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Rethinking yoga and the application of yoga in modern medicine.

Yoga is a Sanskrit word that means union, to yoke, or to join; the merging of the microcosm of our existence in our body with the macrocosm. In the West, yoga is often referred to as a mind-body technique from Asia, usually categorized as meditation (for those seated practices) and yoga (practices that include movement and the active participation of the body). Therefore, "yoga" can be said to be an overarching category that includes all Asian mind-body practices, whether from India (Hatha yoga, etc.), Tibet (Tsa lung Trul khor [rTsa rlung 'Phrul 'khor]), China (T'ai chi, qi gong) or other Asian origin. In the field of complementary and alternative medicine (CAM), yogic practices can be categorized as both "energy medicine" and "mind-body medicine." (1) They can be considered "energy medicine" as they purportedly work with the subtle energies of the body. In the Tibetan tradition, for example, the category of energy (tsel [rtsal]) helps understand the link of mind-body, as mind-energy-body. Energy is usually manifested as breath and/or sound. The aspect of subtle breath or energy-breath is a crucial aspect of all these Asian practices. In China this energy is called qi, in India prana, in Tibet lung (rlung), and although each of these traditions have their own distinct mind-energy-body practices (T'ai chi or qi gong in China, Hatha Yoga in India, and Tsa lung Trul khor in Tibet) they all do emphasize that aspect of energy-breath or breath-energy. Scientific research has also shown that these practices modulate brain activity and diminish the psychological and biological effects of stress. As such, they are also considered in the category of "mind-body medicine." In the West, the scientific community is more comfortable considering these practices within the area of mind-body medicine, as there is still insufficient evidence to support the realm of "energy medicine."

In this article we will discuss the use of the term yoga to describe these pan-Asian mind-body practices, provide an overview of the medical research being conducted with these practices, describe our research studies, and highlight challenges and future ideas on how this interesting field can further develop within the scientific community and be better integrated with conventional medical care.

Yoga: a pan-Asian mind-body practice

There are pros and cons to using the term "yoga" to describe these Asian practices. As any individual label, the term yoga can be an overgeneralization as well as an oversimplification for categorizing different practices and traditions and may dismiss some of the uniqueness of each. However, as we add a qualifier that represents origin or style (e.g., Tibetan yoga, Hatha yoga, Kundalini yoga, etc.), by utlizing the unifying term "yoga," we can use the same category and still acknowledge the similarities and differences. It is not dissimilar from the overarching category of meditation. Most seem to agree on the use of the term "meditation," yet it comes from different traditions with some differences in the practices. The qualifiers added along with the term meditation bring forth the uniqueness of each practice but under the broad category of "meditation" (e.g., Transcendental meditation [TM], mindfulness or vipassana meditation, Zen meditation, etc.).

Although the term "yoga" is of Indian origin from Sanskrit, its use has been incorporated into the English language and adopted to encompass a large range of practices from various other traditions, including mind-body practices of Tibet and China (see, for example, the description of "Taoist yoga" by Paper and Thompson 1998). (2) As the famous religious historian and author of Yoga: Immortality and Freedom, Mircea Eliade, states:
  side by side with this 'classic' Yoga, there are countless forms of
  'popular,' non-systematic yoga; there are also non-Brahmanic yogas
  (Buddhist, Jainist); above all, there are yogas whose structures
  are 'magical,' 'mystical,' and so on. (Eliade 1958)


Indologist David White asserts that the meditative techniques under the large rubric of yoga, as well as the Ayurveda medical system, arose as part of the interactions of the Vedic matrix with Brahmanic and Buddhist philosophical and mystical traditions. (White 1996). White adds that "[t]he organizing principles of the sixth-century BCE] teachings of the Buddha on suffering and its cessation were essentially medical" (White 1996). Stating that, for yogins and alchemists, "the human self is an exact replica of the macrocosm," White writes that yogic practices treat the imbalances and diseases "between the bodily microcosm and the universal macrocosm." (White 1996). This is an appealing argument for the way these practices have migrated into the medical field, or in anthropologist Joseph Alter's words, the "medicalization" of yoga (Alter 2004).

