Evaluating the Effect of Qigong on Cancer-Related Fatigue and Quality of Life

The negative influence of cancer on individual lives, families, communities, and healthcare institutions is widely known. Fatigue is the most common side effect of cancer and is often followed by pain, anxiety, depression, and overall decreased quality of life. Fatigue and quality of life are complex symptoms that are not easily appeased by medication and are difficult to improve with standard therapies. The purpose of this project was to examine the effectiveness of qigong in improving and preventing common side effects of cancer and cancer care. This was accomplished by providing modifiable and accessible qigong classes, assessing the effect of qigong on quality of life and fatigue symptoms, and disseminating results to support the implementation of Integrative Medicine and Health practices into oncology care plans. The prevalence and physical, emotional, and psychological impact of cancer is well documented in medical as well as lay literature. Current standard of treatments for cancer are associated with a multitude of psychosocial and physical side effects, two of the most impactful being cancer-related fatigue and decreased quality of life. Integrative Medicine and Health (IMH) is an approach to care that incorporates standard therapies with complementary therapies such as massage, acupuncture, yoga, and tai chi/qigong. Although recognition and prevalence of IMH is growing across the United States, more research is needed to gain public as well as political recognition and impact standards of care. Objectives of this project included (a) increase knowledge surrounding integrative medicine and the potential benefits of mind-body awareness and qigong; (b) provide accessible, modifiable qigong classes; (c) assess the impact of qigong practice on quality life and fatigue in cancer patients and their caregivers; (d) disseminate results to the Integrative Medicine Community. Before initiation of the study, information on IMH and the availability of qigong classes were provided to patients and cancer care providers at Huntsman Cancer Hospital in Salt Lake City, Utah. Willing study participants were asked to practice qigong for sixty minutes, two times a week for a period of five weeks. The PROMIS-29 questionnaire, a validated tool that assess eight domains related to quality of life including fatigue, was administered to participants at the beginning, middle, and end of the study period and results were analyzed using mixed linear effect models. Participants were also asked to complete a "Journal of Experience" which gathered subjective responses to qigong and was reviewed at study conclusion for thematic comments. Quantitative analysis of the PROMIS-29 questionnaires demonstrated statistically significant improvement in six of the eight domains measured. Review of participant experience journals demonstrated that practicing qigong reduced anxiety, reduced tension, increased mind and body awareness, increased use of deep breathing to manage stress, and improved individual outlooks on life among other perceived benefits. Incorporating mind body practices such as qigong into standard treatment and survivorship plans has the potential to improve quality of life and reduce the emotional, physical, and economic burden of symptom management on individuals, care providers, healthcare institutions, and the healthcare system in the U.S. as a whole.

Running head: QIGONG AND CANCER Evaluating the Effect of Qigong on Cancer-Related Fatigue and Quality of Life Cassidy Doucette, RN, BSN University of Utah College of Nursing In Partial fulfillment of the requirements for the Doctor of Nursing Practice QIGONG AND CANCER 2 Running head: QIGONG AND CANCER Executive Summary The negative influence of cancer on individual lives, families, communities, and healthcare institutions is widely known. Fatigue is the most common side effect of cancer and is often followed by pain, anxiety, depression, and overall decreased quality of life. Fatigue and quality of life are complex symptoms that are not easily appeased by medication and are difficult to improve with standard therapies. The purpose of this project was to examine the effectiveness of qigong in improving and preventing common side effects of cancer and cancer care. This was accomplished by providing modifiable and accessible qigong classes, assessing the effect of qigong on quality of life and fatigue symptoms, and disseminating results to support the implementation of Integrative Medicine and Health practices into oncology care plans. The prevalence and physical, emotional, and psychological impact of cancer is well documented in medical as well as lay literature. Current standard of treatments for cancer are associated with a multitude of psychosocial and physical side effects, two of the most impactful being cancerrelated fatigue and decreased quality of life. Integrative Medicine and Health (IMH) is an approach to care that incorporates standard therapies with complementary therapies such as massage, acupuncture, yoga, and tai chi/qigong. Although recognition and prevalence of IMH is growing across the United States, more research is needed to gain public as well as political recognition and impact standards of care. Objectives of this project included (a) increase knowledge surrounding integrative medicine and the potential benefits of mind-body awareness and qigong; (b) provide accessible, modifiable qigong classes; (c) assess the impact of qigong practice on quality life and fatigue in cancer patients and their caregivers; (d) disseminate results to the Integrative Medicine Community. Before initiation of the study, information on IMH and the availability of qigong classes were provided to patients and cancer care providers at Huntsman Cancer Hospital in Salt Lake City, Utah. Willing study participants were asked to practice qigong for sixty minutes, two times a week for a period of five weeks. The PROMIS-29 questionnaire, a validated tool that assess eight domains related to quality of life including fatigue, was administered to participants at the beginning, middle, and end of the study period and results were analyzed using mixed linear effect models. Participants were also asked to complete a "Journal of Experience" which gathered subjective responses to qigong and was reviewed at study conclusion for thematic comments. Quantitative analysis of the PROMIS-29 questionnaires demonstrated statistically significant improvement in six of the eight domains measured. Review of participant experience journals demonstrated that practicing qigong reduced anxiety, reduced tension, increased mind and body awareness, increased use of deep breathing to manage stress, and improved individual outlooks on life among other perceived benefits. Incorporating mind body practices such as qigong into standard treatment and survivorship plans has the potential to improve quality of life and reduce the emotional, physical, and economic burden of symptom management on individuals, care providers, healthcare institutions, and the healthcare system in the U.S. as a whole. Commitee: Chair: Pamela Phares, PhD, APRN; FNP Specialty Track Director: Julie Balk, DNP, APRN; Assistant Dean MS& DNP Programs: Pamela Hardin, PhD, RN, CNE Content Experts: Qigong Teachers: Sifu Toni Lock; Manager of Huntsman Cancer Hospital Wellness and Integrative Health Center: Shelley White, MSW, LCSW. QIGONG AND CANCER 4 Table of Contents Problem statement ........................................................................................................................... 4 Clinical Significance ....................................................................................................................... 5 Policy Implications ......................................................................................................................... 6 Purpose and Objectives ................................................................................................................... 