SPEAKER_01 0:00

On this episode, a recent study found that yoga may help cancer survivors sleep better and reduce anxiety and fatigue. Which seems somewhat counterintuitive to use movement or exercise, something that requires energy, to help battle low energy. What exactly is going on in a yoga practice that profoundly benefits cancer survivors? Joining me to discuss these findings is Dr. Karen Muschkin, a senior author on the study. She is a dean's distinguished professor in the Department of Surgery at the University of Rochester Medical Center, and an internationally recognized leader in cancer survivorship, integrative oncology, exercise oncology, geriatric oncology, behavioral oncology, and gender, sexuality, and women's health. Dr. Mushin breaks down the details of how and why yoga is a great avenue for survivors to find benefit and hope. We go into details of the style of yoga she uses in her study, even the exact sequence of poses she uses that is optimized for survivors. She also talks about other components of a yoga class that may be contributing to positive outcomes, such as mindfulness, deep relaxation, social connection or community, empowering students, and finding purpose through yoga. Dr. Mukchin also explains what this means in the broader picture of helping to battle cancer. I'm Jake Panistevich, and this is the Yoga with Jake podcast.

SPEAKER_00 1:54

I'm good. How are you, Jake?

SPEAKER_01 1:56

I'm doing well. Did I pronounce that okay?

SPEAKER_00 1:58

Yeah, Mushchen, like your chin. It's perfect.

SPEAKER_01 2:02

Okay, perfect. That's a good way to remember.

SPEAKER_00 2:05

Yeah, that's that's what I tell people. It works.

SPEAKER_01 2:09

Nice. Well, wonderful. I I really appreciate you taking the time to chat with me today.

SPEAKER_00 2:15

No, no, it's my pleasure. I'm happy to do it.

SPEAKER_01 2:18

You know, I was really uh like thrilled when I saw that I was speaking with you because I had looked up some of your work and also just listened to you speak uh on some uh platforms. And you yourself are also um interested in in yoga and obviously working on yoga research. I just wonder if we could start by just getting a sense of who you are and what brought you to this work.

SPEAKER_00 2:44

Oh, that's a wonderful story, and I love telling the story. Um so um I'm formally trained and have degrees in exercise physiology, exercise psychology, biomechanics, gerontology, athletic medicine, and public health. Um, so I'm kind of a mixed bag of lots of things. Um, but for me, I started out my career, my life, uh, you know, teaching, coaching. Uh, I was actually consulting for the United States Olympic Committee and the International Olympic Committee. I was doing biomechanical sport performance enhancement for elite athletes. And really, three things happened in my life that sort of completely derailed where I was and set me on this path. And uh the first thing is that both of my grandmothers got sick with cancer and I helped take care of them as a young adult. Uh, you know, I was the only one in my family at the time who had a college degree. And when they heard the word athletic medicine, I think they thought that I meant uh, you know, I knew a lot more about cancer than I did. So my family was constantly asking me questions. I was, you know, there in the hospitals and with them at their treatments, and I saw all the side effects and toxicities that they were experiencing. And I realized that even the doctors and the nurses at the time who were helping to take care of them didn't have solutions for managing all these side effects and toxicities. We're talking about, you know, back way back in the in the uh late 80s, early 90s. And um the second thing that happened is I was actually also uh as a coach at the time, uh, some folks in my community approached me and asked me to lead the Relay for Life, which is a fundraiser in our community. And if you know anything about the origins of the relay, it was all about doing this sort of 24-hour team relay on a track. And there would be all these teams that would sign up to do it and raise money for the American Cancer Society. And in our community, we had a huge group of survivors who, and actually patients on treatment at the time, who wanted to also participate. So they started training, they participated. I did this over three years, and when they were participating, they would come up to me because they knew I was a coach and I had a background in exercise and all this, and they would tell me stories about how exercising helped them with their cancer. And they were really amazing stories about how they would have these side effects or toxicities, and the minute they would start walking again or trying to do some a little bit of exercise, how much it would really sort of change the course of the severity of these side effects they were experiencing for the better. And then the third thing is I had never been exposed to any mindfulness forms of movement, and I had the opportunity professionally to go to a conference in Stevens Point, Wisconsin, which I thought was going to be a traditional sort of, you know, research conference. And it turned out to be something I never expected, which was a very uh participatory conference where we had yogis uh teaching yoga, we had Tai Chi masters teaching Tai Chi, we had, you know, shamans from South America who were leading us through meditations, uh in my person, you know, and they weren't just talking to us, they were actually, you know, leading us through these. And and I remember my first experience of, you know, several of these activities and yoga being one of them, um, where after years of being a competitive athlete, it was like all of a sudden I realized, oh my gosh, this thing that we try to do, you know, in the way that we work in our sort of Euro Western way of thinking in the United States, where we teach you to move, we're doing aerobics, but we're not really teaching people how to integrate their mind and their body into this practice, right? And my exposure to that was, oh my gosh, here's a way to do this. And people have been doing it for hundreds of thousands of years, and this is the secret. And I, and it just kind of grabbed me in a way that it's never let go. And right after that, um, it didn't take me long. Uh, it took about three years, and you know, with all this sort of happening, and that's when I literally decided, okay, it's time for me to quit my job, go back to school. I'm doing my PhD, and this is what I want to do. I want to do things like yoga and tai chi and exercise with cancer patients. And really, the yoga has been my favorite part of the work, it's the most meaningful part of the work. Uh, I feel like it's really an honor to even be able to do the work with yoga and cancer patients and survivors. And that landed me in Rochester. And 23, almost 24 years later, uh, I've done some really fun, amazing stuff with cancer patients and yoga.