White affirms that the Upanishads of the fourth and third century BCE began "charting the yogic body" and that the practice of yoga is done to achieve experiences beyond the reasoning mind. (White 1996). In the Tibetan Yogas (Tsa lung Trul khor), for example, the releasing of physical, energetic, and mental disease and obstacles allows the vital breath currents to flow better throughout and nurture the organism at all three levels: body, energy, and mind.

It is clear that these yogic practices are not seen as mere exercise or performance, like gymnastics and aerobics are seen in the West. In effect, Eliade asserts that, from the post-Vedic period, yoga was defined as "the means of attaining being, the effectual techniques for gaining liberation" (Eliade 1958).

With the inception of the tantric movement, which began around the fourth century BCE, and reached its apogee in India and Tibet in the eighth century, the body takes primary importance, with the specific esoteric goal of attaining liberation or "enlightenment" by means of enabling vital breath currents to flow and unblock obstacles or interruptions to that enlightenment. It is also important to note that, for the Tibetan and many of the Chinese and Indian spiritual practices known as "Mahayana" or Great Vehicle, part of the goal of the practices is that the enlightenment is not just for the practitioner, but extends to liberate all sentient beings.

On the origins or roots of tantra, White writes:
  Indian tantrism, in its Hindu, Buddhist and Jain varieties, did not
  emerge out of a void. It was on the one hand influenced by cultural
  interactions with China, Tibet, central Asia, Persia, and Europe,
  interactions which had the Silk Road and medieval maritime roues
  and ports as their venue. Much more important, however, were the
  indigenous Indian roots of tantrism, which was not so much a
  departure from earlier forms of Hinduism as their continuation,
  albeit in sometimes tangential and heterodox ways. (White 1996)


Tantra, as Eliade remarks, was a pan-Asian movement influenced by the local religious tradition and culture, as well as by Persia and Europe (mostly Greece) through the trade routes.

Yoga becomes one of the most evident examples in which the yogi makes the body the locus and tool for the liberation of itself. This is consistent with philosopher John Dillon, although focusing on Platonic thought, refining versus rejecting the body, which can be said to exist across cultures and traditions (Dillon 1998).

The concept of rejecting being predominant in ascetic practices and refining presented as the "Perfecting the body," "the body as a temple," and even the "immortality" of the inner or subtle body that are seen as part of the know-how of enlightenment (Eliade 1958). This understanding of the body as a tool to refine the self is more in line with the way mind and body are related both in yogic practices and in mind-body medicine.

The mind-body connection

The belief that what we think and feel can influence our health and healing dates back thousands of years (Shankar and Liao). As we have seen, the importance of the role of the mind, emotions, and behaviors in health and well being was part of traditional Chinese, Tibetan, and Ayurvedic medicine and other medical traditions of the world. Many people are now turning to these ancient practices as a way to reduce stress as there is now substantial evidence showing the negative health consequences of sustained stress on health and well being through profound psychological, behavioral, and physiological effects. These psychological and behavioral effects of stress may include increased negative effect, post-traumatic stress disorder, increased health-impairing behaviors (e.g., poor diet, lack of exercise, or substance abuse), poor sleep, and decreased quality of life, or QOL (Baum and Singer 1987). Research has shown that stress can also decrease compliance with health-screening behaviors.