7 Literature Review............................................................................................................................ 7 Introduction ..................................................................................................................................... 8 Cancer ....................................................................................................................................................... 8 Integrative Medicine and Health ............................................................................................................... 9 Qigong .................................................................................................................................................... 10 Theoretical Framework ................................................................................................................. 11 Implementation and Evaluation .................................................................................................... 12 Recommendations ......................................................................................................................... 18 DNP Essentials.............................................................................................................................. 19 Conclusion .................................................................................................................................... 19 References ..................................................................................................................................... 21 Appendix ....................................................................................................................................... 27 Acknowledgement and Special Thanks Pamela Phares, PhD; Julie Balk, DNP; Pamela Hardin, PhD; Shelley White, MSW; Toni Lock, Qigong Sifu Running head: QIGONG AND CANCER Problem statement The National Cancer Institute estimates that 1,685,210 new cases of cancer will be diagnosed in the United States in 2016. For each of these individuals, and the over 15 million people currently living with cancer, getting out of bed each day and performing daily activities is often the biggest challenge. The most common side effect associated with cancer and cancer treatments is fatigue (Berger, Gerber & Mayer, 2012; Jacobsen & Adrykowski, 2015; Kangas, Bovbjerg, & Montgomery, 2008; Thornton, Andersen & Blakely, 2010). Fatigue is often followed and accompanied by pain, anxiety, depression, and an overall decreased quality of life (Cramer, Cohen, Dobos & Witt, 2013). Although over 91% of people affected by cancer experience fatigue with possibly higher rates affected by decreased quality of life, there is currently no gold standard of treatment for these complex and difficult to treat symptoms (Berger et al., 2012; Kangas et al., 2008). Integrative Medicine and Health (IMH) has been gaining respect in the oncology community as it combines standard treatments with "complementary alternative medicine" practices to reduce side effects and improve quality of life. Qigong is a 5,000 year-old mindbody practice developed in China that incorporates breathing with gentle movement and awareness. In previous studies, qigong has been linked to a plethora of health benefits including improving fatigue and quality of life in cancer patients (Campo et al., 2014; Cramer et al., 2013; Oh B et al., 2010; Oh et al., 2012; Zeng et al., 2014). Clinical Significance In 2014, Americans spent $32.6 billion on oncology drugs and $11.1 billion on supportive oncology treatments (Glover, 2015). Supportive oncology includes side effect management that often involves additional medications, increased clinic visits, and emergency QIGONG AND CANCER 6 hospital admissions. Fatigue and quality of life, however, are difficult to treat through standard therapy and often worsen as supportive treatments intensify. The cost of supportive treatment dramatically impacts patients, caregivers, and families as well as insurance companies, medical facilities, and oncology providers. An increased need for supportive treatments leads to additional expensive prescriptions, increased clinic visits and hospital admissions, and increased demands on medical staff as well as a patient's family and caregivers. These costs amount to more than money as they intimately impact the physical, psychological, and emotional wellbeing of all those involved. Integrative Medicine and Health interventions have the potential to reduce these costs by improving side effect management and overall quality of life. When patients feel better they are less likely to need additional prescriptions, request a clinic visit or require a hospital admission (Bordonaro, 2014; Glover, 2015). Improving quality of life includes improving not only physical measures such as strength, energy, balance, and blood pressure, but also mental, emotional, and spiritual well-being. Integrative treatment options such as qigong have the potential to benefit all stakeholders mentioned above by improving overall health and quality of life. Policy Implications Medicaid, Medicare, and the vast majority of private insurance companies do not currently cover IMH therapies such as acupuncture, massage, yoga, tai chi and qigong (Nahin, Barnes, & Stussman, 2016). Continued research is therefore needed to demonstrate the benefits of IMH and instigate policy changes that would provide insurance coverage for IMH therapies as well as insurance reimbursement for IMH practitioners. If successful, this research project could impact all individuals, not only those affected by cancer, by providing additional evidence to support the coverage of IMH practices in Utah as well as Nationwide. QIGONG AND CANCER 7 Purpose and Objectives The primary goal of this project is to assess the potential of qigong to improve quality of life and fatigue in patients being treated for cancer as well as their caregivers. Quality of life and fatigue are two of the most common and challenging side effects of cancer and cancer treatments. The project setting is the Huntsman Cancer Hospital in Salt Lake City, Utah. Objectives for this project include: 1. Increase knowledge surrounding integrative medicine and health interventions and the potential benefits of mind-body awareness and qigong. 2. Provide accessible, modifiable qigong classes. 3. Assess the impact of qigong practice on quality life and fatigue in cancer patients and their caregivers. 4. Disseminate results to the integrative medicine community through the Academic Consortium of Integrative Medicine and Health. Literature Review The following review of literature was gathered using the PubMed and CINAHL databases and employing the following search terms: Cancer, cancer side effects, qigong and cancer, integrative medicine and cancer, supportive oncology, qigong and fatigue, qigong and quality of life. Results we filtered to only include full text and free articles published in the past 10 years. References used in articles found through this method were also explored, as well references listed on the Consortium for Integrative Medicine and Health website and the Wellness and Integrative Medicine and Health Center website created by Huntsman Cancer Hospital in Salt Lake City, Utah. QIGONG AND CANCER 8 Introduction In January 2016, President Barack Obama announced the establishment of a Cancer Moonshot initiative to fast-track cancer research. The Moonshot initiative includes cancer detection as well as treatment, and involves efforts to make these services available to the millions of people affected by cancer every day. A growing part of cancer care is the emergence of integrative health practices, which in line with the Moonshot initiative's encouragement for disciplines to collaborate, works to incorporate therapies such as yoga, massage, acupuncture, qigong and tai chi with standard therapies to provide more comprehensive and patient-centered care. The following literature review examines the