Mindful Exercise, Quality of Life, and Cancer A Mindfulness- Based Exercise Rehabilitation Program for Women with Breast Cancer Anna M. Tacon, Ph. D.

Learning Objectives After completing this chapter you should have and understanding of: After completing this chapter you should have and understanding of: increased use of mind-body therapies n cancer increased use of mind-body therapies n cancer breast cancer patients’ use of complementary therapies breast cancer patients’ use of complementary therapies the concept of mindfulness as well as the mindfulness- based stress reduction program the concept of mindfulness as well as the mindfulness- based stress reduction program quality-of-life factors in cancer especially cancer-related fatigue quality-of-life factors in cancer especially cancer-related fatigue the benefits of exercise as a complementary therapy in cancer the benefits of exercise as a complementary therapy in cancer

Introduction Breast Cancer Breast Cancer most common cancer among women, accounting for nearly 1 in 3 cancers diagnosed in the U.S. most common cancer among women, accounting for nearly 1 in 3 cancers diagnosed in the U.S. Considered to elicit greater distress than any other diagnosis, regardless of the prognosis, including depression and anxiety Considered to elicit greater distress than any other diagnosis, regardless of the prognosis, including depression and anxiety There is an increase in patients seeking complementary or mind- body therapies to help them cope There is an increase in patients seeking complementary or mind- body therapies to help them cope Patients must endure harsh treatment effects Patients must endure harsh treatment effects Moderate physical activity is also suggested for therapy Moderate physical activity is also suggested for therapy

Mind-Body Medicine, Integrated Care, and Mindfulness Mind-body medicine should be part of an evidence based, cost-effective, quality health care Mind-body medicine should be part of an evidence based, cost-effective, quality health care Psycho-physiological, psychosocial, educational interventions for patient distress Psycho-physiological, psychosocial, educational interventions for patient distress Mindfulness meditation Mindfulness meditation Involves including rather than excluding stimuli from the field of consciousness Involves including rather than excluding stimuli from the field of consciousness Provides means of self-monitoring and self- regulating one's arousal with detached awareness. Provides means of self-monitoring and self- regulating one's arousal with detached awareness.

The Concept of Mindfulness and the Program Mindfulness-based stress reduction program (MBSR) Mindfulness-based stress reduction program (MBSR) Once/week for 2 hours over 8 weeks Once/week for 2 hours over 8 weeks Mindful awareness, being in the present moment, or just paying attention to now Mindful awareness, being in the present moment, or just paying attention to now

The Concept of Mindfulness and the Program Cont’ Training in several basic practices of mindfulness meditations: Training in several basic practices of mindfulness meditations: 1. Body scan: journey through geography of he physical form 2. Hatha yoga: stretches and postures to strengthen and stretch the musculoskeletal system and develop mindful movement 3. Sitting meditation: attention to breath and other psychophysical perception 4. Walking meditation: cognitive-behavioral practice of paying attention to all physical sensations and fluctuations in a concentrative awareness during walking

Research on MBSR Effective in reducing levels of stress and anxiety, chronic pain and fibromyalgia Effective in reducing levels of stress and anxiety, chronic pain and fibromyalgia Improvements pre-post quality of life, significant positive shifts in mood, coping, health locus of control, and mental adjustment to cancer Improvements pre-post quality of life, significant positive shifts in mood, coping, health locus of control, and mental adjustment to cancer Significant positive shift in overall immune profile Significant positive shift in overall immune profile

Exercise Therapy for Cancer 30 minutes of moderate activity 5 or more days per week can help prevent chronic diseases like cancer 30 minutes of moderate activity 5 or more days per week can help prevent chronic diseases like cancer Exercise is gaining acceptance as a major quality of life rehab intervention for cancer survivors Exercise is gaining acceptance as a major quality of life rehab intervention for cancer survivors