Stress-induced physiological changes that can have a direct effect on health include persistent increases in sympathetic nervous system activity and the hypothalamic-pituitary-axis that can cause increased blood pressure, heart rate, catecholamine secretion, and platelet aggregation (Glaser 2005). Further, recent research suggests that stress is associated with increased latent viral reactivation, upper respiratory tract infections, and wound-healing time (Glaser and Kiecolt-Glaser 1998, 2005). Stress also deregulates a variety of immune indices, as has been found in both healthy subjects and people with cancer (Glaser and Kiecolt-Glaser 2005). Such stress-induced physiological changes may affect cancer progression, treatment, recovery, recurrence, and survival (Antoni et al. 2006, Glaser and Kiecolt-Glaser 2005). For example, several studies have linked stress and other psychosocial factors to the incidence and progression of cancer (Gehde and Balthrusch 1990, Greer et al. 1979, Morris et al. 1981). In addition, research has shown that depression, which is a common psychological response to stressful life events or circumstances, is linked to an increased risk of cancer, progression of disease, and decreased survival (Loberiza et al. 2002, Penninx et al. 1998, Steel et al. 2007, Strommel et al. 2002, Watson et al. 1999). Extensive research has also now established that stress and depression cause the suppression of cell-mediated immunity (Irwin et al. 1990, Rabin 1999). Studies in cancer patients have linked immune function, including NK cell function and T-lymphocyte proliferation, to prognosis, recurrence, and survival time. Recent laboratory research has also linked stress directly to changes in the tumor micro-environment and stress was found to be directly responsible for progression of disease and survival (Thaker et al. 2006). The clinical significance of stress-related immune and endocrine system changes and changes in the tumor micro-environment has not been widely studied. However, these changes may be significant enough to affect not only the immediate health of the patient, but also the course of the disease and thus the future health of the patient (Bovbjerg 1991, Fife et al. 1996, Glaser and Kiecolt-Glaser 2005, Redd et al. 1991, Van der Pompe et al. 1994). Decreasing distress and maintaining the functional integrity of the immune system and other physiological systems are therefore important in helping people remain healthy. Although this area of research is relatively new, it has been demonstrated that psychological factors can result in behavioral and regulatory system changes that, in turn, may affect future health (Antoni et al. 2006, Glaser and Kiecolt-Glaser 2005). This has helped to legitimize what is called the mind-body connection and mind-body medicine research.

Thus, the mind-body connection is an important aspect of integrative oncology as emphasized in the recent Institute of Medicine (IOM) report "Cancer Care for the Whole Patient" (IOM, 2008). In this comprehensive report it is mentioned that "cancer care today often -provides state-of-the-science biomedical treatment, hut fails to address the psychological and social (psychosocial) problems associated with the illness. These problems--including ... anxiety, depression or other emotional problems ...--cause additional suffering, weaken adherence to prescribed treatments, and threaten patients' return to health." Extensive research has documented that mind-body interventions appear to address many of the issues mentioned in the IOM report. Some techniques will be discussed below.

Mind-body practices

Mind-body practices are defined as a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms (National Center for Complementary/Alternative Medicine 2008). Mind-body techniques include relaxation, hypnosis, visual imagery, meditation, biofeedback, cognitive-behavioral therapies, group support, autogenic training, and expressive arts therapies such as art, music, or dance. As mentioned earlier, therapies such as yoga (including T'ai chi, qi gong, Tsa lung, and Trul khor) often fall into the CAM category of energy medicine, as they are intended to work with bodily "energetic fields" (e.g., meridians and qi (pronounced chee--China), lung (pronounced loong--Tibet), prana (India), and ki (pronounced kee--Japan). However, they are also likely to exert strong effects through a mind-body connection and as such fall into the mind-body medicine category. Interestingly, when we examine the Asian philosophical origins of these practices, noted above, with humans viewed as a mind-energy-body system, it makes sense to combine the categories of mind-body medicine and energy medicine.

In the West, pioneering research in mind-body medicine conducted by (Benson et al. (1974a), Jon Kabat-Zinn 1982) helped to form the scientific field. Early research by (Benson et al. (1974b), Wallace et al. 1971) found that the practice of TM resulted in lowered blood pressure, reduction in oxygen consumption, heart rate, and metabolic rate, greater than is expected during sleep; with an increase in alpha waves. All these changes indicated a state of relaxation where there was diminished sympathetic nervous system activity following meditation. Benson coined the term the "relaxation response."

Benson and colleagues (Benson et al. 1982) subsequently investigated three advanced practitioners of the Tibetan meditative practice called tum-mo, who were living in the lower Himalayas. Practitioners of tum-mo claim to increase their body temperature through a special meditative technique of deep concentration. Traditionally, these practices are done in a very cold environment with minimal clothes on the practitioners' body to see if they could dry a wet sheet at under 40[degrees]F and then wet the dry sheet by the perspiration of their body as they continued performing the tum-mo practice. In the cold environment the advanced tum-mo practitioners could increase the temperature of their fingers and toes by as much as 8.3[degrees]C (Benson et al. 1982). A significant reduction in their oxygen consumption was also observed.