impact of cancer and its side effects, as well as the role of integrative health practices, such as qigong, which have the potential to reduce fatigue and improve quality of life in cancer patients and their caregivers. Cancer The prevalence and impact of cancer is well documented and established in literature. The number of individuals currently living in the United States with cancer is estimated to be around 15 million with an additional 1,685,210 new cases anticipated in 2016 (NCI, 2016; American Cancer Society, 2016). Standard of care treatments include chemotherapy, radiation, and surgery. A diagnosis of cancer as well as current standard treatments, however, comes with a multitude of psychosocial and physical side effects. The psychosocial impact of cancer is supported in numerous single studies as well as meta-analyses that examine patients undergoing active cancer treatment as well as cancer survivors (Berger, Gerber & Mayer, 2012; Chen et al., 2013; Jacobsen & Andrykowski, 2015; Oh et al., 2010; Thornton, Andersen, & Blakely, 2010; Zeng, Luo, Xie, Huang & Cheng, 2014). Studies vary in their assessment of the most commonly experienced side effects, however almost every study reviewed mentions the impacts of cancerrelated fatigue and quality of life (Berger et al., 2012; Campo et al., 2014; Chen et al., 2013; QIGONG AND CANCER 9 Jacobsen & Andrykowski, 2015; Kangas, Bovbjerg & Montgomery, 2008; Stanton, Luecken, MacKinnon & Thompson, 2013; Thornton et al., 2010). Thornton et al. (2010) as well as Jacobsen and Andrykowski (2015) found in their observational study and review of literature, respectively, that a triad of pain, anxiety, and depression often accompanies increased fatigue and decreased quality of life. These psychological and physical side effects also have a significant financial impact. Side effects often lead to increased office visits, additional prescriptions, and a higher risk of hospital admissions (Bordonaro, 2014; Glover, 2015). According to Glover (2015) Americans spent $32.6 billion on oncology drugs and 11.1 billion on supportive care oncology treatments in 2014. Integrative Medicine and Health Integrative Medicine and Health has been gaining recognition as research emerges supporting this newer approach to patient care. Integrative medicine is a holistic and patientcentered model of care that address the human body as an ecosystem with many interrelated parts. The goal of IMH is to address the physical, mental, emotional, spiritual, social, and environmental influences that impact health by combining standard of care treatments with complementary therapies (Cramer et al., 2013; Horrigan, Lewis, Abrams and Pechura, 2012). Horrigan et al. (2012) discuss the growing prevalence of IMH across the United States, while Cramer et al. (2013) examine the benefits of IMH in cancer care and how it is being applied successfully in major medical centers around the world. Furthering this discussion, Johnson, Finch, Rivard and Dusek (2014) found in their retrospective analysis of 16,191 oncology patients that those who received IMH therapies had reduced pain and anxiety. Although Integrative Medicine is gaining recognition in select communities, more research is needed to gain wider medical acceptance and instigate policy changes that would enable coverage of supportive oncology care (Cramer et al., 2013; Horrigan et al., 2012). QIGONG AND CANCER 10 Qigong Among the many IMH therapies is a 5,000 year-old traditional Chinese mind-body practice known as qigong (Oh et al., 2010). Very similar to tai chi, qigong can be described as exercise that "consists of a series of orchestrated practices including body posture/movement, breath practice, and meditation, all designed to enhance qi function (that is, drawing upon natural forces to optimize and balance energy within)" (Jahnke et al., 2010, p.2). Research supports a relationship between qigong and a myriad of health benefits including reduced blood pressure and lipid levels, decreased stress hormones, enhanced immune function, increased balance, improved mood, and decreased fatigue (Oh et al., 2010; Wayne, 2016). In a systematic review of 77 random controlled trials, Jahnke et. al (2010) found the most common benefits of qigong were related to bone density, cardiopulmonary effects, physical function, balance, quality of life, selfefficacy, psychological symptoms and immune and inflammation-related responses. Research on the effects of qigong on cancer patients has found similar results, with the majority of studies reporting a connection between qigong and improved fatigue and quality of life (Campo et al., 2014; Cramer et al., 2013; Chen et al., 2013; Jahnke et al., 2010, Oh et al., 2010; Oh et al., 2012; Ho et al., 2012; Zeng et al., 2014). Peter Wayne, Ph.D, Assistant Professor of Medicine at Harvard University and Director of Research, adds to this evidence in a recent lecture he delivered for a medicine research lecture series at the National Center for Complementary and Integrative Health. Dr. Wayne discussed his own research in addition to the growing body of evidence that supports mind-body interventions such as qigong and tai chi. Wayne (2016) describes the neuromuscular and biochemical changes that these practices likely incur, leading to improvements in balance, bone health, cardiovascular disease, respiratory disease, motor diseases (such as MS and Parkinson's), cognitive function, cancer symptoms, sleep and mood. There is a wide variation in findings among studies reviewed for this paper with regard to patient QIGONG AND CANCER 11 population and power, however this growing body of evidence supports the continuing investigation and potential for IM and qigong to play a major role in the future of patient centered, holistic cancer care. Theoretical Framework To effectively assess the impact of qigong on an individual with cancer, it is appropriate to also understand how qigong fits into the larger picture of action and health. The Ecological theory builds on the concept that individual behavior both influences and is influenced by social and environmental levels of interest (Glanz & Rimer, 1997). First proposed by Urie Bronfenbrenner, this theory consists of five interrelated systems. The five systems are the microsystem, mesosystem, exosystem, macrosystem, and chronosystem (Bronfenbrenner 1988). Over the years this theory has been applied to public health and spurred the Social Ecological Model, which organizes systems into individual, interpersonal, community and policy level influences (Centers for Disease Control, 2015). Individual. The practice of qigong strives to help individuals be more aware of their bodies and learn how to use breath and movement to improve their physical, mental, and emotional states of being. Interpersonal. Educating providers as well as patients and their caregivers (often friends or family) on the availability and potential benefits of qigong strives to improve knowledge and change attitudes. Organizational/Institutional. Researching qigong within Huntsman Cancer Hospital (HCH) and disseminating results to institution leaders promotes qigong as an effective treatment and supports its continued integration into the standards of care at HCH and throughout the University of Utah Healthcare system at large. Community. Working with the Wellness and Integrative Health Center and the Red QIGONG AND CANCER 12 Lotus School of Movement in Salt Lake City, Utah to provide free qigong classes creates a positive health impact at the community level. Study results have the potential to further strengthen the support of IMH practices such as qigong throughout Utah as a whole. This has the potential to encourage more research opportunities and increase support through the media. Policy. If successful, this study would support current efforts of the Integrative Health Policy Consortium to (a) increase federal funding and support of preventative and health promotion public health initiatives; (b) increase federal research funding for complementary therapies; (c) implement