SPEAKER_01 7:57

That's that's wonderful. I'm curious what makes you most excited about the yoga component of your work?

SPEAKER_00 8:06

What is the most exciting about the yoga component of my work is that when you combined teaching people and facilitating movement with the integration of the breathing and the mindfulness, they really use something special that happens. And it's different from when I tell participants to use like another intervention that I've developed with walking and resistance bands. Both things work. Um, but but when you're really working with someone to integrate the mindfulness components and the breathing, I think there's an extra level of um, I like to use the word sort of healing, not necessarily curing, because we're not saying this cures your cancer. Um, but the healing. I mean, patients experience so much, they have you know so much anxiety and worry and the emotional upheaval of hearing that you have cancer and then going through treatments and maybe losing your hair or you know, losing all of your muscle mass if you're on like uh androgen deprivation therapy, for example, um, all the side effects of the nausea, the vomiting, the hair loss, the all the toxicities, it's just bombarding you all the time. And so to be able to navigate this process with something that steadies the ground for you, I feel like it empowers patients and survivors. They feel like this is a tool that we give them. It's not another drug that they take, and it's something they can control and they have power over when they feel like I often hear them tell me they feel like this disease just sort of took away their power. And so it does a lot. The physical aspects uh help tremendously with function, but it's also those psychosocial, emotional benefits that come along with it that is not there if you just tell someone to wait, train, or walk, or jog.

SPEAKER_01 10:03

Yeah, I I how would you define mindfulness? Um, is it self-awareness or how how does one measure that when they're looking at a yoga intervention? I know my definition of it as a yoga teacher, but I'm always curious because it's definitely a um write a a something that's studied. And so how do you use one define that as a researcher and how do you measure mindfulness?

SPEAKER_00 10:34

So it's interesting because we don't use in my trials a direct outcome measure to say this person is or is not mindful. We don't do that, uh, and we don't really measure changes in the mindfulness, we measure cancer outcomes, right? So my work is focused on using this holistic tool, if you will, or therapy, if you will. Um, but what I can tell you about my definition of mindfulness is how we apply it in the classes and the intervention that we deliver and how we talk about it with participants when uh we're having those discussions or it's coming up or they have questions. First of all, mindfulness is a very complex thing. Um, you know, I think if you talk to some people, they'll say, well, is it meditation or is it not meditation? And I think the answer is yes, it's meditation and it's more than meditation. Um, but I also think that depends on how you define meditation. Um when we are talking about mindfulness, we're trying to convey a concept of being fully present, being fully aware of what you're experiencing. And you know, in the class we'll use tools where we might say, you know, as you're in Shibasana today, you know, and you're lying here, just try to let everything go and just focus on being present. We also sometimes will use something more specific and guided, right? Where we might talk about imagining yourself in, you know, a really special place where you feel wonderful or things like that. To me, those are not sort of the end component of mindfulness, those are tools and methods that we use to help someone become mindful. The same way as if you're moving through asana and we're asking you to control your breathing throughout a full asana in a certain way, um, or we're asking you to control your thoughts in the asana, be aware of them, acknowledge them, move away. We know you might be uncomfortable right now and downward dog. Like, play with that. What does that feel like? How's that make you think? So, really, I think at the end of the day, mindfulness is about being able to pay attention to yourself. And I mean that from an emotional and mental state, but also physically, the sensations, your environment around you, the feeling of a fan blowing up, you know, just be present, notice, be with it, acknowledge it, and move through it in the way that is good and healthy for you at the time. And it may sound really simple, but those are like really big concepts. Um, and I think yoga and the work we do with yoga is a tool for that. And it's another thing is that I also think it's about as we use these tools and we move through it, it's about training it so much that it almost becomes reflexive. And you know, when you have something happen that throws you a curveball in your day, um it's like having it's like having the ability to balance in the bank, right? Like if you could think of you've practiced, you've practiced, you've built this within your capacity to be mindful and to be fully present. When you get knocked off kilter, someone drives in front of you, or you get some bad news that day about something related to your cancer diagnosis or anything else for that matter, it's like having, you know, a lot in your savings account that you can draw on in an instant about how you're going to mentally, emotionally, socially, and physically move through that moment in hopefully a healthy manner.

SPEAKER_01 14:40

Yeah, I love it. I I think when people think of um a cancer diagnosis, they think you know, you ought to rest, and you hear all of these symptoms of being completely drained and over obviously uh uh your life changes so much stress, and it's it's a life-altering experience, and you feel you know worn out, I'm sure, a lot of the time. And so I think maybe traditionally folks hear that and they say, you know, they wouldn't think something like activity um to treat uh a disease that wears you down, that makes you complete like right some of the most prevalent symptoms of cancer is uh insomnia and being uh fatigue, extreme fatigue, right? And so why why is movement so effective with uh a disease that really could knock you down uh and make you feel exhausted? Why it seems it's some I think traditionally folks would hear that and say, you know, maybe less activity, like rest. Um why what is activity so effective?