Kabat-Zinn developed a combination of Vipassana (a Buddhist mindfulness meditation technique), some yoga postures, and a body scan technique in a behavioral medicine setting for populations with various types of chronic pain (J. Kabat-Zinn 1990, Kabat-Zinn et al. 1985). Originally called Stress Reduction and Relaxation Program (SR-RP), and later coined as Mindfulness-based Stress Reduction (MBSR), it was described as "paying attention in a particular way: on purpose, in the present moment, and nonjudgementally" (J. Kabat-Zinn 1990). MBSR has been extensively scientifically investigated in the West and is useful for helping to ease psychological and physical effects of some chronic illnesses and produces changes in brain activity and biological processes (Davidson et al. 2003, Grossman et al. 2004, Ott et al. 2006). Today, practices that fall into the category of mind-body medicine are no longer considered "alternative" and they are well integrated into conventional medicine and most medical settings (e.g., hypnosis, biofeedback, cognitive-behavioral therapy, and group support). As research continues, the treatments that are found beneficial will hopefully become integrated into conventional medical care.

Mind-body practices in cancer

Research has shown that after being diagnosed with cancer, patients try to bring about positive changes in their lifestyles, often seeking to take control of their health (Blanchard et al. 2003). Techniques of stress management that have proven helpful include progressive muscle relaxation (Baider et al. 1994, Sloman 1995), diaphragmatic breathing (Moskowitz 1996, Ross et al. 1999), guided imagery (Spiegel 1997, Walker et al. 1999, K. G. Wallace 1997), social support (M. A. Richardson et al. 1997, Turner-Cobb et al. 2000), and meditation (Coker 1999, Massion et al. 1995). Participating in stress management programs prior to treatment have enabled patients to tolerate therapy with fewer reported side effects (Arakawa 1997, Manyande et al. 1995, Syrjala and Chapko 1995, Troesch et al. 1993). Supportive expressive group therapy has also been found to be useful for patients with cancer (Fawzy et al. 1995, Helgeson et al. 2000, Spiegel et al. 1981). Psychosocial interventions have been shown to specifically decrease depression and anxiety and to increase self-esteem and active-approach coping strategies (Fawzy et al. 1990, Gordon 2008, Helgeson et al. 1999, Richardson et al. 1990).

A meta-analysis of 116 studies found that mind-body therapies could reduce anxiety, depression and mood disturbance in cancer patients, and assist their coping skills (Devine and Westlake 1995). Newell and colleagues (Newell et al. 2002) reviewed psychological therapies for cancer patients and concluded that interventions involving self-practice and hypnosis for managing nausea and vomiting could be recommended, but that further research was suggested to examine the benefits of relaxation training and guided imagery. Further research was also warranted to examine the benefits of relaxation and guided imagery for managing general nausea, anxiety, quality of life, and overall physical symptoms (Newell et al. 2002). More recently, Ernst et al. (2007) examined the change in the state of the evidence for mind-body therapies for various medical conditions between 2000 and 2005 and found that there is now maximal evidence for the use of relaxation techniques for anxiety, hypertension, insomnia, and nausea due to chemotherapy.

Research examining meditation and yoga practices incorporated into cancer care suggests that these mind-body practices help to improve aspects of quality of life including improved mood, sleep quality, physical functioning, and overall well being (Bower et al. 2005, Gordon 2008). Hypnosis, and especially self-hypnosis, has been found to be beneficial to help reduce distress and discomfort during difficult medical procedures (Spiegel and Moore 1997). An NIH Technology Assessment Panel found strong evidence for hypnosis in alleviating cancer-related pain (1996). Hypnosis effectively treats anticipatory nausea in pediatric (Zeltzer et al. 1991) and adult cancer patients (Morrow and Morrell 1982), reduces post-operative nausea and vomiting (Faymonville et al. 1997), and improves adjustment to invasive medical procedures (Lang et al. 2000, 2006, Montgomery et al. 2007).

