Feasibility of Qigong Exercise for Older Adults 1 Feasibility and Acceptability of Qigong Exercise in Community-Dwelling Older Adults

Objectives: Qigong exercise has been shown to improve physical and psychological well-being in adults with chronic conditions, but little is known about the feasibility and acceptability of engaging in a Qigong exercise program in community-dwelling older adults in the United States. The purpose of this study was to explore the feasibility, acceptance, and adherence to an 8-week Qigong exercise intervention in community-dwelling American older adults. Design: An exploratory study design. Setting: Two senior centers in southern Connecticut. Subjects: 45 community-dwelling older adults aged 65 to 85 years enrolled. Intervention: A supervised 1-hour Health Qigong exercise session twice weekly for 8 weeks. Outcome Measures: An investigator-designed questionnaire with 7 items that were rated on a 1 to 6 scale, with higher scores indicating better results and 9 open-ended questions were used to obtain data on feasibility and acceptability. Adherence was calculated as the proportion of the 16 planned sessions attended. Results: Of the 45 older adults enrolled, 6 never started and 6 withdrew, with 33 evaluable at the end of the intervention. The mean age of the sample was 74.8 years; the majority were female (84.4%) and white (91.1%). Mean scores on aspects of difficulty, acceptability, suitability, or effectiveness of Qigong exercise were all ≥5. Participants identified benefits of Qigong exercise, such as calming and relaxing feelings, inner peace, better balance, and flexibility. Attendance rate was 78.8%, with 94% performing Qigong exercise at least once weekly outside the class. All participants indicated that they would recommend Qigong exercise to others. No adverse events occurred. Feasibility of Qigong Exercise for Older Adults 4 Conclusion: An 8-week Qigong exercise program was feasible, acceptable, and safe for American older adults. Future robust randomized controlled trials are needed to confirm our findings. Feasibility of Qigong Exercise for Older Adults 5 INTRODUCTION Healthy aging is the public health goal for older adults. The primary goals of healthy aging are to reduce functional limitations, preserve quality of life, and maintain independent living.1 Exercise improves older adults’ strength, endurance, flexibility and balance.2 Regular physical activity is associated with improved survival, contributes to the preservation of functional ability and helps to defer physical disability.3,4 Even sedentary older adults who become physically active later in life can gain significant health benefits from physical activity.5 Older adults need exercise programs that correspond to age-related changes.6 Chinese traditional medicine exercise, such as Qigong and Tai chi, is a gentle low-impact mind-body exercise and can be performed by people of all ages.7 Both exercises are based on the theory that the body is a small universe where “Qi”, a vital energy, circulates. Illness or injury disturbs the harmony of vital energy circulation. Qigong exercise is believed to be a method of bringing vital energy flow into balance through meditation, breathing exercise, and body movements.8 Although Tai chi and Qigong exercise share a mutual theory, Qigong exercise emphasizes selfhealing by cultivating vital energy internally;9 whereas Tai chi has more and complex movements that are designed for physical fitness and self-defense. The application of Tai chi and Qigong exercise to community-dwelling older adults to promote their general health has been recommended.10,11 Yet, most research addressing the benefits of Qigong exercise on balance, muscle strength, psychological health, and quality of life was not conducted in American older adults.11 Despite evidence of the benefits of Qigong exercise interventions, no study was found that comprehensively addressed the feasibility and acceptability in community-dwelling American older adults. The purpose of this study was to explore the feasibility, acceptability and Feasibility of Qigong Exercise for Older Adults 6 adherence of an 8-week Qigong exercise program in community-dwelling older adults in the United States. METHODS Study Design The primary goal of the present study was to explore the feasibility, acceptability, and adherence of an 8-week Health Qigong (Baduanjin) exercise intervention in healthy communitydwelling older adults and their perception of Qigong exercise. A one-group pretest and posttest study was used; data were collected at baseline and at 8 weeks post-intervention. Ethical Consideration The study protocol was approved by the Yale University Human Investigation Committee. Written informed consent from participants was obtained. Participants and Setting Recruitment was conducted in two senior centers in southern Connecticut from April to August of 2015. Because chronological age does not usually reflect physical age of older adults, a criterion was set for baseline 6-minute walk test (6MWT) to exclude older adults who were too physically fit. The cut-off point for the 6MWT was obtained from an Australia study.12 Eligibility criteria were: age 65-85 years; English speaking; stable medical condition with a primary care provider’s permission to participate; a baseline 6MWT less than 554 meters for males and 530 meters for females; a Mini-Mental State Examination score of at least 25; and no severe bone, joint or other health conditions that would limit exercise training. Exclusion criteria were participation in Tai chi or Qigong classes in the last 6 months, baseline performance of more than 240 minutes of moderate-intensity exercise (i.e., activities that are more strenuous Feasibility of Qigong Exercise for Older Adults 7 than walking but less strenuous than running) weekly, use of an assistive device (i.e., walkers, canes, and wheelchairs), or inability to give informed consent. Flyers were used to recruit participants at the two senior centers, and the principal investigator (P. Chang) visited the centers weekly. Interested people could contact the principal investigator by email or telephone and establish an appointment for eligibility screening. Eligible older adults were given a consent form and demographic and baseline data were collected. Sample Size Determination and Statistical Power Sample size calculations were done using G*Power 3.1. Calculations were based on a one-group repeated measures design using a paired t-test, assuming 80% power, alpha of 0.05, effect size of 0.53 and 2-tailed test for statistical significance. The effect size was obtained from a previous Qigong study using the 6MWT as the outcome measure.13 The sample size needed to detect a significant difference in changes in physical ability was 31. Forty-five subjects were enrolled to allow for attrition, 31 from the Milford Senior Center and 14 from the Orange Senior Center. Qigong Intervention Participants were given the schedule of the Qigong sessions and a date to start. Primary care providers were contacted to obtain permission for participation. When the number of enrolled older adults reached approximately 10, the Qigong intervention class commenced. An experienced Qigong practitioner, who was verified by a Qigong master for eligibility to teach, was employed to lead the Qigong exercise classes. Each session was conducted with musical accompaniment. The Health Qigong program (Baduanjin) included breathing exercise guided by 8 gentle upper and lower body movements and meditation (Figure 1). The participants performed movements in a standing position within their comfort zone. Each session began with warm-up Feasibility of Qigong Exercise for Older Adults 8 exercises for 5-10 minutes, followed by 40-minute Health Qigong exercise, and concluded with 5-10 minutes of relaxation. Participants were asked to attend the session twice weekly for 8 weeks for a total of 16 Qigong sessions, and were encouraged to practice Qigong exercise outside of the class using a video that was provided. Participants were also asked to record their exercise outside of the class weekly using an exercise diary. Direct observation of randomly selected sessions and the number of classes and hours taught were documented to assess intervention fidelity. Outcome Measures Feasibility and acceptability were evaluated by participant feedback, which was obtained by an investigator-designed questionnaire. The questionnaire was reviewed by three experienced researchers and revised. Seven questions were related to the participants’ perceptions and practice experiences with the 8-week Qigong program and were rated on a scale of 1 to 6, with 6 indicating greater ease, acceptability, suitability, or effectiveness. Nine open-ended questions explored beliefs and experiences, perceived satisfaction, barriers and benefits of Qigong exercise (Table 1). Adherence was calculated by the number of actual participated sessions divided by the number of total sessions and the proportion of participants who practiced it at home. RESULTS A total of 45 older adults were enrolled into 3 separate Qigong exercise groups. Six never started and 2 participants dropped out at week 1, 2 at week 2, and 2 at week 5, leaving 33 participants evaluable at the end of the intervention (84.6% retention). There were no significant differences on demographic characteristics, physical activity, health characteristics, or baseline outcome measurements between those who dropped out and those who remained in the study. Feasibility of Qigong Exercise for Older Adults 9 The mean age of participants was 74.8±6.57 years (range 65 to 86 years); the majority were retired (91.0%), white (91.1%), female (84.4%), and had at least a college-level education (64.4%). A history of hypertension (37.8%) and osteoarthritis (35.6%) were the most common chronic conditions (Table 2). The preliminary efficacy of Health Qigong on physical and psychological health and spiritual well-being will be published elsewhere (in review).14 Feasibility and Acceptability of Qigong Exerci