SPEAKER_00 15:58

So I do think there's always a balance. There's clearly times when patients and survivors need to rest, just like all of us have those times we need to rest. But the more we learn about the cancer treatments that are there to, you know, help save lives and reduce the impact of cancer um, you know, in people's lives, we actually have learned that there's a considerable amount of inflammation that occurs. Uh, and there's lots of biological processes that get disrupted throughout the course of receiving treatments for the cancer. And they don't necessarily all um just automatically write themselves, right? Uh even after treatments are done. Um, and so movement, right, when you think about yoga and the asanas related to that, uh, is in and of itself um promotes what we call a self-regulating anti-inflammatory response, right? And so this was part of what was so interesting to me because I studied this in elite athletes, right? The whole training process is the process to stimulate the muscles where they get broken down in the process of doing exercise and training, and that stimulates this sort of reciprocal process that then builds the muscles back up. And that's a very simple way of talking about lots of very complex, you know, processes that go on from cellular level all the way through or, you know, organ systems in the body. And what we've learned with respect to these types of therapies with cancer is that these side effects we experience are in many ways, they are um caused by a lot of this uh dysregulation of this inflammatory responses. And it's a chronic situation. You know, chemo goes on for months, radiation can go on for weeks. By the time someone's done with even their primary curative intent treatment, it can be almost a year, right? And sometimes longer. So um being we have to actively go in and use a tool that can help initiate that sort of self-regulatory response. Um, and so that's one piece is that it does really help regulate some of the immune responses. It does help with rebuilding actual tissue, it helps with regulating organ responses, like for example, in the circulatory system, which is your heart, in the in the pulmonary system, which is your lungs, and your actual muscles that make you feel tired, right? And there's a deconditioning effect. And so we can counter that with these types of movement therapies. And again, I think the mindfulness-based therapies have a little added extra there because you're also at the same time dealing with a lot of the psychosocial components where people are experiencing high levels of anxiety. Um, and then you have things like sleep and fatigue, which are sort of complex because they have the psychosocial emotional components as well as the physical. And so we're able with these movement therapies to actually help reduce the inflammation, help either prevent deconditioning or recondition a person if that's the case. Um, and with the emotional aspects of it, um, we know that movement actually can have these anoxalytic effects, right? They can be, they can provide their, they also have like antidepressant effects. So, and we're learning through our work with like sleep and particularly fatigue, um, that it really does influence a person's biology. And I think we forget that sometimes. You know, we've presented work showing that the yoga actually reduces inflammatory profiles in our participants and patients. Uh, we also just recently published a paper where we've actually been able to show that our yoga has an influence on changing the gene expression profiles of circadian genes in patients. So it's pretty powerful stuff that I think we don't always think about. We think, oh, yes, do some exercise. It'll make you feel better, it'll make you stronger, it'll help your heart and your lungs. But there's real cellular stuff that goes on in there. Um, and it's really at that level that we believe a lot of these toxicities are arising from the cancer treatments too. That what goes on, you know, systemically throughout a person's body.

SPEAKER_01 20:41

Wow, there's there's so many questions I have. Um that uh, but what you had just mentioned there, you know, I I was wondering if you could speak on the what you're looking at with genes. And what do you do we know yet what's going on with DNA methylation we're talking about? Or um what what was that paper all about? I don't know if I saw that one.

SPEAKER_00 21:05

Um so I'm the last author on that paper, and it the first author on that paper is a researcher named Dr. Brian Altman. Um, and basically uh I'll give you sort of in a nutshell what we looked at. So um there's been work that has actually developed um something that we call their circadian clock distance. And basically what it is, is a it's a list of circadian genes, genes that we know are related to a person's circadian rhythm. And as they're expressed, they have downstream effects on your circadian rhythm. And we think about circadian rhythm being responsible for a person's sleep. Most people acknowledge that. But circadian rhythms are responsible for every single thing in our body, okay? They regulate hormones, they regulate cytokine expression. Things like cortisol, you people hear about a lot about that in terms of stress. Um, they regulate your desire to eat, they regulate your desire to sleep, they regulate your your your motivation to move, right? It's it's all these are all rhythms, okay, that are controlled by the circadian rhythm um in your body. And so what we did, what what is we took this, we took this list of genes and we correlated them in people who were good sleepers. So you can see what they look like in a what this pattern looks like of the gene expression at a certain point in time in a person's day. And so we're figuring if people are good sleepers, this is what a good profile looks like. And it's like a signature. You can think of this as not one gene acting in isolation, but it's all of them acting together, and that's what's important that they act together well, right? I'm trying to use very simple language to explain it. Um but what we found is that in people who are not good sleepers, our cancer survivors who are not good sleepers, their signature is not at all the same as those in in good sleepers. And so we're really looking at this signature. So it's it's kind of like a pattern at a point in time of a whole bunch of these genes. And it's the gene expression at the RNA level, right? We're not looking at like we're not looking further upstream at like uh methylation, like you talked about, or histone modification. So we're not looking at the epigenetics yet. This is just what's going on at your RNA level. So once your DNA has been transcribed to your RNA, how are these things operating? Because they're giving signals to the rest of your body, and you want them to be operating in a healthy pattern as opposed to a dysregulated pattern. And what we see is in the people who are participating in our yoga intervention, their pattern is more regulated. Um, and so think of this as a snapshot in time. I take a picture of, you know, your gene expression of these genes, and you're a good sleeper. And I take a picture of someone who has cancer who's not a good sleeper at the moment, and their signature does not resemble what we would call a healthy signature, but yours would. Um, that's what we can say at this point. It's a very we're very early in this work, um, and we're we're hoping to take this further and look at this in a lot more patients in our future trials to be able to understand where where in that pathway from DNA to RNA to proteins and you know other things, what's really going on that's different. But it's exciting work. Um, and we also might now also have a biomarker, something that we can follow and measure in our patients as they're doing yoga or any other intervention for that matter, to see if we're actually causing changes physiologically at that at that cellular level of gene expression.