Mind-body practice at the University of Texas M. D. Anderson cancer center

Ten years ago, with the advise of Tenzin Wangyal Rinpoche of the Ligmincha Institute, we began a Tibetan meditation class at The University of Texas M. D. Anderson Cancer Center's Place ... of wellness in Houston, Texas. Place ... of wellness is M. D. Anderson's clinical delivery center for complementary and integrative medicine. The program was called Connecting with Your Heart, a technique to help cancer patients and their families calm their minds and use their breath to connect to their inner home.

For more than ten years, we have also been conducting scientific research on the possible benefits of these yoga practices in people with cancer. Our research simultaneously examines the behavioral, physiological, psychological, and spiritual outcomes of these practices in different cancer populations at different points in their cancer journey. There are a number of ongoing studies funded by the National Cancer Institute (NCI), The National Institutes of Health, investigating the effects of yoga (from the Indian tradition--Patanjali-based practices; Tibetan tradition--Tsa Lung, Trul Khor; and Chinese tradition-qi gong/T'ai chi).

Two initial studies conducted by our group examined the effects of Tsa lung and Trul khor. For these pilot studies, a seven-session program called "Tibetan Yoga" (TY) was designed, and included practices from the Tibetan Bon tradition, included in the Mother Tantra (Ma rgyud) and Great Completeness Oral Transmission of Zhang Zhung (Zhang zhung snyan rgyud). The intervention, chosen in consultation with Tenzin Wangyal Rinpoche, consisted of four main components: (1) breathing exercises, (2) meditative concentration, (3) tsa-lung sitting yogic postures, and (4) trul-khor yogic postures involving more physical movement. These components have been used in the Bon tradition for centuries and we chose them with the intention that they would help in ameliorating side-effects and hastening recovery for patients who were either undergoing active treatment or who had recently completed treatment.

The breathing exercises help participants to regulate their breath and prepare for the movement-based practice. The breathing techniques are thought to help calm the mind and manage physical, emotional, and mental "obstacles." The meditative concentration techniques the patients learned helped them to use the calmness of the mind towards self-observation and to guide the breath to clear away obstacles. They also learned a simple meditative technique that incorporated sound and visualization. The tsa lung exercises applied the meditative concentration techniques and the breathing exercises already learned with five specific simple movements focused in different areas of the body at points called chakras (located at the head, neck, chest, lower abdomen, and perineum), to help participants relax and feel invigorated. The first five movements from the trul khor were then introduced and again the participants used the meditative concentration techniques and the breathing exercises while performing the simple movements. All the techniques were done either sitting on a cushion on the floor or sitting in a chair. The classes were taught by an instructor authorized by the Ligmincha Institute. The hour long classes were taught once a week for seven weeks. This provided the participants the opportunity to learn the techniques and practice them with the instructor, so that they could continue to practice them on their own. At the end of each class, the participants received printed material to take home and use as support of the techniques learned in that session. At the end of the course, the participants were given an audiotape with guided practices of all the techniques they learned. Participants were advised to continue daily practice at home in addition to the class at the clinic and also to continue their practice after the seven-week course was over. Patients completed measures of intrusive thoughts and avoidance behaviors, depressive symptoms, sleep disturbances, fatigue, and quality of life at baseline, one week, and one and three months after the last class.

In the first pilot study we examined the feasibility, acceptability, and initial efficacy of the TY program described above for patients with lymphoma. Patients had to be currently undergoing treatment or had to have completed treatment within the past twelve months. Thirty-nine patients were randomly assigned to either the TY group or to a waitlisted control group. The intervention group received the seven-week TY program and the wait list control group could receive the instruction after the end of the study.

Overall, the results indicated that the TY program was feasible and well liked by the patients. The majority of participants indicated that the program was "a little" or "definitely" beneficial, with no one indicating "not beneficial," and they continued practicing at least once a week, with many continuing to practice twice a week or more (Cohen et al. 2004). The study results indicated that the TY group reported lower overall sleep disturbances during the follow-up period than did the control group, with better overall sleep quality, less difficulty falling asleep, slept significantly longer, and used fewer sleep medications. Improving sleep quality in a cancer population may be particularly salient as sleep is crucial for recovery. Fatigue and sleep disturbances are common problems for patients with cancer.