Exercise, Quality of Life, and Cancer Cancer treatments and the process of cancer can destroy a persons quality of life Cancer treatments and the process of cancer can destroy a persons quality of life Exercise can increase the quality of life even during high dose cancer treatments Exercise can increase the quality of life even during high dose cancer treatments

Exercise, Quality of Life, and Cancer Exercises prescription for those with moderate- intensity exercise includes: Exercises prescription for those with moderate- intensity exercise includes: 3 to 5 time a week 3 to 5 time a week 20 to 30 minutes per session 20 to 30 minutes per session Walking most preferred Walking most preferred High-intensity exercise should be avoided during cancer treatment because of potential immunosuppressive effects High-intensity exercise should be avoided during cancer treatment because of potential immunosuppressive effects

Cancer-Related Fatigue and Exercise: Definition and Rationale Most common symptom of cancer patients is fatigue Most common symptom of cancer patients is fatigue which can be even more distressing and disruptive to a patient’s daily activities than the pain associated cancer which can be even more distressing and disruptive to a patient’s daily activities than the pain associated cancer Fatigue may affect patient’s ability to tolerate treatments Fatigue may affect patient’s ability to tolerate treatments Treatments may be delayed which impacts disease progression Treatments may be delayed which impacts disease progression Exercise training stops the loss and even increases functional capacity which reduced effort and decreased fatigue at any level Exercise training stops the loss and even increases functional capacity which reduced effort and decreased fatigue at any level

Summary Evidence exists to support that both Mindfulness-based stress reduction programs and exercise rehabilitation are two complementary therapies that can produce positive effects for those with cancer Evidence exists to support that both Mindfulness-based stress reduction programs and exercise rehabilitation are two complementary therapies that can produce positive effects for those with cancer

Mindfulness-Based Exercise Rehabilitation Program (MBER) Format and Structure Format and Structure Prior to program, women be cleared by physician Prior to program, women be cleared by physician Baseline physical fitness assessment conducted Baseline physical fitness assessment conducted

Mindfulness-Based Exercise Rehabilitation Program (MBER) Format and Structure Format and Structure First 8 weeks: First 8 weeks: Same basic format and mindfulness practice of original program (modified program for cancer patients also) Same basic format and mindfulness practice of original program (modified program for cancer patients also) Participants meet 2 hours, 1 night per week for 8 weeks, where exposed to: Participants meet 2 hours, 1 night per week for 8 weeks, where exposed to: Didactic, inductive, and experiential modes of learning mindfulness strategies Didactic, inductive, and experiential modes of learning mindfulness strategies 6- week exercise program showed improvement 6- week exercise program showed improvement Expected to perform daily “homework” that emphasizes strategies learned in the sessions Expected to perform daily “homework” that emphasizes strategies learned in the sessions

Session Contents Weeks 1 & 2 Weeks 1 & 2 At the first session: At the first session: Reasons for participating are shared and overview of the intervention is presented Reasons for participating are shared and overview of the intervention is presented To ease participants fear about unrealistic expectations To ease participants fear about unrealistic expectations Let participants know that they will be at a different place with different abilities and limitations. Let participants know that they will be at a different place with different abilities and limitations. The body scan is introduced laying on mats The body scan is introduced laying on mats

Session Contents First Session cont’ First Session cont’ Meditation is used to get women reacquainted with their bodies, especially if treatment has changed the body landscape Meditation is used to get women reacquainted with their bodies, especially if treatment has changed the body landscape The assigned homework for the first week: The assigned homework for the first week: to do the guided body scan on the first audiocassette tape (45 min) at least 5 days/week to do the guided body scan on the first audiocassette tape (45 min) at least 5 days/week 15 minutes of walking at a moderate pace at 50-70% of their maximum heart rate 15 minutes of walking at a moderate pace at 50-70% of their maximum heart rate