SPEAKER_01 25:17

That's fascinating. When um when you present a uh yoga practice or a yoga intervention and study it, how what kind of practice is it? I'm assuming what's beneficial about one of the benefits of yoga is that you could modify someone's practice, you could meet them where they're at, you know, you're not asking them to go out and run a mile or a 5K. Like you mentioned, you're it sounds like they are in a group, there's a social benefit in being in a community. Um I think the like you mentioned the mindfulness aspect, but but how does how do you approach, does every study look at a different type of yoga intervention? Do you work with yoga studios? Do you I know with the hot yoga um and depression study that got all the press in Harvard that used Vikram Yoga Studios, which is a whole nother animal? But you know, how did you organize um the yoga aspect of of your studies? Or is it different every time? Or how does it work with the cancer?

SPEAKER_00 26:30

We actually have a standard yoga uh prescription that we've developed. It includes a specific set of asanas that we do, um, and we combine gentle hatha yoga with restorative yoga. And when we started this work a long time ago, I worked with a cancer survivor named Marguette Braun. Um, and she was also a wonderful yoga instructor, and she helped develop this. Um, and as we talk through yoga theory and the things that we were all bringing to the table to create this, um what we decided that we wanted is first we wanted the yoga that we were doing to be very accessible to people, no matter what their bodies were like, what their experience was previously with yoga, um, which is why we wanted to focus on some gentle Hatha yoga and the restorative. And the other thing we started to talk about from a yoga theory perspective is this notion of trying to create some stimulus throughout the course of a class that would promote sleep. And we came up with this idea of why don't we craft a session or a um flow that basically starts with the gentle hatha and you know requires you know active muscle contraction and sort of bringing people into the class. But then the last half of the class, we're going to transition into restorative postures, which are, you know, the whole opposite, right? You're trying to relax the muscles instead of contracting them. It's all about relaxation and bringing a person down. So literally we created a class that emulates the healthy circadian rhythm flow. Um, we really didn't know how it was going to work. It's turned out to work fabulously. Um, we use this same flow in all of our studies that we've conducted. We've done about five of them now, two really large nationwide clinical trials um with data coming out of the second one now, but and then some smaller studies. And um it it we do also offer all kinds of modifications, right? So every instructor that we work with, um we we teach them the flow, but they're empowered. We we we have some modifications we suggest, but as you know, it's not possible to provide everyone because every person's different. So they are empowered to do modifications and teach that to the participants. That's really important. Uh, we fully integrate the mindfulness and the breathing into every class that we're teaching. Um, we provide all the participants with a kit that includes mats, blocks, straps, you know, manuals, access to videos. We've done that in a variety of different ways. So to promote a home practice, that's a really important part of what we've done. And in our work, we also have found that uh attending two classes a week, which is part of what we prescribe, is important, but it's also important that they get at least one more day. Depending on the studies that we're looking at, on average, getting somewhere in the neighborhood of about 182 minutes a week of yoga is important. Um, two of those sessions are usually by attending our 75-minute classes with an additional, say, 30 to 40 minutes on your own during the week. We have delivered this in communities across the United States. Um, we worked with yoga instructors in the two nationwide clinical trials. We actually hired people in those local communities across the country, and we set up for participants to actually physically go to a class. Sometimes that was a yoga studio that was working with the community oncology practice. Sometimes it was a building that the community oncology practice had access to and the instructors came in. We provided, you know, all the bolsters and blankets and mats and props. You know, we bought them for the sites and the locations. And actually, when we were done with the studies, we left, we left those in those communities so they would still have them to use. And now, more recently, because it's not possible to get everyone always to a physical location, some of these patients travel two and three hours to see their oncologists. So their ability to come to a class um, you know, two times a week that is supported through through their oncology providers wasn't feasible. So we've now conducted a study, uh a smaller study where we used a Zoom platform to deliver our classes. Um, we're also in the process right now. We have IRB approval and we're getting ready to recruit our first participants to a study with a new yoga app that we have developed that basically has all of our materials in our app. And then also we have live classes that we're going to be teaching, but there's also a schedule where they can, you know, go on and join those live classes a couple of times a week, two times usually. Um, but then there's everything they need to do a home practice on their own, including tons of pre-recorded classes. And what's nice about what we have that's different, I think, from what they might experience if they went to a yoga studio in their in their hometown is that, you know, we now have data in well over a thousand, almost 1500. You know, we're we're starting to hedge up into the 1500 patients that across the country that have used this exact flow in our intervention. And we have scientific evidence, you know, showing that if you're able to do these aspects, um, you should have some tremendous benefits for a wide variety of side effects. And again, the the hatha yoga and the restorative super accessible. And it's not, it's not like uh a vinyasa flow or a heated vinyasa flow. It's you know, it's going into a heated room is intimidating for people without cancer. Going into a bikram 100 plus degree heated room at times, you know, might not even be appropriate for cancer patients at certain stages. Um I think all forms of yoga have great merit. Um, but I think that's one of the things that's great about our work is that it's standardized, it's very clear, it's repeatable. So we we can teach yoga instructors to do this and they can go in their communities and use it and do it, and it works. And yeah, I mean, we've probably worked with now over probably in the neighborhood of between 50 and 60 instructors across the United States to do this.