A second study examined the benefits of the same seven-week TY program for women with breast cancer. Women with stage I--III breast cancer who were undergoing active treatment (radiotherapy or chemotherapy) or who underwent treatment less than one year prior to enrollment were recruited to participate in the study. Fifty-nine women were randomized to either the yoga group or a wait list control group. Initial analyses have been conducted and presented at national meetings (Cohen et al. 2005). On average, the participants in the TY group said they found the program useful or very useful, and they practiced it around twice a week. Results indicated that the yoga group reported lower cancer-related intrusive thoughts scores than the control group by the three-month assessment. They also reported lower scores for cancer-related symptoms at the one-week follow-up than the control group.

These pilot studies are among the few studies of yoga in a cancer patient population and the only scientific studies of TY in any population. We are now conducting a large NCI-funded trial examining the effects of TY for women with breast cancer undergoing chemotherapy. Women in the TY group are being compared to women who learn some simple stretching exercises and to women in a wait list control group.

A subsequent randomized pilot trial examined the effects of yoga from the Indian tradition (Vivekananda yoga from the Patanjali yoga tradition). This was a collaborated study between the M. D. Anderson and the Vivekananda Yoga Anusandhana Samsthana (VYASA), a yoga research foundation and University in Bengaluru, India with extensive clinical and research experience conducting this form of yoga with healthy and medical populations (Nagarathna and Nagendra 1985, Nagendra and Nagarathna 1986a,b). Sixty-one women with breast cancer undergoing radiation treatment were either assigned to the yoga group or a wait-list control group that could participate in the yoga after the study was completed. Patients in the yoga group participated in the yoga sessions twice a week for the duration of their radiotherapy, each session lasting about one hour. The yoga program consisted of four main components: (1) various loosening exercises; (2) seven simple postures and a deep relaxation technique; (3) alternate nostril breathing; and (4) meditation. The components were specifically designed and selected for use in patients with cancer, with particular emphasis on the problems that women experience while undergoing radiotherapy for breast cancer and recovering from surgery and/or chemotherapy. The overall aim of these techniques was to train the participants to regulate their breathing, be aware of the various changes that occur in the body while performing the maneuvers, and by doing so the participants can calm the mind and relax parts of the body. In the beginning, patients were introduced to each of the four different areas over a period of four one-hour classes conducted by a VYASA certified Instructor. During the remainder of the sessions, the participants practiced the complete program. The exercises were done to meet each patient's needs. At the end of each of the first four classes, the participants were given a CD with a recording of the technique they just learned and some printed materials that they could take home. After the fourth session, they were given a CD with all instructions as well as a complete printed version. Participants were advised to continue daily practice at home in addition to the class at the hospital and also after the completion of radiotherapy.

The loosening and breathing exercises consisted of various gentle, sometimes repetitive, movements of the arms, legs, neck, and eyes in standing, sitting, and supine positions. Postures, or asanas, were done standing, sitting, or lying down (either face down or face up). These postures consisted of simple movements that included a side bending posture, two forward bending postures, three back bending postures, and a partial shoulder stand with wall support. The session always ended with the supine relaxation posture to allow the body to relax completely. In this position, they practiced the deep relaxation technique that incorporated gentle sounds that would resonate their body (e.g., "aah", "uuu", "mmm", "om"). Alternate nostril breathing was done for five rounds, sitting with the back and neck straight. Meditation was done sitting in any comfortable position or sitting on a chair. The patients were instructed to close their eyes, and concentrate on their breath and their thoughts. They were then encouraged to repeat the syllable "mmm" mentally. They were instructed to sit in silence and dwell on a single positive thought of their choice. This could be continued for about ten to twenty minutes.