section 2706 of the Affordable Care Act (ACA) (Oberg, Guarneri, Herman, Walsh & Wostrel, 2015). Section 2706 of the ACA would provide insurance coverage for individuals seeking care through IMH therapies as well as provide insurance recognition and therefore reimbursement of licensed practitioners providing these services. Implementation and Evaluation Objective 1: Increase knowledge surrounding integrative health interventions and the potential benefits of mind-body awareness practices such as qigong. This project was presented to University of Utah College of Nursing faculty and approved on October 21, 2017 (Appendix A). To increase knowledge of IMH interventions, particularly the benefits of mind-body awareness practices such as qigong, a combination of technology, physical posters, and word-of-mouth recruitment were employed for this project at Huntsman Cancer Hospital (HCH) in Salt Lake City, Utah. This study was determined to be exempt by the University of Utah Institutional Review Board (Appendix B) and recruitment took place from January 5th, 2017 through February 1st, 2017. Working with the HCH Communications Department, website banners, blogs, and news posts were created and disseminated through the HCH Wellness and Integrative Health Center website, HCH Nursing website, HCH internal website, and HCH public website. Initial posts included brief information QIGONG AND CANCER 13 on qigong and its potential benefits as well as a statement regarding optional enrollment in a Qigong and Cancer study. A "learn more" link then directed readers to more detailed information about qigong, the Qigong and Cancer study, and directions on how to enroll for those who were interested in being part of the study. An email with this same information was sent to patients, caregivers, and staff using HCH Wellness Center and HCH Nursing email lists. Posters providing a brief description of qigong and its benefits, and the option of enrolling in a study at HCH were posted on communication boards throughout HCH (Appendix C). The implementation of this objective was evaluated through successful completion of the above action items and participant enrollment of at least 30 people in the Qigong and Cancer study. Results. All intended recruitment materials were successfully created and distributed throughout the HCH facility and online community. Study participation surpassed the goal by enrolling 34 participants: 26 individuals with a diagnosis of cancer and 8 caregivers. Due to delays in the IRB review process and the time constraints of a school semester, the time period allotted for study recruitment was reduced from 4 weeks to 2.5 weeks. Once the study began participant barriers led to 10 participants dropping out of the study. A total of 23 individuals completed the study: 18 cancer patients, 3 cancer patient/caregivers, and 2 caregivers. Objective 2: Provide accessible, modifiable qigong classes. Providing accessible, modifiable qigong classes for patients, caregivers and staff at HCH was accomplished through multiple partnerships. The Wellness and Integrative Health Center at HCH has an established relationship with the Red Lotus School of Movement in Salt Lake City, Utah. Toni Lock is a Sifu (teacher) with the Red Lotus School of Movement who has studied tai chi and qigong for 18 years and has taught the forms for over 9 years. Toni currently teaches tai chi and qigong classes at the HCH Wellness Center and agreed to participate in the Qigong and QIGONG AND CANCER 14 Cancer study. Free qigong classes were offered to study participants every Monday and Thursday from 9:30 am to10:30 am for five weeks, from February 2, 2017 through March 6, 2017. Specifically for this study, Toni developed classes that included modifications for individuals confined to a wheelchair or who could not tolerate standing for 60 minutes. To increase accessibility of the classes, two qigong classes taught by Toni were recorded before the study began and were uploaded on to the Wellness and Integrative Health Center tai chi and qigong web page. Recorded classes were then available to study participants, allowing them to practice at home if they were unable to attend class at HCH. Class participation was tracked through a sign-in sheet as well as in each individual's "Journal of Experience" booklet, which was used to record personal data each day after they had practiced qigong and whether they practiced at HCH or through a class recording at home. This objective was evaluated by study participants' completion of 10 consecutive qigong classes as well as monitoring participant access to recorded qigong classes through the HCH Wellness and Integrative Health Center website from home. Results. At the end of the study period, 23 participants completed at least 10 qigong classes, with two individuals participating entirely at home through class recordings. The rest of the participants practiced from home an average of three times throughout the study. Although the goal was to have at least four qigong classes recorded, budget constraints and uncontrollable barriers limited this to only two recordings. Allowing participants to practice at home if they were unable to attend class at HCH was key to study enrollment and participation. Since the study was conducted in the middle of winter, multiple participants missed one or more classes at HCH due to acute illness, weather, or pre-scheduled personal obligations. These individuals expressed gratitude in the ability to continue study participation by practicing qigong at home despite these barriers. Having recorded classes available was also central to the success of the QIGONG AND CANCER 15 study as the sixth consecutive class of the study fell on Presidents Day, Monday, February 20, which would have precluded participation due the HCH Wellness Center being closed for this holiday. Interestingly, many individuals also commented on the power and responsibility of being part of a study to motivate them to attend class as much as possible. Objective 3: Assess the impact of qigong practice on quality of life and fatigue in cancer patients and their caregivers. As study participants arrived for the first day of class they were given a number-coded packet that included a description of the study and their rights to stop participating at any time, a consent form, a PROMIS-29 questionnaire, and a "Qigong and Cancer: Journal of Experience" booklet (Appendix D). The booklet contained a brief description of the purpose of the study, the date, time, and location of classes, expectations for attendance and directions on how to access the recorded classes if they were unable to physically attend a class. The booklet also contained a section for participants to enter basic demographic information including gender, age, if they are a patient/caregiver/staff, and details about their type of cancer and treatments they have had if applicable. The rest of the booklet was comprised of pages that corresponded to each day they were asked to practice qigong. Each of these pages provided the opportunity to record when qigong was practiced, if they practiced at home or in a class setting, additional questions to help explore how their breath, body, and mind felt, and free space to write any other thoughts or discoveries. This information was then reviewed for thematic content and is discussed further in later sections of this paper. Data Collection. Quantitative data was gathered using the Patient-Reported Outcomes Measurement Information System (PROMIS-29) Quality of Life assessment instrument (Appendix E). This tool consists of 29 questions that are grouped into eight separate categories: physical function, anxiety, depression, fatigue, sleep disturbance, ability to participate in social QIGONG AND CANCER 16 roles and activities, pain interference, and pain intensity. Each category is measured independently using topic specific ranking measures, which are stated on the instrument. The PROMIS-29 Profile is a validated tool and is available in the University of Utah