SPEAKER_01 33:32

It's incredible. Is are are you able to tell me or walk folks, walk me through what that exactly looks like? And when people hear Hatha, you know, they might not be entirely sure what what you're describing and and even restorative, even though that's a little bit more um easy to understand what that might look like. But I don't know if you're able to maybe walk through that process. Is it starting with breath work seated and then moving into standing poses into then stupine? Maybe the restored is more seated stupine with props. But I don't could you kind of give me a sense of or even.

SPEAKER_00 34:11

So this is part of the mystique of yoga, right? So I think people think that we're gonna ask you to be doing handstands and standing on your head or you know, bending your legs and arms in really like interesting positions. Um basically the class starts seated and it starts with sort of coming to your place on the mat. It starts with breath work. Um, you're not doing a lot of uncomfortable moving. As a matter of fact, you're sitting in a very comfortable position. Um, and and that's part of the modifications is to even make sitting comfortable, right? Uh, and I do know that uh I'll just interject that like people have told us that when they take this class and they learn modifications for the class, that those modifications also frequently become part of their daily routine for different things that they do because they incorporate some of what they're learning about their bodies throughout their day into other activities. Um, but it'll start definitely seated, you know, becoming present on the mat, breathing. Um, we will move through some postures that are, you know, on the mat, and then you move to like intermediate. So you might be on your hands and knees, for example, doing a cat cow where you're like breathing and you're like just basically, you know, curling your back and expanding your belly and curling your back and breathing in and out with that. Um, so we have these intermediate poses, and then we move to some standing postures. And then after we're moving to that, we're gonna definitely move back down onto the mat for the restorative postures. And the restorative postures, I love to call them just luscious, right? I mean, that's everybody's favorite part, you know. I think Judith Lassiter did us a huge favor, right? When uh when she really started working on, you know, restorative uh yoga. And so people don't picture this usually at all in their yoga practice. But here you're gonna have like two or three of these big, huge pillows and bolsters. You're gonna have some blocks. We we teach them how to prop the bolsters and the pillows in a way so that you get into these poses. One of them is nice reclining pose where you're sort of reclined back against the bolster. You have nice bolsters on either side of you and blankets, sort of almost like propping you up in your favorite clumpy armchair at home. Um, and just you know, opening up your chest, your belly region, you know, really expanding and being able to get breath, right? So relax and get breath and just be present and mindful. Um, you know, it's interesting because I think a lot of people also think that they come away from yoga being exhausted after every class. Um, I I find that people tell us that after these classes, they're the opposite. They're enter energized, right? They almost feel like sometimes they'll say, I feel like I just took the world's best nap. Like even when I sleep, I don't feel that rejuvenated afterwards. Um, so as opposed to going out going, wow, that was like a really hard workout. I'm really tired now. Um, it's more like, wow, I feel refreshed. I feel like I'm, you know, better than I felt when I woke up in the morning. Um, and so it's again, it's really accessible. Um, we're not asking people to stand on their head or do handstands, you know. We do do downward dog, but um, we're very conscious of what that might need to look like with lots of modifications. So, you know, some people can't get all the way down on the floor. They might be doing the whole class from a chair with us. Um, and so we are able to um work with patients and participants to to really make it again. I keep using the word accessible because this is like in everybody's yoga, which is what I love about it. Um, you know, um, yeah.

SPEAKER_01 38:23

Wonderful. And I imagine there's a shavasana, yeah, at the end.

SPEAKER_00 38:27

That's the very end. Yes.

SPEAKER_01 38:29

Okay.

SPEAKER_00 38:29

And that's like that's like making an ice cream sundae without the whipped cream and the cherry on top. Of course, there's shavasana at the end.

SPEAKER_01 38:38

Yes, I agree. I totally speak in my language. I um I love it. It sounds like a really beautiful program. I um I was curious, you know, as far as like theory and philosophy goes, I love, you know, allowing some uh sometimes I allow students to, you know, set your own intention, you know, or maybe you make a suggestion like to get to know yourself and the bliss that arises from that knowledge by moving through your practice is like another one that I could just kind of maybe suggest. Is there freedom for the teacher to speak what they love or interject their own personal experience and philosophy?

SPEAKER_00 39:22

Yeah, I you know, that's something that people ask me a lot. They because we do we train the instructors, but what's interesting is I do not train the instructors on how to teach yoga. We hire yoga instructors who already have a considerable amount of experience. The majority of them have already worked with people who maybe have other chronic illnesses, maybe all they've already worked with some cancer uh patients or survivors. Um so there's there's not only room for that, um, we actually ask them to bring it to the table, right? Because they are trained in yoga and they understand how to create that space. And one of the things that I do ask the yoga instructors when we're um speaking with them about working with us is to please bring those kinds of things to the mat, you know, how you're how you discovered yoga, why yoga is special for you, how it's helped you maybe in a really challenging part of your life, sharing that can sometimes be really helpful. Um, just creating that space, that safe space for participants to experience the yoga and all that comes with it. Um, you know, there may even be situations where I'm sure you've probably experienced this where you may have a person in the class that becomes tearful or begins to cry uh because of just the release, right, of the emotions and things that can happen when you move. Um and when you're sort of trying to be aware and mindful. Um, yes, I mean, we definitely need that. When we train our yoga participant, our teachers, what we really are bringing and training them in is how to work with us in a research study. Uh, you know, there are some parameters that we we do have to be standardized with. So for example, we do say these are the asanas. Please don't add in your favorite one, and please don't take away one that we have that might not be your favorite one to do. You know, we need you to do these. Um, but we also leave room open for them to use the mindfulness parts and the breathing parts and to access all the repertoire that they bring. So it's not like we do one-step breathing pattern or one-step mindfulness approach. It's really uh those pieces are uh uh very dynamic and organic. And they, although the spirit and the core of them is the same, it's not always the same thing every day.