Patients completed measures at baseline, one week, and one and three months after the last radiation therapy. The results indicated significantly better general health perception and physical functioning scores one-week post-radiotherapy, higher levels of cancer-related intrusive thoughts one-month post-radiotherapy, and greater finding meaning (ability to find meaning in the cancer experience) three-months post-radiotherapy (Chandwani et al., 2010). Due to the unexpected group differences in intrusive thoughts one-month post-radiotherapy, with the yoga reporting significantly greater scores than the control group, we explored the association between intrusive thoughts one month post-radiotherapy and finding meaning three months post-radiotherapy. There was a significant positive correlation between intrusive thoughts one month post-radiotherapy and finding meaning three months post-radiotherapy, suggesting that the higher the level of intrusive thoughts the greater the finding meaning at three months post-radiotherapy. Although the increase in intrusive thoughts was not expected, it does fit a model for contemplative-based mind-body practices. Within the yoga program, similar to mindfulness practices, participants are told to not avoid negative thoughts, but to simply observe them in a non-judgmental manner. This could lead to the increased frequency of intrusive thoughts, but the intrusive thoughts do not result in negative outcomes and, in fact, help with processing of the cancer experience. Comments from individual patients also indicated high acceptance of the program. A similar study funded by the NCI was recently completed where the participants were randomized to one of three groups--a yoga group, stretching group, or a wait list control group. In this study we are examining the biobehavioral effects of the yoga program using a more appropriate control group in order to separate the effects of yoga from social support and simple stretching exercises. The initial analyses suggest similar outcomes as the previous study, with the yoga group having the best outcomes followed by the stretching group. We will now be conducting a much larger trial funded by the NCI with 600 women with breast cancer undergoing radiotherapy to definitely show the benefits of incorporating yoga into the treatment plan and in addition to the standard assessments we will be examining cost-effectiveness analysis, work and/or home productivity, and health care utilization.

A mindfulness relaxation study headed by Dr. Jon Hunter from Mount Sinai Hospital, Toronto, Canada, is being conducted within the M. D. Anderson Community Clinical Oncology Program (CCOP). The purpose of the study is to test this relaxation intervention in reducing psychological and physiological side effects of chemotherapy in cancer patients. In this randomized trial, patients with newly diagnosed cancer who are about to undergo chemotherapy are randomly assigned to one of three groups: the mindfulness relaxation group (MR), a relaxing music group (RM) where participants listen to relaxing music for the same amount of time as the MR participants, or a standard care control group (SC) where participants receive standard medical education on chemotherapy. Patients complete assessments before being randomized (baseline), in the middle of their course of chemotherapy, at the end of treatment, and three months after the end of treatment. They also complete very brief diary assessments for three days before the start of each cycle of chemotherapy and for three days after. Blood samples for immune indices are also being obtained.

The mindfulness relaxation intervention consists of a script containing elements of relaxation induction, yoga breathing, guided imagery, and a "mindful" attitude, which encourages people to become aware and take notice of physical sensations without having to alter or respond to them (J. Kabat-Zinn et al. 1985). Nurses at each site are trained in the administration of the script, and subsequently deliver it to patients before their first chemotherapy session, in order to establish a pre-emptive association between relaxation and the chemotherapy setting, that will in turn diminish the development of conditioned symptoms. The patients are also given a CD of the MR recorded by the site nurse who delivered the MR training to use at home for practice sessions, and for all chemotherapy sessions.

Each time the patient attends a chemotherapy session the MR exercise is conducted prior to and during chemotherapy delivery, via use of a portable CD player with the recorded version. Participants are instructed to use the CD at home at least once daily throughout chemotherapy delivery in order to become familiar with and build skill in the technique. The participants in the RM group use a CD with relaxing music. Patients in the RM group utilize their CD in a manner identical to the MR CD, but they do not receive any specific instructions on relaxation or meditation. They also receive general information on the management of symptoms related to chemotherapy in a session of equivalent time to the MR training session. The SC arm receives general information on the management of symptoms related to chemotherapy in the manner that is typical of that CCOP site. The single arm feasibility pilot trial went well and the large phase III randomized trial is now underway (N = 300; 100 patients in each group).

We are also examining the feasibility and initial efficacy of implementing a Tibetan Sound Meditation program for women who have undergone chemotherapy for breast cancer and report cognitive deficits. There is evidence to suggest that meditation would be especially useful for this common side effect of chemotherapy (Biegler et al. 2009). The women are randomized to a meditation group or a wait-list control group. Participants in the meditation group attend two meditation sessions each week for six weeks. Standardized objective tests assessing higher order cognitive function and self-report measures of fatigue, quality of life, mental health, and sleep disturbances are administered one week prior to starting the meditation intervention. The self-report measures are then administered during the middle and final week of the intervention and 1 month after the meditation intervention ends. The standardized cognitive assessments are administered again 1 month after the meditation intervention ends. We predict that scores assessing cognitive function for women receiving the intervention will improve from baseline to post-intervention assessments and the women in the control group are expected to stay the same. Women in the intervention group will also report fewer or less severe side effects and better QOL than women in the control group.