Research Electronic Data Capture (REDCap), which was used for data collection and storage for the purposes of this study. The PROMIS-29 instrument, and more information about this instrument, is also available through the National Institute of Health website. This tool was administered to study participants before the first qigong class, at the midpoint of the study before the fifth class, and before the final tenth class. To evaluate this objective, trends from the PROMIS-29 instrument were analyzed using linear mixed effects models and participant experience journals were reviewed for thematic comments. Results. Twenty-three individuals completed at least two PROMIS-29 questionnaires and 20 individuals submitted their "Journal of Experience" for review. Included in the "Journal of Experience" was an optional page to share demographic data. Demographic data of participants can be found in Table 1. Participants represent a range of diagnoses, roles, and treatment experiences from minimally invasive treatments over 5 years ago, to undergoing surgery or receiving chemotherapy during the study, to practicing at home with assistance due to stage 4 disease and the constraint of being wheelchair bound and on a ventilator. All participants, however, expressed through comments in their experience journals that they enjoyed practicing qigong and found it beneficial for a variety of reasons. Review of participant experience journals demonstrated that practicing qigong reduced anxiety and increased a feeling of calm (n=18), reduced tension (n=14), reduced pain (n=10), improved balance (n=7), improved strength (n=10), increased mind and body awareness (n=17), increased breath expansion (n=17), improved stress QIGONG AND CANCER 17 management (n=18), and created a more positive outlook on life and self (n=15). Comments at the beginning of most journals reviewed (n=15) exhibit a focus on negative feelings and reflections such as "it was hard to breath deep", "hard to focus", "I feel tired", "I got distracted", "I felt agitated", "I was restless", "it was difficult to relax", and "my balance is horrible". After completing four to six classes, these negative comments began to shift to positive comments that focused on improvements and changes participants were experiencing such as, "I have less anxiety", "my mind is more clear thinking", "my mind isn't wandering as much", "I have become more patient", "I am more calm", "I feel more relaxed", "I felt more balanced", and "calmness is now staying with me longer after class". Even participants that were unable to practice a full 40 to 60 minutes or were wheelchair bound and practiced through visualization and passive assisted motion found qigong to be enjoyable and beneficial. One individual in particular, who practiced exclusively at home with the assistance of her daughter, commented in her journal: "I have to visualize a lot of the movement but it is calming to follow along…although I am unable to physically do qigong movements, my daughter moves one side at a time, doing the movements for me and it feels wonderful. I typically just have range of motion type exercises and while there are some similarities, combining the breath, focus on chi, etc. have all helped me feel less pain and decrease stiffness. I'm also sleeping better. Visualizing the movements also helped and felt relaxing. There aren't many options or sources that I have gotten much relief from so it has been great to find something that helps me mentally and physically." A collection of more detailed quotes from participant journals can be found in Appendix F. A quantitative analysis of PROMIS-29 questionnaires was performed using linear mixed effect models to assess individual changes over time. Improvement was found in six of the eight domains. The most dramatic improvements were seen for fatigue (p = .0009) and sleep disruption (p < .0001) (See Figure1 and Figure 2 for plot of scores and regression lines). Other findings showed significant changes in social functioning (p = .0069), decreased pain QIGONG AND CANCER 18 interference (p = .0194), decreased pain intensity (p = .0150) and decreased depression (p = .0342) (See Figure 3, Figure 4, Figure 5, and Figure 6 respectively for plotted scores and regression lines). No significant change was seen in physical function (p = .0596) or anxiety (p = .0871) (See Figure 7 and Figure 8 for plotted scores and regression lines). Details regarding the analysis of each of these domains can be viewed in Appendix G through Appendix N. Objective 4: Disseminate results to the Integrative Medicine Community through the Academic Consortium of Integrative Medicine and Health. An abstract of findings from the Qigong and Cancer study was submitted to the Academy of Integrative Health and Medicine 2017 Annual Conference and a poster was created and presented to College of Nursing Faculty (Appendix O). This objective was evaluated through completion of the project and successful abstract submission. Acceptance or rejection of the abstract submission will not be known until May 2017. Recommendations This project was successful in meeting the objectives of increasing cancer caregiver and cancer patient knowledge surrounding Integrative Medicine and the practice of qigong, providing accessible and modifiable qigong classes, and evaluating the impact of qigong on cancer-related fatigue and quality of life in cancer patients and their caregivers. Results demonstrate that incorporating qigong into standard treatment and survivorship plans has the potential to improve quality of life and reduce the emotional, physical, and economic burden of symptom management on individuals and care providers. This study also demonstrates the potential for virtual qigong classes to be offered within and outside of a healthcare setting. Linear mixed effect models were chosen for analysis of study data because of their ability to assess random and fixed variables simultaneously and increase the power of results. Intrapersonal variation among study participants was accounted for while assessing trends over QIGONG AND CANCER 19 time in relation to practicing qigong and PROMIS-29 results. For the purpose of this project only variation over time was evaluated. Additional analysis could be conducted to investigate other variables such as age, gender, role of the participant, diagnosis and types of treatments. Due to time limitations, no control or comparison group was used in this pilot study. Conducting a larger study using a control or comparison group may elicit more powerful results. Major barriers encountered during this study were lack of time, minimal monetary funds, and participant compliance. A longer study with use of a control group, transportation assistance for individuals, and provision of additional virtual sessions and wider online access would have the potential to increase study power by recruiting more cancer patients and their personal and professional caregivers. Additional quantitative measures such as pre and post physical strength and balance tests, cognition tests, cortisol levels, and/or vital sign measurements could also strengthen this study by providing objective biological measurements and data to determine physical effects of qigong. Future research arising from this study may include (a) comparing differences in benefit of practicing qigong in a physical group setting versus participation through virtual recordings at home; (b) exploring whether the effects of qigong differ in patients versus caregivers; (c) determining if qigong has a greater effect on individuals with cancer in active treatment versus those who have completed treatment; (d) analyzing if the frequency of practicing qigong affects outcomes; (e) exploring the effects of qigong on hospitalized patients if recordings were made available in hospital rooms. Qigong practitioners and teachers can be found in many communities across the United States and a handful of NCI designated cancer institutions have established or are developing integrative medicine and