Session Contents Second Session Second Session Participants discuss the previous week’s homework and share their experiences Participants discuss the previous week’s homework and share their experiences The women participate in experimental exercise of mindfulness eating known as the raisin exercise The women participate in experimental exercise of mindfulness eating known as the raisin exercise Two purposes: Two purposes: 1. Reinforce idea that meditation is a natural act of paying attention and that there is nothing mysterious about it 2. Initiate the topic of food and nutrition in the context of cancer and exercise

Session Contents Second Session Cont’ Second Session Cont’ Sitting meditation is presented Sitting meditation is presented Mindful walking is then presented where they pay close attention to all sensations involved during this daily, routine activity Mindful walking is then presented where they pay close attention to all sensations involved during this daily, routine activity The assigned homework for the second session The assigned homework for the second session continue the body scan as per the previous week continue the body scan as per the previous week increase daily walking to 25 minutes increase daily walking to 25 minutes add 15 minutes of sitting meditation daily at least 5 days/week add 15 minutes of sitting meditation daily at least 5 days/week

Session Contents Weeks 3 & 4 Weeks 3 & 4 Week 3 Week 3 walking mediation is followed by Hatha yoga walking mediation is followed by Hatha yoga then an increased period of sitting meditation then an increased period of sitting meditation Homework assigned for week 3: Homework assigned for week 3: tape 1 of a 45 minute guided yoga routine as daily practice tape 1 of a 45 minute guided yoga routine as daily practice

Session Contents Week 4 Week 4 the topic of stress and the physiological stress response is presented with a discussion of mindfully tuning in to the body’s language the topic of stress and the physiological stress response is presented with a discussion of mindfully tuning in to the body’s language Homework assigned for week 4: Homework assigned for week 4: continue tape 1 of yoga continue tape 1 of yoga brisk walking of now 40 minutes per day, at least 5 day/week brisk walking of now 40 minutes per day, at least 5 day/week alternate 30 minutes of meditation daily with 30 minutes of mindfulness eating alternate 30 minutes of meditation daily with 30 minutes of mindfulness eating

Session Contents Weeks 5 & 6 Weeks 5 & 6 Different yoga asanas introduced Different yoga asanas introduced Homework assigned for weeks 5 & 6 Homework assigned for weeks 5 & 6 tape 2 is of a new 45-minute guided yoga routine daily tape 2 is of a new 45-minute guided yoga routine daily Brisk walking is 45 minutes per day at least 5 days/week Brisk walking is 45 minutes per day at least 5 days/week alternate 30 minutes of sitting meditation daily with 30 minutes of mindfulness eating alternate 30 minutes of sitting meditation daily with 30 minutes of mindfulness eating

Session Contents Weeks 7 & 8 Weeks 7 & 8 Last 2 sessions involve discussing the primary mental attitudes of coping with cancer and exploring issues of internal versus external locus of control and irrational beliefs Last 2 sessions involve discussing the primary mental attitudes of coping with cancer and exploring issues of internal versus external locus of control and irrational beliefs Mindfulness-based strategies are reviewed and discussed in terms of being applied to stressful, real life situation and challenges Mindfulness-based strategies are reviewed and discussed in terms of being applied to stressful, real life situation and challenges The purpose is say that “quality” of life takes work The purpose is say that “quality” of life takes work

Session Contents Weeks 7 & 8 cont’ Weeks 7 & 8 cont’ Homework assigned for weeks 7 & 8: Homework assigned for weeks 7 & 8: alternating 45 minutes of daily brisk walking with 45 minutes of yoga alternating 45 minutes of daily brisk walking with 45 minutes of yoga Alternating 45 minutes of daily sitting meditation with the body scan or with mindful eating as desired Alternating 45 minutes of daily sitting meditation with the body scan or with mindful eating as desired Finally, the role of conscious awareness in exercise motivation and behavioral maintenance are discussed along with the needed commitment to healthy lifestyle choices Finally, the role of conscious awareness in exercise motivation and behavioral maintenance are discussed along with the needed commitment to healthy lifestyle choices