A recently completed pilot project examined the effects of qi gong for patients with breast cancer undergoing radiotherapy. This study was conducted at the Fudan University Cancer Hospital, Shanghai, China as part of an International Center of Traditional Chinese Medicine for Cancer funded by the NCI. Patients with breast cancer who are undergoing radiotherapy were randomly assigned to either a qi gong group or a wait-list control group. Participants in the qi gong group attend daily qi gong sessions five days/week throughout their six-week radiotherapy schedule. The sessions were coordinated with the treatment schedule. The patients were taught a modified version Gualin Qi Gong including preparation exercises (standing posture, breathing exercise, and opening and closing of the dantian (an important focus point for internal meditative techniques, located in the abdomen three finger widths below and two finger-widths behind the navel), main exercise (slow exercise and fast exercise), and then the closing exercise. The focus is on working with gentle movements and breath to help regulate the patients' qi. Measures were obtained prior to randomization, mid-way through radiotherapy, during last week of radiotherapy, and one and three months after the end of radiotherapy.

A similar trial, funded by the NCI, is being conducted at M. D. Anderson where we are examining incorporating qi gong and T'ai chi into the treatment plan for patients with anal, rectal, or prostate cancer during radiotherapy. The program consists of several breathing and moving exercises, along with a short eight-form T'ai chi set. The overall aim of these techniques is to train the participants to regulate their breathing and become aware of the various changes that occur within their body while performing the various forms. By doing so, the participants will learn to easily calm the mind after stimulation; relax various parts of the body and the mind; and revitalize their qi. Patients in the comparison groups either participate in a light exercise program or receive the standard of care. Similar to our other studies, measures are obtained prior to randomization, mid-way through radiotherapy, during last week of radiotherapy, and one and three months after the end of radiotherapy.

Conclusions

For thousands of years, many cultures of the world have been examining yoga and how it leads to better understanding human existence. This experimentation has mainly been through introspection and the first person narrative. It is only within the past few decades that Western science has begun to seriously examine these yogic practices to determine how they affect psychological, behavioral, physiological, and biological processes. It is clear that at minimum these practices result in an acute relaxation response, lowering blood pressure, heart rate, and subjective rating of stress. More recent research is showing that these different practices can help people suffering from chronic illnesses. Each year the evidence mounts showing another medical population that is helped with the incorporation of these practices alongside conventional Western medical care.

The big strides in our understanding of the role of mind-body practices in health and well being comes from some of the studies examining psychological, behavioral, and biological outcomes. Demonstrating that these yogas not only make you feel better but also have an impact on our brain activity, immune function, and endocrine function, as an example, provides a better indication for the profound implication these practices can have within a medical setting. Scientists need to push the boundaries even further and examine the clinical implications and conduct the important cost-effectiveness research to begin to understand the role of these practices to improve the health and well being of humankind. A challenge to the field has always been the limited funding available to this kind of research versus the conventional biomedical fields of study. Although the funding still remains relatively quite limited, it has increased in the past ten years and interest continues to mount. The more evidence accumulates for the role of mind-body practices in medical care the greater the allotment of funding this area will receive.

Many medical centers already have incorporated mind-body practices as part of the standard of care. Although these practices are not necessarily prescribed and thought of in the same way as conventional medications, they are being delivered alongside medical treatments to help improve outcomes. As more evidence accumulates, the day will come when mind-body practices are a form of medical treatment provided and prescribed as part of standard medical treatment around the world.

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Notes

(1.) The four main categories that the National Center for Complementary and Alternative Medicine use to define CAM: Mind-body medicine, Biologically based practices. Manipulative and body-based practices, and Energy medicine (http://nccam.nih.gov/health/whatiscam/overview.htm).

(2.) We also find the use of the term Tibetan Yoga in Evans-Wentz 1935 (rp. 1958), Michael Roach 2004, and Namkhai Norbu 2008, among others.
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