health programs. DNP Essentials The Qigong and Cancer study fulfills DNP essential II, "organizational and system leadership for quality improvement and systems thinking" (AACN, 2006, p. 9) as well as DNP QIGONG AND CANCER 20 essential IV, "interprofessional collaboration for improving patient and population health outcomes" (AACN, 2006, p. 14). Evaluating the effect of qigong on individuals affected by cancer strives to spark organizational change and improve standards of care by providing evidence for an accessible and safe intervention that can improve patient and healthcare outcomes. This study worked to be more inclusive and reduce disparities by offering qigong classes free of charge to anyone affected by cancer. It also encouraged HCH as an organization, as well as healthcare providers within HCH, to consider a new care delivery model that supports and incorporates mind-body practices such as qigong. Interdisciplinary collaboration was essential to complete this project as the implementation and evaluation required individuals of multiple disciplines and backgrounds to work together. This project would not have been possible without the cooperation and dedication of Chinese movement masters, social workers, communication and IT specialists, physical therapists, oncologists, nurses, medical assistants, administrators, managers, and cancer patients. Conclusion The prevalence of cancer with its attendant physical, emotional, psychological, and economical impact is well documented in medical as well as lay literature. Current cancer treatment protocols are associated with a multitude of psychosocial and physical side effects, the most common of which are fatigue and decreased quality of life. Integrative medicine has the potential to play an important role in the future of cancer care by approaching treatment more holistically to include mental, emotional, social, environmental, and physical influences. Practices such as qigong provide time and space for a person to reconnect with their mind and body, breathe deep and move gently. These actions have physical as well as psychological effects on the autonomic, central and peripheral nervous systems. Practices that involve deep QIGONG AND CANCER 21 breathing have been shown to improve circulation, reduce heart rate and blood pressure, enhance tissue oxygenation, relax muscles and ease the mind (Edry, Barnes & Jerath, 2006). This study followed a group of 23 individuals impacted by cancer as they practiced qigong twice a week for five weeks. A comparison of PROMIS-29 Quality of Life questionnaire results from the beginning, middle and end of the study demonstrated significant improvement in fatigue, sleep, depression, social function, pain interference, and pain intensity. Thematic comments from individuals "Journal of Experience" expressed improved quality of life through creation of a more positive outlook on life and self, improved stress management, improved strength, increased balance, reduced tension, reduced anxiety, and less pain. These findings demonstrate the impact and many benefits that qigong can have on individuals affected by cancer. Integrating qigong into standard patient treatment plans has the potential to reduce common side effects associated with cancer, therefore reducing the financial and social burdens of symptom management on individuals, families, healthcare institutions, and the healthcare system in the U.S. as a whole. Running head: QIGONG AND CANCER References Berger, A. M., Gerber, L. H. and Mayer, D. K. (2012). Cancer-related fatigue. Cancer, 118: 2261-2269. doi:10.1002/cncr.27475 Bordonaro, S., Romano, F., Lanteri, E., Cappuccio, F., Indorato, R., Butera, A., … Tralongo, P. (2014). Effect of a structured, active, home-based cancer-treatment program for the management of patients on oral chemotherapy. Patient Preference and Adherence, 8, 917-923. doi:10.2147/PPA.S62666 Bronfenbrenner, U. (1988). Interacting systems in human development. Research paradigms: Present and future. In N. Bolger, A. Caspi, G. Downey, & M. Moorehouse (Eds.), Persons in context: Developmental processes (pp. 25-49). Cambridge, U.K.: Cambridge University Press. Campo, R., Agarwal, N., LaStayo, P., O'Connor, K., Pappas, L., Boucher, K., . . . Kinney, A. (2014). Journal of Cancer Survivorship, 8(60). doi: 10.1007/s11764-013-0315-5 Centers for Disease Control. (2015). Social ecological model. Retrieved from http://www.cdc.gov/cancer/crccp/sem.htm Chen, Z., Meng, Z., Milbury, K., Bei, W., Zhang, Y., Thornton, B., . . . Cohen, L. (2013). Qigong improves quality of life in women undergoing radiotherapy for breast cancer: results of a randomized controlled trial. Cancer, 119, 1690-1698. doi:10.1002/cncr.27904 Cramer, H., Cohen, L., Dobos, G., & Witt, C. M. (2013). Integrative oncology: Best of both worlds-theoretical, practical, and research Issues. Evidence-Based Complementary and Alternative Medicine : eCAM, 2013, 383142. doi: 10.1155/2013/383142 Edry, J., Barnes, V., and Jerath, V. (2006). Physiology of long pranayamic breathing: Neural respiratory elements may provide a mechanism that explains how slow deep breathing QIGONG AND CANCER 23 shifts the autonomic nervous system. Medical Hypotheses, 67(3): 566-571. http://dx.doi.org/10.1016/j.mehy.2006.02.042 Glanz, K. and Rimer, B. (1997). Theory at a glance: A guide for health promotion practice. Bethesda, MD: U.S. Department of Health and Human Services, National Cancer Institute. Glover, L. (2015). Oncologists worry about rising costs of cancer treatment: A task force of doctors has proposed a system to help patients better manage cancer costs. U.S. News & World Report. Retrieved from http://health.usnews.com/health-news/patientadvice/articles/2015/07/01/oncologists-worry-about-rising-costs-of-cancer-treatment Ho, R.T., Chan, J.S., Wang, C.W., Lau, B., So, K.F., Yuen, L.P., & Sham, J. (2012). A randomized controlled trial of qigong exercise on fatigue symptoms, functioning, and telomerase activity in persons with chronic fatigue or chronic fatigue syndrome. Annals of Behavioral Medicine, 44(2), 160-170. doi:10.1007/s12160-012-9381-6 Horrigan, B., Lewis, S., Abrams, D. I., & Pechura, C. (2012). Integrative medicine in America- How integrative medicine is being practiced in clinical centers across the United States. Global Advances in Health and Medicine, 1(3), 18-94. doi:10.7453/gahmj.2012.1.3.006 Jacobsen, P. B., & Andrykowski, M. A. (2015). Tertiary prevention in cancer care: Understanding and addressing the psychological dimensions of cancer during the active treatment period. American Psychologist, 70(2), 134-145. doi:10.1037/a0036513 Jahnke, R., Larkey, L., Rogers, C., Etnier, J., Lin, F. (2010). A comprehensive review of health benefits of qigong and tai chi. American Journal of Health Promotion, 24(6). doi:10.4278/ajhp.081013-LIT-248 QIGONG AND CANCER 24 Johnson, J., Finch, M., Rivard, R., and Dusek, J. (2014). Effects of integrative medicine on pain and anxiety among oncology inpatients. The Journal of Alternative and Complementary Medicine, 20(5). doi:10.1089/acm.2014.5027 Kangas, M., Bovbjerg, D. H., & Montgomery, G. H. (2008). Cancer-related fatigue: A systematic and meta-analytic review of non-pharmacological therapies for cancer patients. Psychological Bulletin, 134(5), 700-741. doi:10.1037/a0012825 Nahin, R., Barnes, P., and Stussman, B. (2016). NCHS data brief: Insurance coverage for complementary health approaches among adult users: Unites States, 2002 and 2012. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db235.pdf National Cancer Institute. (2016). Cancer statistics. Retrieved from http://www.cancer.gov/about-cancer/understanding/statistics Oberg, E., Guarneri, M., Herman, P., Walsh, T., & Wostrel, A. (2015). Integrative health and medicine: Today's answer to affordable healthcare. Retrieved from http://www.ihpc.org/wp-content/uploads/CEBooklet_June2-2015.pdf Oh, B., Butow, P., Mullan, B., Clarke, S., Beale, P., Pavlakis, N., . . . Rosenthal, D. (2010). Impact of medical Qigong on quality of life, fatigue, mood and inflammation in cancer patients: a randomized controlled trial. Annals of Oncology, 21(3): 608-614. doi: 10.1093/annonc/mdp479 Oh,B., Butow, P., Mullan, B., Clarke, S., Beale, P., Pavlakis, N., . . . Larkey, L. (2012). Effect of medical Qigong on cognitive function, quality of life, and a biomarker of inflammation in cancer patients: a randomized controlled trial. Supportive Care in Cancer, 20(6):12351242. doi: 10.1007/s00520-011-1209-6 Stanton, A. L., Luecken, L. J., MacKinnon, D. P., & Thompson, E. H. (2013). Mechanisms in psychosocial interventions for adults living with cancer: Opportunity for integration of QIGONG AND CANCER theory, research, and practice. Journal Of Consulting And Clinical Psychology, 81(2), 318-335. doi:10.1037/a0028833 Thornton, L. M., Andersen, B. L., & Blakely, W. P. (2010). The pain, depression, and fatigue symptom cluster in advanced breast cancer: Covariation with the hypothalamic- pituitary-adrenal axis and the sympathetic nervous system. Health Psychology, 29(3), 333-337. doi:10.1037/a0018836 Wayne, P. (2016). Minding your balance with Tai Chi: The interdependence of cognitive and motor function in the elderly [PowerPoint slides]. Retrieved from https://videocast.nih.gov/summary.asp?Live=19669&bhcp=1 Zeng, Y., Luo, T., Xie, H., Huang, M., & Cheng, A. K. (2014). Health benefits of qigong or tai chi for cancer patients: a systematic review and meta-analyses. Complementary Therapies In Medicine, 22(1), 173-186 14p. doi:10.1016/j.ctim.2013.11.010 25 Running head: QIGONG AND CANCER Table 1 Qigong and Cancer study participant demographic information Treatment Current Treatment Qigong Experience Yes No No Yes No No Age Sex Role Diagnosis 67 F Patient Breast, 2016 61 F Patient Breast stage 1 grade 3, 2012 56 F Patient Breast stage 2b, 2007 59 42 F F Staff Caregiver 70 M Patient Melanoma, 2012 46 M Patient ALL, 1974 68 F Patient Meningioma stage 3, 1977 Surgery Radiation 62 F Renal cell, 2012 Surgery 44 F Patient Patient and Caregiver No, palliative care. On Ventilator No Breast, 2017 Surgery Yes Yes 51 F Patient Breast stage 3, 1995,1999 No Yes 68 F Patient 2014 No Yes 71 F Patient Peritoneal cancer stage 4, 2012 Chemo Yes Yes 26 F Patient H. Lymphoma stage 2B, 2016 Chemo Yes No 60 F Caregiver 67 M Patient Prostate stage 4, 2009 45 F Patient Breast, 2016 70 F Patient Uterine, 2007 70 M Patient Prostate, 2010/16 58 F Patient and Caregiver Melanoma Chemo Radiation Chemo Radiation Surgery Chemo Radiation Surgery No Yes Chemo Surgery Chemo BMT Chemo Radiation Surgery Chemo Radiation Surgery No Yes No Yes No No No Hormones Surgery Chemo Hormones Chemo Radiation Surgery Radiation Surgery Surgery Yes Yes Yes Yes No No No Yes No No Running head: QIGONG AND CANCER Figure 1. Fatigue scores and regression line analysis from linear mixed effect model procedure. Individual fatigue scores are plotted from the first visit (obtained from PROMIS-29 questionnaire administered before the first qigong class), the second visit (obtained from PROMIS-29 questionnaire administered before the fifth qigong class), and the third visit (obtained from PROMIS-29 questionnaire administered before the tenth qigong class). Figure 2. Sleep disturbance scores and regression line analysis from linear mixed effect model procedure. Individual sleep disturbance scores are plotted from the first visit (obtained from PROMIS-29 questionnaire administered before the first qigong class), the second visit (obtained from PROMIS-29 questionnaire administered before the fifth qigong class), and the third visit (obtained from PROMIS-29 questionnaire administered before the tenth qigong class). QIGONG AND CANCER 28 Figure 4. Social function scores and regression line analysis from linear mixed effect model procedure. Individual social function scores are plotted from the first visit (obtained from PROMIS-29 questionnaire administered before the first qigong class), the second visit (obtained from PROMIS-29 questionnaire administered before the fifth qigong class), and the third visit (obtained from PROMIS-29 questionnaire administered before the tenth qigong class). Figure 4. Pain Interference scores and regression line analysis from linear mixed effect model procedure. Individual pain interference scores are plotted from the first visit (obtained from PROMIS-29 questionnaire administered before the first qigong class), the second visit (obtained from PROMIS-29 questionnaire administered before the fifth qigong class), and the third visit (obtained from PROMIS-29 questionnaire administered before the tenth qigong class). QIGONG AND CANCER 29 Figure 5. Pain intensity scores and regression line analysis from linear mixed effect model procedure. Individual pain intensity scores are plotted from the first visit (obtained from PROMIS-29 questionnaire administered before the first qigong class), the second visit (obtained from PROMIS-29 questionnaire administered before the fifth qigong class), and the third visit (obtained from PROMIS-29 questionnaire administered before the tenth qigong class). Figure 6. Depression scores and regression line analysis from linear mixed effect model procedure. Individual depression scores are plotted from the first visit (obtained from PROMIS29 questionnaire administered before the first qigong class), the second visit (obtained from PROMIS-29 questionnaire administered before the fifth qigong class), and the third visit (obtained from PROMIS-29 questionnaire administered before the tenth qigong class). QIGONG AND CANCER 30 Figure 7. Physical function scores and regression line analysis from linear mixed effect model procedure. Individual physical function scores are plotted from the first visit (obtained from PROMIS-29 questionnaire administered before the first qigong class), the second visit (obtained from PROMIS-29 questionnaire administered before the fifth qigong class), and the third visit (obtained from PROMIS-29 questionnaire administered before the tenth qigong class). Figure 8. Anxiety scores and regression line analysis from linear mixed effect model procedure. Individual anxiety scores are plotted from the first visit (obtained from PROMIS-29 questionnaire administered before the first qigong class), the second visit (obtained from PROMIS-29 questionnaire administered before the fifth qigong class), and the third visit (obtained from PROMIS-29 questionnaire administered before the tenth qigong class). QIGONG AND CANCER 31 Appendix A Scholarly Project Proposal Presentation QIGONG AND CANCER 32 QIGONG AND CANCER 33 Appendix B IRB Determination IRB_00096480 Cassidy Doucette Evaluating the effect of Qigong on cancer-related fatigue and quality of life in cancer patients and their caregivers 1/4/2017 Date The above-referenced protocol has received an IRB exemption determination and may begin the research procedures outlined in the University of Utah IRB application and supporting documents. IRB: PI: Title EXEMPTION DOCUMENTATION Review Type: Exemption Review Exemption Category(ies): Category 2 Exemption Date: 1/4/2017 Note the following delineation of categories: • Categories 1-6: Federal Exemption Categories defined in 45 CFR 46.101(b) • Categories 7-11: Non-Federal Exemption Categories defined in University of Utah IRB policy in Investigator Guidance Series, Exempt Research You must adhere to all requirements for exemption described in University of Utah IRB policy in (Investigator Guidance Series, Exempt Research ). This includes: • All research involving human subjects must be approved or determined exempt by the IRB before the research is conducted. • All research activities must be conducted in accordance with the Belmont Report and must adhere to principles of sound research design and ethics. • Orderly accounting and monitoring of research activities must occur. Ongoing Submissions for Exempt Projects • Continuing Review: Since this determination is not an approval, the study does not expire or need continuing review. This determination of exemption from continuing IRB review only applies to the research study as submitted to the IRB. You must