SPEAKER_01 42:02

Okay. And I can imagine, I mean, it's great that you're able to study and standardize it to some capacity to study it and to research it. Um, but I can imagine too, it's looking at it through a yoga teacher's lens at least. I mean, it it seems like it'd be very difficult to kind of pick apart what mechanism is creating what benefit in the research, whether it's the movement component, the, like we said, the social component, the deep relaxation, the uh, you know, energy in the room, the, you know, the um, you name it, I'm trying to think. There's so many uh mechanisms that could potentially potentially look at, how the teacher shows up, how the teacher interjects their own personal experience, how the teacher supports them in their language, how they their voice there seems like there's so many variables. But at the end of the day, what matters is that it works, like point A to point B, where at least we can study it and get some sort of uh sense of its effectiveness. But do we understand though that that's a long-winded question of do we understand what aspects of this whole process with yoga um is causing these effects, these profound benefits for cancers uh those with cancer?

SPEAKER_00 43:27

I haven't seen a study yet that goes it's this. What I have what what I do know is that it doesn't matter whether you're an oncologist treating a patient, a nurse, a yoga therapist, you know, a a counselor, a social, a licensed social worker, uh whenever you're showing up for a patient or a survivor, all of those things matter. Right? They all always matter. So if you're Not bringing the best version of yourself that day, and you're a little off-kilter as a physician or as a yoga therapist, it's going to impact what goes on in that session. The same is true with our yoga therapists. And we, most yoga therapists I've ever met are fully aware that how they show up that day is completely going to influence their class. Um, it's also the same I tell people, you know, maybe you show up and you find this yoga instructor's class to be amazing. And the other, this one over here is not quite the best fit for you. It's the same way as people say, Oh, I love this doctor. This doctor's not my favorite, right? Um, so I believe it's really all of it. I don't think you can unpack it and say, oh, it's just this thing. So now let's get rid of all the rest of this and just do this one thing. And because then obviously it's not yoga, right? You know, if we just do the movement without the breathing and the mindfulness, it's exercise, it's calisthenics, it's not yoga, right? Um, and so it really is that integration, it's the creation of the space, whether it's a virtual space or a physical space that you're all in together. It's it's um the presence of the instructor. It's also the presence that people start to bring to those groups and classes and what they're doing. Um it's an interesting scientific question. What's more salient, the movement versus the breathing versus the you know, mindfulness components of it? I think we have studies that look at breathing in isolation with like no movement, or basically seated move, you know, or and then we have people that look at meditation and mindfulness in isolation, um, where they're not really encouraging like a certain pattern of breathing or a certain type of movement during that. And then there's, you know, so to me, if we're talking about yoga, we're talking about these things together, and it all sort of creates the magic. But, you know, it's uh it's an interesting scientific question. I don't think we've answered.

SPEAKER_01 46:13

Yeah, I think we all seek really tidy, neat answers, Wikipedia type of uh explanations, but yeah, life doesn't lend itself to that, uh, neither does good science, it sounds.

SPEAKER_00 46:25

I also think when you're working with a patient or a survivor, you know, anyone for that matter, because you know, all of us are dealing with something on any given day in our life, right? Um but I think um if we bring the whole thing and we know the whole thing works, the notion of of starting to subtract parts of it just seems so counterintuitive to me, right? Especially when you think about what we're talking about with this intervention. So in less than a month, four weeks, okay, less than a month taking and doing this type of gentle Hatha yoga and restorative yoga, your the list of things that we know patients can derive benefit from is super long. So we know it can, we know it can decrease your insomnia. Even clinical insomnia can be decreased enough that it's no longer, you know, deemed a clinically, you know, insomnia clinical insomnia. Sleep quality can be improved, your anxiety can be reduced, your overall mood can be improved, your fatigue can be significantly reduced. We can see that the inflammatory, what we call this like super inflammatory profile that people have throughout the course of their treatments, and in some cases for months and years after they're done with the primary treatments can be regulated. We're seeing that it can actually change gene expression. And this is just the tip of the iceberg. I think we're going to see so much more explode with that in the future in the next decade over what goes on with these things. And like you were talking about, all the way from the epigenetics through you know what we see going on with the RNA down to the proteins in your in your body and and what goes on at your cellular level. Um it's it's tremendously impactful. I don't know that we have a pill that can do that. And we're talking about four weeks. Now we want people to continue after that, but think about what I'm saying. You can go through one or two cycles of chemotherapy in four weeks, right? Depending on your regimen. You can get a lot of radiation during that time. If you're doing this and you're working through this as a survivor, the things that you can change during the first month after you're done with your treatments, it's profound. It really is.

SPEAKER_01 48:54

Yeah. And and all of those things, I imagine, contribute too to someone's pain experience. Right? I mean, all also pain.

SPEAKER_00 49:03

Our data has shown that it can reduce overall pain ratings, it can reduce the pain from arthralgias in women who are taking hormone therapies, who are breast cancer survivors. Pain was a big thing. We also have shown in our data that it can improve, it can decrease cognitive impairment. You know, everybody's worried about this thing we call chemobrain. Um, we have published a paper showing that the yoga improves memory and reduces cognitive impairment. Um, so it's again the the list of things that can come from this, what I consider to be relatively simple, very accessible. Nowadays, when I started this work 20 years ago, you could not find yoga on most corners in cities. Now it's much more available and ready there for people, both on the internet and in their physical communities. Um we're talking this can all happen with four weeks of of this.

