cues” visualize the following for at least a minute each: o Give yourself permission to be in this quiet moment, standing as a tree in a peaceful temperate forest. o Imagine your feet growing roots into the earth, creating stability, and drawing nutrients. o Imagine your legs form the sturdy trunk of a pine tree. o Feel the spine gently rising toward the heavens, as a tree grows taller for greater sunlight. o Allow the arms and upper body to relax, as the branches of a pine tree sway downwards. o Breathe gently and evenly toward the legs, as a tree breathes without explicit movement. o Reflect on the whole image of a pine tree: Stable and grounded at the base, relaxed and flexible at its branches and upper trunk. o Maintain the quiet stillness of a powerful, yet relaxed pine tree!

APPENDIX J

HANDOUT 3

Handout 3: Meditation Concepts #2 Yin and Yang Traditional Focus  Yin and Yang are the dynamic complementary opposite forces understood to exist in all things according to Chinese literature. Yang, represented as the white portion of the symbol, is associated with rising, warmness, hardness, fullness, activeness, and masculine qualities. Yin, represented as the black portion, is associated with sinking, coolness, softness, emptiness, passiveness, and feminine qualities. Yin and Yang are not absolutes, static, or in any way tied in with good or bad. They exist and fluctuate in all things.  After you have adjusted to the “five basic cues” visualize the following for at least a minute each: o The front of the body is yin in nature, the back is yang in nature. Hence, the back feels full, while the front empty. o The bottom half of the body is yin in nature, the top half is yang in nature. Hence the lower half feels like it is sinking into the ground, while the upper half feels as though it is rising. o With these ideas in mind, imagine your qi (energy) rising from the back of your heels, up the spine, to the crown of the head. The qi then sinks down over your face, chest, abdomen, and back to the feet before starting the cycle anew. o The Dantien (lower abdomen) is yin in nature, while the chest is yang in nature. Imagine a smaller cycle of qi starting from the bottom of the abdomen, rising to the heart, and sinking back to the dantien. o For women, the left side of the body is yin in nature, while the right side is yang in nature. Therefore, the yang right hand is placed over the yin dantien, and the yin left hand is placed over the right for balance. This is opposite for men. o Meditate on these complimentary opposites of yin and yang existing within yourself, and all physical space.

APPENDIX K

HANDOUT 4

Handout 34 Tai Chi and Meditation Concepts #3 “Empty Mind”

Allowing the mind to become “empty” or “still” is the primary goal for most forms of meditation. This does not literally mean thinking of nothing, but instead calming the constant chatter of the inner dialogue, and entering a deep state of observation of the whole self. When the inner dialogue—which is largely linked to one’s ego—is taken out of the spotlight, space is made for a more authentic understanding of one’s self. While the inner dialogue may distract one with superficial thoughts and judgements, the empty mind is unbiased, and linked with our intuition, passions, and core values. The inner dialogue is typically experienced as a flow of words or images, while the empty mind is not as concrete, and typically experienced as a deep intuitive feeling, outside the realm of language and attachment. In this deep quiet state, one typically experiences a sense of peace, and will experience greater focus and efficiency of the mind afterward.

Empty mind meditation takes years, if not decades, of practice to become proficient. However, beginners can still begin to experience the benefits of peacefulness, stress-reduction, and focus with consistent practice.

Practice Cues: 1. Set your meditation posture, and start by giving yourself permission to practice meditation. 2. Let the body sink into a relaxed upright posture, and begin to observe your breath. 3. Think of the breath moving as a continuous circle, gently inhaled through the nostrils, drawn to the very bottom of your lungs, and rising to be slowly expelled from the nostrils before starting the cycle anew. 4. You may count each breath, from one to nine, and at nine start over again from one. 5. As you observe your breath, begin to observe the passing thoughts of your inner dialogue. It may be a stream of thought experienced as both words and images. 6. Observe these thoughts passing through your mind until you experience a small gap between two thoughts where there is no thought. 7. Focus on those gaps, making them last longer and longer until the conscious stream of the inner dialogue is almost nonexistent. 8. As the mind becomes quiet and still, continue to observe and experience the peace of stillness.

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