follow the proposed protocol. QIGONG AND CANCER 34 Appendix C Study Recruitment Poster Running head: QIGONG AND CANCER Appendix D Qigong and Cancer: Journal of Experience QIGONG AND CANCER 36 QIGONG AND CANCER 37 QIGONG AND CANCER 38 QIGONG AND CANCER 39 QIGONG AND CANCER 40 QIGONG AND CANCER 41 QIGONG AND CANCER 42 QIGONG AND CANCER 43 QIGONG AND CANCER 44 Running head: QIGONG AND CANCER Appendix E PROMIS-29 Questionnaire-Quality of Life Assessment QIGONG AND CANCER 46 QIGONG AND CANCER 47 QIGONG AND CANCER 48 Appendix F A Selection of Qigong Journal comments "I am more calm" "Qigong has a calming, relaxing effect on me" "I was always rushing to get to the next chore or event. I have become more patient" "I have learned to take time and practice qigong. Sometimes just to breathe" "Qigong is relaxing, I want to keep it up" "Qigong calms and centers me" "Focus on breathing is like going to a calm place. Very peaceful effect." "I am less tense after class. Overall relaxed feeling- better well being" "Breath helps during the day. I find myself, when getting more tense, taking my own long deep breathes" "The tools of Qigong really help me re-center in stressful situations" "When I feel distracted, agitated or unfocused, I can stop, breath and move forward in a more aware way" "I've learned that your mind can redirect itself- you can smile, gather energy and completely change your outlook and physical energy. "Deep breathing allows more presence in the moment thereby heightening one's awareness of others around them as well as other surroundings of space." "The moments of being lost in the present are like opening a door to a place of total peace and oneness" "Empowered to go forward with more confidence" "Mood was much better" "I have increased gratitude for my body" " I am only human and can only do so much" "I feel I have come to a place where I don't get so bothered internally by not being able to fix things out of my control- and I am okay with that" "Breath is an instant relaxer and empowerer" "My mind is aware of my body movements" "More awareness, more gratitude, more peace" "I have control over the tension in my body and I can allow it to go away and not ruin my day" "When I'm feeling stressed out I try to remember to take a few slow deep belly breathes to release my tension and re focus. It helps me relax, feel quiet and calm…" "I'm able to calm my mind by using imagery and breathing in stressful situations" "Focus on my breath and body helps me to relax my body during stressful situations" " I feel more relaxed and do movements when stressed at home. Has helped with life stress recently" "I am more at peace- less critical-more aware of beauty in all things. My cup is more ½ full". "Moving more slowly after class and throughout my day I actually feel more productive" "I feel more clarity" "I am able to focus on each task I have to do calmly instead of feeling rushed and overwhelmed". "Breathing brings focus and expansion which lasts through the day" "Qigong allows my mind to quit jumping from one thing to another- it calms my minds and allows for focus and clarity. Calmness abides!" "I look forward to each class because I have a feeling of peace and calm during and after class" "I feel stronger and more self-confident then when we first started (class 10)" "It makes me feel more energized and more productive" "Qigong helps me move forward with a disability" "Every time I don't feel like doing this I still do it and feel like I get something new out of it" "Although physically I am sick (GI issues as well as medication side effects) it felt good to stretch!" "Best to practice even if your feeling flat because you will feel better after, stronger and more optimistic overall" "Qigong helps me feel grounded and peaceful.. this helps me be more aware and make better decisions" "This class is helping me build a better quality of life" QIGONG AND CANCER 49 "I can feel my body and mind releasing and letting go" "I feel more energized" "I have to visualize a lot of the movement but it is calming to follow along" "I have to visualize a lot of the movement but it is calming to follow along…Although I am unable to physically do qigong movements, my daughter moves one side at a time, doing the movements for me and it feels wonderful. I typically just have range of motion type exercises and while there are some similarities, combining the breath, focus on chi, etc. have all helped me feel less pain and decrease stiffness. I'm also sleeping better. Visualizing the movements also helped and felt relaxing. There aren't many options or sources that I have gotten much relief from so it has been great to find something that helps me mentally and physically." "I have lung issues and this has been very helpful!" "I am more aware of my body" "With a new cancer diagnosis and having surgery in the middle of this study, I can say that qigong healsmind/body/spirit." "I feel less anxious and sore. I feel more in control of my mind/body" "My mood is more open, more accepting. Calm energy- focused" "I believe qigong really helps you create a body mind link- creates a trust between mind and body and improves awareness…helps you see the bigger picture- you are not so focused on your own problems. Also you learn to allow your mind to check in with your body and vice versa…This enabled me to not give up. To start moving even when I felt I couldn't, and embrace a strength from fellow practitioners, teachers, and from within myself" "I like qigong because its one time I feel a bit graceful." "I felt sad, confused, and agitated last night for no reason. This mornings practice wiped all that away, I feel warm, peaceful and calm." "During class I feel centered, calm and controlled. After class I feel energized, ready to tackle things that require attention" "I felt happy and centered after class" "My arms and shoulders don't tingle like they did at the beginning" "Before class I had a sore upper back and headache, during class I realized my hips were sore, after class, it all felt so much better- headache gone!" "I've been away from home for ten months- this class improved my ability to deal with stress and helped me be a better ‘caregiver' because I'm able to be present and calm" "Yesterday I was driving in my care and all of the sudden I could feel my whole body relax. I don't think that this has ever happened before" "I was sick multiple times during this study, which I think "colored" my questionnaire responses. Overall, I found myself using qigong mentally in daily activities which was extremely helpful in stressful situations…I'm grateful for this study...thank you for providing this wonderful way of living and breathing" "I was sick the last half of the study and fear the questionnaire will show things got worse for me. I loved participating and Toni has given me a new love for Qigong- thank you!" "I have learned that the present is all that I really have control over and breath helps bring me in to the moment" "Since treatment for my cancer I strongly feel that along with cancer treatments I should have had a support system that included counseling, diet and exercise. That is why I signed up for this study. I hope to continue with Qigong as I feel that it has been very good for me." "Qigong has helped me cope with large crowds" "I fell calmer and nourished with love and acceptance of change and what is" "I feel less anxious. Gentle movement is an amazing tool" "I am more open to love, appreciation and acceptance of what is" QIGONG AND CANCER 50 Appendix G Fatigue Mixed Procedure QIGONG AND CANCER 51 Appendix H Sleep Disturbance Mixed Procedure QIGONG AND CANCER 52 Appendix I Social Function Mixed Procedure QIGONG AND CANCER 53 Appendix J Pain Interference Mixed Procedure QIGONG AND CANCER 54 Appendix K Pain Intensity Mixed Procedure QIGONG AND CANCER 55 Appendix L Depression Mixed Procedure QIGONG AND CANCER 56 Appendix M Physical Function Mixed Procedure QIGONG AND CANCER 57 Appendix N Anxiety Mixed Procedure Running head: QIGONG AND CANCER Appendix O Poster Presentation