SPEAKER_01 50:03

I um all these aspects and benefits that are having such a profound impact on survivors. How big does this move the needle in the big picture when we're talking about survivorship or just your overall livelihood as you could work through or with the time you have, even if if it just profoundly uh improves your your life? Like how much does that move the needle on both longevity at once you've got a diagnosis of cancer and just your quality of life? Um, could you speak a little bit onto that big picture?

SPEAKER_00 50:42

We can't really talk about yoga's effect on survival yet. I I hope I'm gonna be able to do that with something that we have in the next few years, um at least to take a look at it. Um but the moving the needle of the overall quality of life. And when I say overall quality of life, I'm talking about a person's ability to walk through the your day and do all the things that you normally want to do. That includes if you want to go back to work or working through your treatments, that includes spending time with your children or your parents or your grand, you know, parents, whatever that looks like, your friends, right? It includes being able to engage in activities that give you pleasure, um, but also not suffering. The burden of the side effects and toxicities that patients experience is really hard. And and finding ways to mitigate that is crucial. It also does, if we're able to do this, you know, we worked with survivors who were post-primary treatment, but there's also literature out there in patients who are going through treatment. And even though they're post-curative intent, a lot of times they're on what are called maintenance therapies. So they may be on hormone therapies or other things for like five years or more after they're done with these therapies we typically think of, like surgery, chemo, and radiation. And to be able to continue to take those treatments, right? Not having to miss a dose, not having to lower your doses of these of these therapies because your side effects are so um severe. And be by lowering that, people can get all their treatments, they can get them on time. And you know, if we believe that if that's happening, it should have a positive impact on prognosis and ultimately survival. But but really one of the things we've learned from cancer patients, even older patients, they will tell you that what they want more than anything is the higher quality. If they had to choose between a little bit longer that wasn't so great quality versus a little bit shorter with really great quality of life, that time and time again, that's what we learn that patients will choose. And I would say yoga has helped move that needle so far that it's now actually recommended in oncology treatment guidelines. If you had asked me 20 years ago if I ever thought ASCO, the premier, you know, that's the American Society of Clinical Oncology. It's the huge professional organization that puts out treatment guidelines, right? They're telling surgeons what chemotherapy, I mean, sorry, surgeons, what surgery, what what chemotherapies, what radiation therapies. They're also telling us what supportive care therapies we should be giving to patients. And now yoga is actually a recommended therapy. Um, that, you know, I had hoped we might get to that level 20 years ago, but the fact that I can actually see this now 23 years later in my career is profound. It's also why we no longer call it alternative or complementary medicine. We talk about yoga as being integrative medicine in oncology. That means fully integrated right alongside with all the traditional treatments that you think of your surgery, your chemos, your radiations, all hormone therapies, all of that. We're integrating these supportive care therapies like yoga right alongside all of it. And it's called integrative now because there's good scientific evidence to support it. Uh, it wouldn't be that way if it wasn't. And that and this is true for lots of other integrative medicine therapies as well. But um, you know, yoga's there. It's there in the supportive care guidelines. And that's that in and of itself tells me that there's enough acceptance of this in the oncology world that it's made its way into treatment guidelines.

SPEAKER_01 54:46

That's really uh really hopeful, hopeful. And it I um for someone who is in the throes of of this and or just want to help a loved one out in finding an appropriate yoga teacher or studio. I told you in the beginning um how I'm trying to work with somebody to help develop a tool for doctors to more accurately find, help the patient, bridge the gap between doctor, patient, yoga teacher or studio that's going to be a good, hopefully a good fitter, or at least the best chance at really being effective at what they're looking for. So for someone who's a survivor or wants to help a loved one and find a an appropriate class or someone who maybe even knows your work in sequence, is there somewhere we could point them or advice to to give them?

SPEAKER_00 55:43

So I give a lot of what I call sort of practical advice, um, which is it's hard, it's hard to do what exactly you're trying to get your tool to do. If we could do that, that would be magical. Uh, there's a lot of pieces that have to be able to work for that to work. But when oncologists or family members or survivors themselves say to me, okay, so we want to we want to access this or provide this for our patients. So what should we do in our communities? The first thing I tell people is, you know, go to the internet, get out the phone book if you still have the good old-fashioned phone book, yeah, and start to look around for what is available in your community. And for some people, that means online services. For some people, that means looking within a 20-mile radius, and for others, it might mean an hour radius or something like that. But basically start to look in your community and familiarize yourself with all the different options that you have for yoga. And then, you know, if oncology um practices are really interested in being able to say, hey, we recommend you to go here or there, to actually familiarize yourself with those practices, take the time to contact them, take the time to meet some of the participants, uh, some of the instructors, ask them questions about their comfort level working with patients. Um, you could even do some education for those yoga instructors about working with cancer patients, but it's really important to become familiar. The other part is to make sure that you have well-trained yoga instructors. Um, it's it's a it's a regulated slash unregulated system, right? Meaning you can get yoga instruction lots of different places, and all yoga instructor training is not the same. Um, but there are some organizations out there that um can give you sort of a signal if the instructor has, you know, a certain level or pretty good amount of training. Um, any instructor that we worked with in our studies across the country, no matter where their training was, we asked them to actually um look at the yoga alliance into if they weren't already a member of Yoga Alliance to become a member and to get their the Yoga Alliance sort of blessing of their training. Uh, and that's because it was an organization at the time, a long time ago. It was like the only organization that allowed us to say across all these different types of yoga instructor training, yeah, like, yes, this person has good training and they've got a certain amount of hours of experience. So they would meet like a minimum threshold of good training. Um, now we also encourage people to work with the uh IAYT, uh, look for people who might have yoga therapists um training and background. Um, that being said, everybody doesn't have that. And so it's really important to get to know the yoga instructors. And I really try to empower patients and survivors when they talk to me to actually have a conversation with those instructors and you know, be willing to say, hey, look, you know, I'm I'm coming to you. I want to take your class. I have, you know, these limitations and things like that that I'm working with or concerned about. And um, try to make sure you're getting a good trained instructor and that you feel safe and comfortable.

SPEAKER_01 59:09

Yeah. And open those lines of conversation if you're comfortable with that teacher. You know, I feel like that's a big part of the conversation, is the conversation component, you know, be willing to even if you, I don't know if this is a thing, but I always thought if doctors could somehow prescribe, like, hey, this is what that you ought to avoid in even in a yoga class. It would be nice if uh if, yeah, just to be willing to open up or at least tell your instructor this is what I'm going through, and and if I'm doing something to modify or if you can help me, this is what I need to avoid. They're more than usually more than willing or able to do that. If they're not, they ought to be honest with you. And I think works both ways, instructor and teacher dynamic there. Um this is all really exciting stuff. I'm really happy I got to speak with you, someone who's I didn't realize initially that I'd be speaking with someone who is also very versed in in yoga itself. And so this made for a really uh helpful conversation. And um thanks for communicating the science in a way that can be disseminated to a lot of folks. Everyone could understand that that's a skill I know. And so I appreciate you um explaining things in a way that that I could understand and and share with with my uh audience. But is there anything before I let you go that you want to end with that you're excited? You talked a lot about what you're excited about with the future of this, but if we did we miss anything or anything you want to put out there for folks, or if they want to support your work that we could put out there for them?

SPEAKER_00 1:00:48

You know, I think the thing that I always like to leave with is if you are a cancer patient or a survivor uh or a yoga instructor, even, um, you know, I would encourage patients to just be open and be willing to give this a try. Um you know, it's not painful, it's way easier than most people think, you know, approaching this. And for yoga instructors, I would say, you know, also don't be afraid to work with cancer patients and survivors. They they need you and they need your help. Um, and you know, be willing to to reach out and open your classes and encourage them to come. Sometimes instructors have told me they've been nervous, they have been worried about working with patients. Um, if you're a good yoga instructor, you don't have to worry. You're you're gonna be fine. Um, I just would love for people to be open and to give it a shot. And I also would say, you know, in particular, I hope we have, you know, millions more people like you, Jake, that are, you know, showing up in communities, you know, like in the middle of New York and off Cayuga Lake, which is, you know, there's not the lot of big cities or towns around where you are, and just like bringing this into communities where it's not already there. Big cities tend to have plenty of yoga, small rural locations, like you're talking about, not so much. Um, you know, I would love to see more people doing stuff like you're doing, and I hope that it really is successful for you on the lake over there. Um, and uh, I mean, we really need that. I I would like to see this thing grow a hundred times more than what it has in the last 20 years, so that this is as accessible to people as walking around their block. And it's just there and it's easy for them to grab and try and and utilize. Um yeah, that's yeah, and and to any cancer patient or survivor, I would just say, you know, uh you you got this journey. Yeah.

SPEAKER_01 1:02:59

It's really a really sweet message. And um, yeah, I I I'm always thinking of this dynamic because I grew up rural, went to the city like I think a lot of folks do, 18 years in Philadelphia, want to be closer to family and kind of quality of life and and some space, come back and and bring um forward and and offer that in these types of communities as well in rural areas. And I think um, yeah, I think it could be done. I think, you know, a lot of I think a lot of teachers would uh love to be able to live outside of cities and still contribute. And and I think it's the uh making a living doing it's the tricky part.

SPEAKER_00 1:03:46

And and so it is the tricky part for everybody.

SPEAKER_01 1:03:50

Yes. But finding meaningful work and working with survivors is I mean, I think a lot of teachers could their eyes light up hearing you say and and and knowing that they've got something to offer and to to give it a shot and and don't be scared. It it sounds like something like even I'm thinking of ways already that I could contribute potentially. And so thank you for that. I I really appreciate it. And um, this is a really awesome conversation, a really enlightening conversation and uh a hopeful one. It's great great to hear so much positive movement on yoga and its its uh benefit with cancer. So thank you for your time and and your willingness to to come on and and share your work with us.

SPEAKER_00 1:04:36

Oh, thank you. It's great. It's a highlight of my day today. So thank you.

SPEAKER_01 1:04:40

Wonderful. I well, I appreciate it. I'd love to do it again sometime.

SPEAKER_00 1:04:44

Awesome.

SPEAKER_01 1:04:45

All right, take care. Thanks for tuning in. If you found my conversation with Dr. Mushjin to be helpful, informative, if it got you thinking or inspired you, please share the podcast with a friend, subscribe, and leave a review on Apple Podcasts. I'd really appreciate it. You can find me on all social media platforms, especially Instagram at Yoga with Jake, and at my website, yogawithjake.com. Until next time, take care of it.